Fascial Space Infections
Submandibular, sublingual, and submental spaces are collectively called perimandibular spaces.
When the perimandibular spaces are involved in an infection, it is known as Ludwig’s angina.
Bacteriology
- As Ludwig’s angina is of dental origin streptococci or mixed oral flora are the most commonly reported microorganisms.
- The presence of staphylococci, E. coli, Pseudomonas, and anaerobes including Bacteroides and Peptostreptococcus, Prevotella species have also been isolated.
- The role of anaerobes as primary or synergistic organisms should not be omitted in the culture.
“What Is Ludwig’S Angina”
Spread Of Perimandibular Space Infection
- Infection from a lower third molar reaches the submandibular space.
- From here it spreads along the submandibular salivary gland above the mylohyoid muscle to reach the sublingual space.
- From one side of the sublingual space, it moves across the genioglossus muscles and reaches the sublingual space on the other side. It can then cross over the mylohyoid muscle and reach the opposite side submandibular space.
- The submental space gets involved via the lymphatics.
Since it is cellulitis and not an abscess, it does not remain localized but rapidly spreads along the fascial planes and tissue spaces. - After involving the three spaces, the cellulitis spreads within the substance of the tongue posteriorly along the course ofthe sublingual artery in the cleft between the genioglossus and geniohyoid muscles. This reaches the region of the epiglottis producing edema and inflammation of the laryngeal inlet. This causes severe airway compromise.
- Also from the submandibular space, it can pass along the investing layer of the deep cervical fascia all along the anterior aspect of the neck to the clavicle and continue into the mediastinum.
- Communication of the submandibular space with the pterygomandibular, masseteric, and lateral pharyngeal spaces causes trismus and further enhances airway compromise.
Perimandibular Space Infection Management
The main aspects of management are:
- Airway maintenance
- Parenteral antibiotics
- Surgical decompression of tissues
- Hydration of patient
- Removal of cause
“Risk Factors For Ludwig’S Angina”
Perimandibular Space Infection Airway Maintenance
- Edema of the glottis is what leads to airway obstruction and death of the patient, if untreated. Maintaining a patent airway is thus of prime importance.
- Intubation is done by an experienced anesthetist.
- Bulging of the posterior pharyngeal wall makes intubation difficult. Perforation may lead to aspiration of pus if an endotracheal tube is forced in blindly.
- A tracheotomy or cricothyroidotomy may be advisable.
Tracheostomy is usually difficult because the anatomical landmarks on the neck are not easily identifiable with the swelling.
Perimandibular Space Infection Parenteral Antibiotics
- Penicillin is the antibiotic of choice.
- Others such as Amoxicillin and cloxacillin may also be used.
- Metronidazole is given against anaerobic organisms.
- Gentamycin can also be given along with penicillin for coverage of Pseudomonas.
Perimandibular Space Infection Surgical Decompression
- It is usually preferred under LA instead of GA. The main aim is to relieve the pressure within the tissues for the edema to reduce. Also, the pressure within the tissues compresses the blood vessels preventing the penetration of antibiotics in the area of interest. Thus decompression improves vascularity and potentiates the action of antibiotics.
- If there is pus, it provides a channel for the drainage of pus.
- Pus obtained from a drainage may be sent for culture and sensitivity testing.
- A decrease in edema reduces respiratory embarrassment.
“Understanding The Causes Of Ludwig’S Angina”
- Ethyl chloride spray may be used or LA may be injected locally in the area of incision.
- Bilateral submandibular incisions with a midline submental incision may be placed.
- Blunt dissection through the skin, superficial fascia, platysma, deep fascia, and mylohyoid muscle is done to reach the sublingual space. The sublingual space may alternatively be drained intraorally by an incision in the floor of the mouth if the mouth opening is adequate.
- A drain is inserted through all these layers and stabilized.
There may be no pus at all in most cases of Ludwig’s angina. Pus may only be seen at later stages.
A loose dressing is placed which is changed every day after careful cleaning of the drain.
“Early Signs Of Ludwig’S Angina”
Perimandibular Space Infection Hydration Of The Patient
- Pyrexia and dysphagia may lead to dehydration of the patient.
- It is necessary to put the patient on IV fluids.
Removal Of Cause
Once the patient is stabilized and the trismus relieved to an extent, the offending tooth may be removed
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