Bilateral submandibular gland infection presenting as Ludwig's angina: First report of a case

Ear, Nose & Throat Journal, April, 2001 by Carlo P. Honrado, Samuel M. Lam, Matthew Karen

The mortality rate reported by Ludwig approached 60%. [9] The mechanism of death was originally attributed to sepsis, but by the 1900s it had become evident that death occurred because of airway obstruction, as pressure on the airway resulted in asphyxia. Another factor that has been implicated in death is the impairment of the medullary respiratory center by acapnia or hypersensitivity of the carotid sinus pressure receptors. [10] The high mortality rate of this disease persisted even after the advent of surgical decompression as a treatment because either the procedure was undertaken too late or the drainage of the infection was inadequate. [11] It was not until the antibiotic era and the more widespread practice of good oral hygiene that the mortality rate dropped to less than l0%. [2,12] In 1982, Patterson et al reported no deaths or complications in a series of 20 patients. [3]

A thorough understanding of the anatomy of the spaces of the deep neck and the fascial planes is a prerequisite for treating this disease process properly. Detailed anatomic descriptions of the fascia and fascial planes have been published by many authors [13,14]--most notably by Grodinsky and Holyoke [15] in 1939. They described the submandibular space as a potential space above the hyoid bone. The submandibular space is made up of both the sublingual space, which lies superior to the mylohyoid muscle, and the submandibular space, which lies below the muscle. These spaces can be considered as one single unit because the free border of the mylohyoid muscle posteriorly allows them to communicate (figure 3). The superficial layer of the deep cervical fascia acts as a barrier to the spread of infection. Along with the mandible and the hyoid bone, the fascia limits the amount of edema that can occur. Any significant swelling that arises in the submandibular space will cause a superior and posterior displacement of the floor of mouth and the tongue. Airway compromise can thus ensue.

The superficial layer of the deep cervical fascia also envelops the submandibular gland. Any infect ion or swelling that occurs in this gland is first contained by this layer. However, any prolonged swelling and inflammation can weaken the fascia and allow the infection to rapidly spread into the submandibular space. [11,16,17]

Our current understanding of Ludwig's angina is that it is a potentially lethal, rapidly spreading cellulitis of the sublingual and submandibular spaces. The clinical features of this inflammation include swelling under the tongue, a wood-like swelling of the neck, and difficulty with speech, deglutition, and occasionally respiration. Grodinsky developed strict criteria for the diagnosis of Ludwig's angina. [14] He said the disease can be recognized by five identifying characteristics: (1) the infection is a cellulitis of the submandibular space, not an abscess; (2) it never involves only one space, and it is usually bilateral; (3) the cellulitis causes gangrene with serosanguineous infiltration and very little or no frank pus; (4) the cellulitis attacks the connective tissue, fascia, and muscles, but not the glandular structures; and (5) the cellulitis is spread by continuity, not by the lymphatics.