What is the anatomy of the submandibular space relevant to deep neck infections?

Updated: Apr 30, 2020
  • Author: Alan D Murray, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Submandibular space

  • The submandibular space is bounded inferiorly by the superficial layer of the deep cervical fascia extending from the hyoid to the mandible, laterally by the body of the mandible, and superiorly by the mucosa of the floor of mouth.

  • It is considered to have 2 subdivisions, the sublingual and submaxillary spaces, which are divided by the mylohyoid muscle. The sublingual space contains the sublingual gland, hypoglossal nerve, and Wharton duct. It is in continuity with the submaxillary space via the posterior margin of the mylohyoid muscle, around which pus can readily tract. The submaxillary division is further subdivided by the anterior belly of the digastric into a central submental compartment and a lateral submaxillary space.

  • Infection in the submandibular space may be secondary to oral trauma, submaxillary or sublingual sialadenitis, or dental abscess of mandibular teeth.

  • The term Ludwig angina describes inflammation and cellulitis of the submandibular space, usually starting in the submaxillary space and spreading to the sublingual space via the fascial planes, not the lymphatics. As the submandibular space is expanded by cellulitis or abscess, the floor of the mouth becomes indurated, and the tongue is forced upward and backward, causing airway obstruction. Ludwig angina does not require the presence of a focal abscess. It typically includes bilateral involvement and manifests with drooling, trismus, pain, dysphagia, submandibular mass, and dyspnea or airway compromise caused by displacement of the tongue. This is a life-threatening condition that requires tracheostomy for airway control. Before antibiotics, the mortality rate of Ludwig angina was 50%. With modern antimicrobial and surgical therapies, the mortality rate is less than 5%.

  • Submandibular space infections may spread to the parapharyngeal space or retropharyngeal space.


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