Sublingual Space Research Articles

Spread of odontogenic infections: a retrospective analysis and review of the literature

To provide an empirical description of the relationship between the spread of head and neck infections, and the causal tooth. The hospital records of 155 patients presenting with odontogenic head and neck infections due to a single identifiable tooth from January 2000 to August 2011 were reviewed. The following data were collected: age, sex, clinical presentation, etiology, location, and spread of infection. The causal tooth and location of infection were subsequently compared to the literature. In the present study population, the causal tooth most frequently (47.1%) consisted of the third mandibular molar. Infection of maxillary teeth most commonly spread to the buccal space, whereas infection originating in the mandible mostly spread to the submandibular, pterygomandibular, and buccal spaces. The literature search provided 18 usable articles. Fourteen studies discriminated between mandibular and maxillary origin of infection, and three articles elaborated on the direct relationship between causal tooth and location of infection. Spaces most frequently affected in the literature are the submandibular, masticator, lateral pharyngeal, buccal, and sublingual spaces. A large amount of discrepancy was found between studies. When describing the location of infection, most studies do not discriminate between maxillary and mandibular origin. Although the literature seems to be unambiguous about the predetermined spread, this article demonstrates that it is more difficult to predict the spread of an infected tooth than previously expected. Large studies with clearly noted causal teeth in relation to location of spread should shed more light on the discrepancies found in this review.

Giant plunging ranula: a case report

A ranula is a bluish, transparent, and thin-walled swelling in the floor of the mouth. They originate from the extravasation and subsequent accumulation of saliva from the sublingual gland. Ranulas are usually limited to the sublingual space but they sometimes extend to the submandibular space and parapharyngeal space, which is defined as a plunging ranula. A 21-year-old woman presented with a complaint of a large swelling in the left submandibular region. On contrast-enhanced CT images, it dissected across the midline, and extended to the parapharyngeal space posteriorly and to the submandibular space inferiorly. Several septa and a fluid-fluid level within the lesion were also demonstrated. We diagnosed this lesion as a ranula rather than cystic hygroma due to the location of its center and its sublingual tail sign. As plunging ranula and cystic hygroma are managed with different surgical approaches, it is important to differentiate them radiologically.

Angina de Ludwig. Reporte de 2 casos

Ludwig's angina (LA) is an odontogenic infection, a pathological condition that represents an emergency in Oral and Maxillofacial Surgery as it threatens the life of the patient, as it progressively obstructs the airway, due to the advance of the infection in the submandibular, sublingual and submental spaces. An updated review of the literature is presented here, including the management, treatment, origin, its transmission routes, the possible complications, as well as a report of two cases seen in the West General Hospital “Dr. José Gregorio Hernández” (HGO) in Los Magallanes de Catia (Caracas, Venezuela). The diagnosis of LA, clinical handling, and the relevance of the role played by the oral and maxillofacial surgeon in the diagnosis, in order to save the life of the patient, is also discussed.

Textual Research on Chiding Disease and Matixiang Herb in Da he wai ke (External Medicine of Da He)

Recorded in Da he wai ke (The External Medicine of Da He) in the Ming dynasty without a corresponding disease title in contemporary scholarly concepts of Traditional Chinese Medicine (TCM), Chiding disease was described as an acute symptomatic disease with inevitable serious conditions of convulsion-like or mania-like behavior, and as a refractory ailment. It was also considered as an alias of Hongsiding (namely the acute lymphangitis) in few ancient books. Matixiang, a Chinese herb for treatment of Chiding, was regarded as a nonsuch drug by Da he wai ke, and was considered as a take-then-cure drug by Chuang yang jing yan quan shu (Compendium for Experience in Sores Diseases). The present studies about Chiding and Matixiang show that: (1) the name of Chiding was first seen in Zhong zang jing (Master Hua's Classic of the Viscera) ; (2) Chiding was rarely mentioned in medical literature of the Song, Yuan and Qing Dynasty, but mostly seen in the Ming Dynasty; (3) Xinding and Huoyanding were found as synonyms of Chiding ; (4) the distinction between Chiding and Hongsiding (flaming sore) was revealed by comparison analysis of their etiology, affected part(s), symptoms, prognosis and syndromic pictures; (5) Chiding on the tongue is the same as "Tongue Ding" or "Sublingual Ding" in contemporary TCM and as "Sublingual Space Infection" in Western Medicine. Moreover, Chiding on the hands, feet or other skin parts could be classified as "Hands/Feet Ding" in contemporary TCM and as "Furuncle" (i.e., Acute Suppurative Folliculitis and Perifolliculitis or cellulites of the tongue) in Western Medicine; (6) Matixiang is probably deduced as Asarum forbesii Maxim., A. ichangense C. Y. Cheng et C. S. Yang, family Aristolochiaceae, or Valeriana jatamansi Jones., family Valerianaceae.

Rânula congênita: diagnóstico ultrassonográfico antenatal

Rânula congênita uma rara malformação cística visualizada na cavidade oral. É um pseudocisto habitualmente localizado no espaço sublingual entre o músculo milo-hioideo e a mucosa da língua. Relata-se um caso de gestante de 24 anos, G3P2, com idade gestacional de 29 semanas, encaminhada por conta de polidrâmnio e grande massa de cavidade oral de natureza cística.

Emergency Imaging Assessment of Deep Neck Space Infections

Deep neck space infection may lead to severe and potentially life-threatening complications, such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and intracranial abscess. The clinical presentation is widely variable, and often early symptoms do not reflect the disease severity. The complication risk depends on the extent and anatomical site: diseases that transgress fascial boundaries and spread along vertically oriented spaces (parapharyngeal, retropharyngeal, and paravertebral space) have a higher risk of complications and require a more aggressive treatment compared with those confined within a nonvertically oriented space (peritonsillar, sublingual, submandibular, parotid, and masticator space). Imaging has 5 crucial roles: (1) confirm the suspected clinical diagnosis, (2) define the precise extent of the disease, (3) identify complications, (4) distinguish between drainable abscesses and cellulitis, and (5) monitor deep neck space infection progression. Ultrasonography is the gold standard to differentiate abscesses from cellulitis, for the diagnosis of lymphadenitis. and to identify internal jugular thrombophlebitis in the infrahyoid neck. However, field-of-view limitation and poor anatomical information confine the use of ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or drainage. Computed tomography (CT) combines fast image acquisition and precise anatomical information without field-of-view limitations. For these reasons, it is the most reliable technique for the evaluation of deep and multicompartment lesions and for the identification of mediastinal and intracranial complications. Contrast agent administration enhances the capability to differentiate fluid collections from cellulitis and allows the detection of vascular complications. Magnetic resonance imaging is more time-consuming than CT, limiting its use to selected indications. It is the technique of choice for assessing the epidural space involvement in pre- and paravertebral space infections and complements CT in the evaluation of the infections reaching the skull base.

Composition of the blood supply in the sublingual and submandibular spaces and its relationship to the lateral lingual foramen of the mandible

The purpose of this research was to contribute to minimizing arterial disruption during mandibular surgical procedures by clarifying the course of the arteries supplying the sublingual and submental regions. Heads of 75 human cadavers were dissected to identify the arterial supply of the sublingual and submental regions. Computed tomography scans were performed to visualize the lateral lingual foramina of the mandibles. The facial artery was found to contribute to the composition of almost half of the sublingual arteries studied. Furthermore, it was demonstrated that the arterial supply to an incisor tooth is often from the submental artery. Our data provide important information for coping with bleeding or hematoma occurring during surgical procedures in the mandibular region.

Iatrogenic Displacement of Lower Third Molar Roots Into the Sublingual Space: Report of 6 Cases

To describe the clinical characteristics of patients who have had sublingual displacement of a mandibular third molar root, to identify potential risk factors, and to provide the clinician with information on how to prevent and treat this complication. A retrospective analysis was performed of a series of 6 patients who underwent third molar removal with accidental displacement of a root into the sublingual space. All patients were attended at the Department of Oral Surgery, Faculty of Dentistry, University of Barcelona (Spain) from 2000 through 2010. Four patients were men, and the mean age was 38.2 ± 11.3 years. In 1 case, the fragment was removed immediately after the complication, in the same surgical procedure. In 4 cases (66.7%), the displaced root remained asymptomatic (mean follow-up, 25.5 mo), and only 1 patient presented symptoms (swelling and pain in the sublingual region). A second surgical procedure using an intraoral approach was used to extract the displaced fragment in 2 patients. These 2 cases presented transitory nerve impairment of the lingual and inferior alveolar nerves, respectively. Accidental displacement of a lower third molar root into the sublingual space is an uncommon complication. When the fragments are small, surgical removal of the displaced roots seems to be unnecessary, because patients usually remain symptom free. When surgery is needed, a considerable incidence of complications should be expected.

Ludwig′s angina - An emergency: A case report with literature review

Ludwig's angina is a form of severe diffuse cellulitis that presents an acute onset and spreads rapidly, bilaterally affecting the submandibular, sublingual and submental spaces resulting in a state of emergency. Early diagnosis and immediate treatment planning could be a life-saving procedure. Here we report a case of wide spread odontogenic infection extending to the neck with elevation of the floor of the mouth obstructing the airway which resulted in breathlessness and stridor for which the patient was directed to maintain his airway by elective tracheostomy and subsequent drainage of the potentially involved spaces. Late stages of the disease should be addressed immediately and given special importance towards the maintenance of airway followed by surgical decompression under antibiotic coverage. The appropriate use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection remains the standard protocol of treatment in advanced cases of Ludwig's angina.

The lingual lymph node identified as a sentinel node on CT lymphography in a patient with cN0 squamous cell carcinoma of the tongue

We performed CT lymphography on an 81-year-old female patient with a histologically confirmed squamous cell carcinoma of the tongue with no clinical or radiological evidence of cervical lymph node involvement. The lateral lingual lymph node was identified as a sentinel node, which is the first lymph node to receive drainage from a primary tumour. CT lymphography also showed draining lymphatics passing through the sublingual space, the medial side of the submandibular gland and near the hyoid bone and connected with the middle internal jugular node. Although metastasis to the lateral lingual lymph node is known as one of the crucial events in determining survival outcome in cancer of the tongue and floor of the mouth, very few reports are available on the imaging of the lateral lingual lymph node metastasis. This is the first report regarding the lateral lingual lymph node identified as a sentinel node demonstrated on CT lymphography.

Variation in arterial supply to the floor of the mouth and assessment of relative hemorrhage risk in implant surgery

Bleeding in the floor of the mouth during implant surgery is attributed to arterial injuries in the sublingual space: clinicians may injure the submental and sublingual arteries, which originate from the facial and lingual arteries, respectively. This study aimed to clarify the three-dimensional courses of submental and sublingual arteries and their topographic relation to the mandible. During the gross anatomy course at the Faculty of Dentistry and Graduate School, Niigata University (2009-2011), we investigated the relationship between the courses of submental and sublingual arteries and their dividing patterns of the mylohyoid muscle, sublingual gland, and mandible using 27 human cadavers. The courses of submental and sublingual arteries were divided into four patterns: (1) the sublingual space was supplied by the sublingual artery (type I: 63%), (2) it was supplied by both the sublingual and submental arteries (type II: 5.6%), (3) it was supplied by the submental artery without the sublingual artery (type III: 29.6%), and (4) type III without the deep lingual artery originated from the lingual artery (type IV: 1.8%). In type II, III, and IV, the submental artery perforates the mylohyoid muscle or takes a roundabout route to travel near the surface of the mandible. The percentage occurrence of arteries traveling between the sublingual gland and mandible in type II, III, and IV (55%) is higher than that in type I (8.8%). Susceptibility of the submental artery in type II, III, and IV to injury during implant surgery is suggested.

SIG 5 Perspectives Vol. 21, No. 2, October 2011

You have accessPerspectives on Speech Science and Orofacial DisordersCE Questions1 Oct 2011SIG 5 Perspectives Vol. 21, No. 2, October 2011Earn 0.1 CEUs on This Issue James M. Hillenbrand James M. Hillenbrand Google Scholar More articles by this author https://doi.org/10.1044/ssod21.2.1-ce SectionsAboutPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In Hillenbrand: Acoustic Analysis of Voice: A Tutorial 1. A challenge associated with use of the airborne acoustic signal to study vocal function is that it is quite distinct from the signal that enters the ear. it requires the use of very expensive, sophisticated laboratory equipment. it strongly emphasizes the lower frequency components of the voice signal. it not only reflects laryngeal function, but also resonant characteristics of the vocal tract. 2. A disadvantage of performing acoustic analysis on monotone sustained vowels is that analysis results do not necessarily generalize to connected speech. is that it introduces problems associated with individual variability in speaking style. stems from a lack of acoustic analysis approaches that may be used with this vocal task. is that sustained vowels are technically difficult to record. 3. Jitter or pitch perturbation is defined as an estimate of the cycle-to-cycle fluctuation in the amplitudes of adjacent pitch pulses. estimates the relative energy located in the high frequency regions of the sound spectrum. is one of many measures that reflect signal periodicity. has a single, well-defined method of calculation uniformly implemented within the professional discipline. 4. A measure that is strongly correlated with listener ratings of breathiness is Cepstral Peak Prominence (CPP). fundamental frequency. jitter. vocal intensity. 5. A challenge associated with using acoustic measures to infer underlying laryngeal pathology is that we have a very poor understanding of laryngeal pathology. audio recording equipment does not currently have the fidelity to accurately record pathological voice qualities. there are currently no acoustic measures that correlate with perceptual ratings of voice. different laryngeal pathologies can exhibit similar acoustic features such as turbulent noise. Callahan Mandulak: “I Can See What You're Saying”: Clinical Utility of Spectral Moment Analysis 6. Spectral moment analysis can distinguish between [s] and [f] due to the degree of categorical distinction between sibilant and nonsibilant fricatives. the distinctive spectral shapes of sibilant fricatives versus nonsibilant fricatives. the difference in appearance of sibilant and nonsibilant fricatives on a spectrogram. the relationship between auditory-perceptual analysis of sibilant versus nonsibilant fricatives. 7. The consonant [s] has higher frequency noise energy compared to [ʃ] because periodic sound waves contain higher frequency noise compared to aperiodic noise. articulation of [s] requires a sublingual space to be created for resonance of aperiodic noise. [ʃ] is produced posterior to [s], reflecting distinct articulatory configurations and therefore differing acoustic output. increased airflow for [s] production increases the frequency of noise contained in the fricative. 8. A time-history plot displaying fricative production allows for inspection of qualitative details regarding individual speaker's speech sound patterns, including duration or degree of distinction. comparison of group data for the purposes of determining statistically significant differences. documentation of speech outcomes from a quantitative standpoint. objective computation of fricative duration. 9. It is important to inspect data such as range of performance for an individual speaker's speech production skills in addition to group data because individual speakers often behave differently than the group average. it is not important to investigate the range of normal performance. adult speakers all produce the fricatives [s] and [ʃ] with similar dynamic patterns. individual speaker data is not as important as group data. 10. Which of the following statements is true about spectral moment analysis and children with repaired cleft palate? Spectral moment analysis would not be useful to measure pre- and post-intervention progress on specific obstruent consonant targets. Children with repaired cleft palate have velopharyngeal dysfunction and hypernasal resonance, which can be objectively measured with spectral moment analysis. The turbulence produced by fricative consonants is not typically distorted in children with repaired cleft palate, and therefore spectral moment analysis would not be adequately utilized for speech assessment. Spectral moment analysis provides an objective measure of articulation skill. Additional Resources FiguresReferencesRelatedDetails Volume 21Issue 2October 2011Pages: C1-C2 History Published in issue: Oct 1, 2011 Get Permissions Add to your Mendeley library Metrics Topicsasha-topicsasha-sigsasha-article-typesCopyright & Permissions© 2011 American Speech-Language-Hearing AssociationPDF downloadLoading ...

Imaging the Floor of the Mouth and the Sublingual Space

A wide range of pathologic processes may involve the floor of the mouth, the part of the oral cavity that is located beneath the tongue. They include lesions that arise uniquely in this location (eg, ranula, submandibular duct obstruction) as well as various malignancies, inflammatory processes, and vascular abnormalities that may also occur elsewhere in the head and neck. Some lesions that arise in superficial tissues such as the mucosa may be easily diagnosed at physical examination. However, computed tomography, magnetic resonance imaging, or ultrasonography may be necessary for a reliable assessment of lesion extension to deeper structures. In such cases, knowledge of the complex muscular, vascular, glandular, ductal, and neural anatomy of the region is important for accurate diagnosis and treatment planning. Familiarity with the radiologic imaging appearances of the floor of the mouth and recognition of anatomic landmarks such as the mylohyoid and hyoglossus muscles are especially useful for localizing disease within this region.

Pathology Quiz Case 1

A 10-YEAR-OLD GIRL PRESENTED WITH A 4-month history of a large oropharyngeal mass and a left-side upper neck mass that remained stable in size since its discovery. The patient complained of dysphagia without significant weight loss but denied dyspnea, dysphonia, or otalgia. The patient was otherwise healthy, up-to-date on immunizations, and had no prior tobacco exposure. On examination, a well-mucosalized, nonfluctuant, firm mass was palpable on the left side of the base of the tongue, causing leftward deviation of the tongue. There was also a palpable level II neck mass that was contiguous on bimanual palpation intraorally with no other cervical lymphadenopathy. Computed tomography (CT) of the neck revealed a nonenhancing, well-circumscribed, solid 4.3 2.73-cm mass in the region of the sublingual space and tongue base, displacing the sublingual and submandibular glands. The mass appeared contiguous with the tongue musculature and exhibited several dystrophic calcifications. Magnetic resonance imaging (MRI) with gadolinium was obtained to further characterize the lesion shown in Figure 1. Grossly, the mass was well circumscribed, with a thin capsule, and was firm and pale tan in color. Histopathologic findings of the specimen in hematoxylin-eosin stain are shown at both low and high magnifications (original magnification 10 and 20, respectively) in Figure2 and Figure 3, respectively. In the background, prominent thin-walled capillaries were found on CD34 staining. The collagenous cores stained positive for vimentin and negative for desmin, smooth muscle actin, S-100, CD34, anaplastic lymphoma kinase, and epithelial membrane antigen (EMA). Fluorescence in situ hybridization (FISH) using a FUS gene rearrangement probe applied to formalin-fixed, paraffin-embedded tissues is shown in Figure 4. What is your diagnosis?

Sonographic anatomy of the neck: The suprahyoid region

The suprahyoid region extends from the base of the skull to the hyoid bone and includes the pharyngeal, parapharyngeal, parotid, carotid, masticator, retropharyngeal, and perivertebral spaces, as well as the oral cavity. The areas that can be explored by ultrasound include the parotid, carotid, and masticator spaces; the oral cavity; the submandibular and sublingual spaces; the floor of the mouth; and the root of the tongue. The parotid space contains the parotid gland and the excretory duct of Steno, the facial nerve, the external carotid artery, the retromandibular vein, and the intraparotid lymph nodes. The carotid space in the suprahyoid region of the neck contains the internal carotid artery, the internal jugular vein, cranial nerves IX to XII, and the sympathetic plexus. Only some parts of the masticator space can be explored sonographically: these include the masseter muscle, the zygomatic arch and the outer cortex of the ramus of the mandible, and the suprazygomatic portion of the temporalis muscle. The submandibular space houses the submandibular gland, the submental and submandibular lymph nodes, and the anterior belly of digastric muscle. The facial artery and vein and the lower loop of the hypoglossal nerve all pass through the submandibular space. The sublingual space includes the sublingual gland, the deep portion of the submandibular gland and its main excretory duct, the hypoglossal nerve (cranial nerve XII), the lingual nerve (branch of the mandibular branch of trigeminal), and the glossopharyngeal nerve (IX cranial nerve), and the lingual artery and vein. The mylohyoid muscle forms the floor of the mouth. The deepest portion of the oral tongue, the root, consists of the genioglossus and geniohyoid muscles and includes the septum of the tongue. In this article we present the ultrasound features of the structures located in the suprahyoid region of the neck.

Huge Plunging Ranula

Ranula is a form of mucocele which specifically occurs in the floor of the mouth in association with the ducts of the submaxillary or sublingual gland. The term Ranula is derived from the Latin word Rana which means ‘Belly of frog’, because the lesions in the floor of the mouth resemble the bulging underbelly of a frog. The formation of ranula is thought to be due to the excretory duct rupture followed by extravasation and accumulation of saliva into the surrounding tissue. The accumulation of mucous in the surrounding connective tissue forms a pseudocyst that lacks an epithelial lining. Ranulas have classically been divided into simple and diving/plunging/cervical. Simple ranulas remain confined to the sublingual space, whereas diving ranulas extend beyond it [1]. Plunging ranula though rare are well documented causes of neck swelling. It is accepted that they arise as a result of extravasation of saliva from the sublingual gland through a hiatus in the mylohyoid muscle. If the only presentation is a cervical swelling, diagnosis can be difficult and advanced diagnostic technique like CT plays an important role in diagnosis.

First Report of Accidental Displacement of Mandibular Third Molar Into Infratemporal Space

One of the most common procedures in the dental office is surgical removal of the maxillary or mandibular third molars. 1 Yaclin S. Akta I. Atalay B. Accidental displacement of a high-speed hand piece bur during mandibular third molar surgery: A case report. Oral Med Oral Pathol Oral Radiol J Endod. 2008; 105: E29 Google Scholar Of the complications associated with third molar extraction, the most commonly mentioned have been dysesthesia, alveolar osteitis, infection, hemorrhage, fracture of the mandible, and damage to the adjacent teeth. Accidental displacement of the fractured roots or teeth into the submandibular, pterygomandibular, and sublingual spaces is a less common complication. 2 Tumuluri V. Punnia-Moorty A. Displacement of a mandibular third molar root fragment into the pterygomandibular space. Austra Dent J. 2002; 47: 68 Crossref PubMed Scopus (26) Google Scholar , 3 Sverzut C.E. Trivellato A.E. Defigueiredolopes L.M. et al. Accidental displacement of impacted maxillary third molar: A case report. Braz Dent J. 2005; 16: 167 Crossref PubMed Scopus (23) Google Scholar One of the very rare occurrences during mandibular third molar extraction is displacement of the tooth into the infratemporal space, such as reported in the present study. A review of the published data revealed little information on the incidence, cause, and management of displaced tooth and root fragments. 2 Tumuluri V. Punnia-Moorty A. Displacement of a mandibular third molar root fragment into the pterygomandibular space. Austra Dent J. 2002; 47: 68 Crossref PubMed Scopus (26) Google Scholar

Unrecognised displacement of mandibular molar root into the submandibular space

We describe a case of swelling in the right submandibular and sublingual space caused by displacement of a lower second molar root in the submandibular space. This displacement was not recognised at the time of extraction. The techniques used to minimise the risk of accidental displacement of teeth and roots, during extraction are discussed. The importance of recognising this complication and methods of retrieval are highlighted.

A Unique Case of a Sublingual-Space Schwannoma Arising from the Mylohyoid Nerve

We describe a unique case of a sublingual-space schwannoma presenting as a painless, 3 x 2-cm enlarging mass in the oral cavity of a 63-year-old man. Computed tomography demonstrated a distinct, well-encapsulated mass in the right side of the floor of the mouth. Findings on fine-needle aspiration cytology were consistent with a pleomorphic adenoma. Transoral excision was performed. Intraoperatively, the mass appeared to involve the nerve to the mylohyoid muscle. Upon removal, the gross tumor measured 4.4 x 3.5 x 2.5 cm. On microscopic examination, the spindle-cell neoplasm was found to be consistent with a schwannoma. Schwannomas of the sublingual space are exceedingly rare. Moreover, to the best of our knowledge, this case represents the first published occurrence of a schwannoma that arose from the mylohyoid nerve.

Ludwig’s angina

Patients with Ludwig’s angina require urgent evaluation for airway obstruction due to elevation and posterior displacement of the tongue. Emergency physicians should remember that risks of laryngospasm preclude blind oral or nasotracheal intubation. A 54-year-old female presented to the emergency department (ED) with right-sided facial pain, subjective fever, and chills for 1 week. Physical examination revealed right-sided facial swelling, trismus, tongue elevation (Fig. 1), submandibular and sublingual swelling, and tenderness with adenopathy. Computed tomography (CT) findings were (Fig. 2) consistent with Ludwig’s angina. The patient was treated with dexamethasone and clindamycin, and taken for surgical decompression and tooth extraction then discharged home. Pathological analysis showed polymicrobial flora including Staphylococcus aureus, Eikenella corrodens, Clostridium clostridiforme, and Prevotella buccae. Fig. 1 Clinical appearance Fig. 2 Computed tomography findings Ludwig’s angina, a rapidly progressive cellulitis of the floor of the mouth, involves the submandibular, submaxillary, and sublingual spaces. Patients have swelling, pain, and elevation of the tongue, malaise, fever, neck swelling, and dysphagia. The submandibular area can be indurated, sometimes with palpable crepitus. Inability to swallow saliva and stridor raise concern because of imminent airway compromise. The most feared complication is airway obstruction due to elevation and posterior displacement of the tongue. The mortality rate for Ludwig’s angina is currently below 8% down from the preantibiotic numbers over 50% [1]. Nasal fiberoptic evaluation should be performed with imminent airway obstruction. Securing the airway by blind oral or nasotracheal intubation is contraindicated because of the risk of laryngospasm. Diagnostic sensitivity of clinical examination alone is 55%. In less urgent cases, contrast-enhanced CT may increase this to 95% [2]. Immunocompetent patients should receive ampicillin-sulbactam, with clindamycin reserved for penicillin-allergic patients. Immunocompromised patients require empiric broad-spectrum antibiotics. Any source of infection should be removed. Needle drainage can be performed to reduce the risk of spreading infection [3].