Cervico-Fascial Infections &
Ludwig’s Angina
The head and neck (cervical) region has a large number of fascial spaces.  These
spaces’ are bounded by the fascia, which may stretch or be perforated by the
purulent exudates (pus), facilitating the spread of infection.  These ‘spaces’ are
potential areas and do not exist in healthy individuals.  There are a number of them
including the:

Infections in the buccal space and buccinator space are usually localised on the
lateral side of the mandible.

Sub-masseteric infections occupy the potential space between the lateral border of
mandible and the masseter muscle.  This is not a fascial-lined space; infection
in this area is in direct contact with the
masseter muscle and usually induces
intense spasm in the muscle, resulting in a profound limitation in mouth opening

Internal pterygoid space infections occupy the fascia-lined space between the
internal pterygoid muscle and the medial aspect of the mandible.  Infections in this
area cause a less profound
trismus but can result in airway embarrassment.  They
can also result from
Inferior Alveolar Nerve block.

sub-mandibular space consists of a splitting of the investing fascia of the neck
to enclose the
submandibular salivary gland and is in continuity with the internal
and para-pharyngeal spaces.  Infections in this region can cause airway
embarrassment and, when bilateral with associated
cellulitis, is termed Ludwigs
.  This is very serious and potentially life-threatening.

Infections occur between the
pharyngeal mucosa and superior constrictor muscle.  
Infections in this region are also potentially life-threatening and require urgent

Fascial Space Infections - key features

•        Potentially life-threatening infections due to spread of bacteria into peri-oral
fascial spaces
•        Infection usually arises from lower second or third molars (wisdom teeth).
•        Affected tissues are swollen and of 'board-like' hardness
•        Severe systemic upset
Glottic œdema (swelling) or spread into the mediastinum may be fatal

The main principles of treatment remain surgical with (
dependent) drainage of pus
augmented by
antibiotic therapy.  The infective organisms are normal oral flora and
penicillin family of antibiotics remains the antibiotics of first choice.

With the increasing recognition of the role of
anærobic oral bacteria in these
clindamycin can be substituted for penicillin in severe infections or
metronidazole added to the penicillin.  Studies show an average of four bacterial
species in any oral infection with
anærobic species outnumbering ærobic species,
streptococci remain the largest single group of organisms.
Ludwig's Angina

Ludwig's Angina is a severe form of cervico-fascial infection / cellulitis which
usually arises from the lower second or third
molars (wisdom teeth).

Deep fascial space infections cause gross inflammatory exudates (a fluid with a
high content of protein and cellular debris which has escaped from blood vessels
and has been deposited in tissues or on tissue surfaces, usually as a result of
inflammation. It may be septic or non-septic) and
tissue œdema (swelling),
associated with fever and
toxæmia (blood poisoning).  Before the advent of
antibiotics, the mortality was high and the disease is still life-threatening if
treatment is delayed.
Photos of varying severities of Ludwig's Angina
The main fascial spaces involved in Ludwig’s Angina are the sublingual,
submandibular and para-pharyngeal.  Normally, the spaces both side of the
midline (ie
bilateral) are effected.

The characteristic features are:

•        diffuse swelling, pain, fever and malaise.
•        The swelling is tense and tender, with a characteristic ‘
board-like’ firmness.
•        The overlying skin is taut and shiny.
•        Pain and
œdema (swelling) that limit opening the mouth and often cause
dysphagia (difficulties in swallowing)
•        Systemic upset is severe, with worsening fever,
toxæmia (blood poisoning)
•        The regional lymph nodes are swollen and tender.
•        In
Ludwig's Angina particularly, airway obstruction can quickly result in


Anærobic bacteria are primarily responsible and infection mainly spreads from
mandibular third molars (lower jaw wisdom teeth) whose apices (root tips) are
closely related to several fascial spaces.  Fasciæ, covering muscles and other
structures are normally adherent but can be spread apart by inflammatory

Spaces created in this way are almost
avascular (do not have a blood supply) and
exudate carries bacteria widely through them. It involves the sub-
lingual and sub-mandibular spaces bilaterally (on both sides) almost
simultaneously; it readily spreads into the
lateral pharyngeal and pterygoid spaces  
and can extend into the
mediastinum. The main features are rapidly spreading sub-
and sub-maxillary cellulitis with painful, brawny swelling of the upper part
of the neck and the floor of the mouth on both sides.  With involvement of the
pharyngeal space
, the swelling tracks down the neck and œdema can quickly
spread to the

Swallowing and opening the mouth become difficult and the tongue may be pushed
up against the
soft palate.  The latter or œdema of the glottis causes worsening
respiratory obstruction. The patient soon becomes desperately ill, with fever,
respiratory distress, headache and malaise.


The main requirements are:

•        immediate admission to hospital
•        procurement of a sample for culture and sensitivity testing
•        aggressive antibiotic treatment
•        securement of the airway by
tracheostomy if necessary, and
•        drainage of the swelling to reduce pressure.

Useful Articles:

British Dental Journal 2009.  Cervicofacial infection of dental origin presenting to
Maxillofacial units in the UK - A national audit.
Last Updated 4th November 2010
Cervico-Fascial Space Infections / Cervico-Facial Cellulitis /
Peri-Mandibular Infections

Due to the strategic position of the wisdom tooth (3rd molar) at the junction of a
number of different
fascial spaces, any infection in this area must be taken
seriously as an infection here can easily spread along the
fascial planes and
compromise the airway.