LUDWIG'S ANGINA is an inflammation 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 formation, the floor of the mouth becomes indurated and the tongue is forced upward and backward, causing airway obstruction. Ludwig's angina does not necessarily mature to form an abscess, it is more likely to produce a cellulitis or a phlegmon. It is typically bilateral and presents with drooling, trismus, pain, dysphagia, submandibular swelling airway obstruction caused by displacement of the tongue. The tongue may protrude outside the mouth. This is a life-threatening condition that requires tracheotomy. Before antibiotics, the mortality rate of Ludwig's angina was 50%. With modern antimicrobial and surgical therapies, the mortality rate is less than 5%.
This patient developed acute upper respiratory obstruction. The swelling became so severe that the tongue protruded outside the mouth. A tracheotomy was performed to provide an airway. After resolution of the infection, a large stone was found in the submandibular gland duct (Wharton's duct). The radio-opacity in the occlusal film on the left represents the stone that was removed (see picture below)
Ludwig's Angina requiring a tracheotomy and drainage.
Click picture to enlarge.
Small calculi are usually removed in the office using topical anesthesia. The duct is incised over the calculus which is then extracted. Calculi that are in the substance of the gland require resection of the gland through an external incision.
If for some reason an occlusal film is impractical or unavailable, a CT scan would show the calculus as in the picture above.