Submandibular space infection: a potentially lethal infection

OBJECTIVES: The aims of this study were to review the clinical characteristics and management of submandibular space infections and to identify the predisposing factors of life-threatening complications. DESIGN AND METHODS: This was a retrospective study at a tertiary academic center. We retrieved and evaluated the records of all patients admitted to the University of Padua Otolaryngology Clinic at Treviso Regional Hospital with the diagnosis of submandibular space infection for the period 1998-2006. The following variables were reviewed: demographic data, pathogenesis, clinical presentation, associated systemic diseases, bacteriology, imaging studies, medical and surgical treatment, and complications. A multivariate logistic regression analysis was undertaken using a forward stepwise technique. RESULTS: Multivariate analysis identified four risk factors for complications. Anterior visceral space involvement (odds ratio (OR) 54.44; 95% confidence interval (CI) 5.80-511.22) and diabetes mellitus (OR 17.46; 95% CI 2.10-145.29) were the most important predictive factors in the model. Logistic regression analysis also confirmed other comorbidities (OR 11.66; 95% CI 1.35-100.10) and bilateral submandibular swelling (OR 10.67; 95% CI 2.73-41.75) as independent predictors for life-threatening complications. CONCLUSIONS: Airway obstruction and spread of the infection to the mediastinum are the most troublesome complications of submandibular space infections. Therefore, the maintenance of a secure airway is paramount. Patients with cellulitis and small abscesses can respond to antibiotics alone. Surgical drainage should be performed in patients with larger abscesses, Ludwig's angina, anterior visceral space involvement, and in those who do not respond to antibiotic treatment. Moreover, the clinical assessment in patients with comorbidities, especially diabetes mellitus, requires a high level of suspicion for potential life-threatening complications. Early surgical drainage should always be considered in these patients, even in seemingly less critical cases.