Definition

Submandibular abscess is an infection that occurs in the tissues beneath the mouth, specifically under the tongue. An abscess forms when a collection of infected fluid or pus accumulates at a particular site in the body. In the case of submandibular abscesses, they can originate from infections in the neck area and extend into the submandibular space, affecting the mouth, neck, and jaw. These abscesses spread rapidly, infecting the soft tissues under the tongue.

The infection causes swelling beneath the tongue or in the lower jaw, resulting in the tongue being pushed upward. This swelling can lead to difficulties in breathing or airway obstruction if not promptly addressed. Patients may also experience trouble swallowing saliva due to the swelling under the tongue.

This condition is more prevalent in adults than in children, and there is no gender predisposition. Around one-third of cases are associated with other conditions such as HIV and diabetes mellitus, often linked with poor oral hygiene and health practices.

Before the advent of antibiotics, the mortality rate from submandibular abscesses exceeded 50%. However, with prompt management of the airway, antibiotic therapy, advanced imaging techniques, and surgical interventions, the mortality rate has decreased to approximately 8%. With appropriate treatment, infections can usually be fully resolved.

Causes

Submandibular abscesses are typically caused by bacterial infections, with Streptococcus and Staphylococcus bacteria being the primary offenders. These abscesses often arise from infections or injuries within the oral cavity. Infections originating from the throat, salivary glands, or submandibular lymph nodes can spread, leading to the accumulation of pus in the submandibular space.

Dental infections, particularly those affecting the back molars, are the most common cause of submandibular abscesses. Several dental conditions can contribute to their development, including:

• Poor dental hygiene: Inadequate oral care can lead to bacterial buildup and infection in the mouth, increasing the risk of abscess formation.
• Oral injuries or ulcerations: Trauma or open sores in the mouth can provide entry points for bacteria, facilitating infection and abscess formation.
• Recent tooth extraction: Extraction of teeth, particularly in the posterior regions of the mouth, can sometimes lead to submandibular abscesses, especially if proper postoperative care is not followed.

Risk Factor

You may be at increased risk of developing a submandibular abscess if you have any of the following conditions:

• Jawbone fracture
• Tongue piercing
• Jawbone infection
• Mouth injury
• Tonsillar abscess
• Salivary gland infection
• Presence of cysts or fluid-filled lumps in the thyroglossal duct, a remnant duct near the thyroid gland located in the neck area
• Poor oral hygiene

Symptoms

Symptoms of submandibular abscess include:

• Pain or tenderness at the base of the mouth, under the tongue
• Difficulty and pain when swallowing
• Excessive saliva production
• Speech impairment
• Swollen or reddened neck
• Difficulty opening the mouth
• General body weakness
• Ear pain
• Tongue swelling, causing the tongue to press against the roof of the mouth
• Fever
• Chills

In severe or untreated cases, the following complaints may arise:

• Chest pain
• Difficulty breathing or shortness of breath
• Confusion or difficulty thinking
• Severe dehydration or severe fluid deficiency

Diagnosis

Doctors can diagnose this condition by conducting a thorough interview regarding the patient's complaints and medical history, physical examination, and diagnostic tests. Diagnostic tests that can be performed include abscess fluid culture to identify the causative microbes and imaging tests. The doctor's observation of the following symptoms typically forms the basis for the diagnosis of a submandibular abscess:

• Redness and swelling on the head, neck, and tongue
• Swelling extending to the base of the mouth
• Extreme tongue swelling
• Tongue out of position

If a diagnosis cannot be made through physical examination alone, the doctor will use other examinations. Contrast-enhanced MRI or CT scans can show swelling at the base of the mouth. The doctor may also perform abscess fluid culture tests to identify the types of bacteria causing the infection.

Management

Clearing and Freeing the Airway

If swelling interferes with breathing, the first goal of treatment is to clear and free the airway. The doctor may use a breathing tube inserted through the nose or mouth into the lungs.

In some cases, the doctor may need to create a hole in the patient's neck to insert a tube into the throat. This procedure is called a tracheostomy, and it can be performed by the doctor in an emergency.

Draining the Abscess Fluid

Submandibular abscesses and serious neck infections can cause swelling and airway obstruction. Therefore, surgery may be needed to drain the abscess fluid causing swelling in the oral cavity.

Treating the Infection

Antibiotic therapy is required to treat bacterial infections. Antibiotics are administered intravenously. If the condition improves and the patient can eat or drink normally again, antibiotic treatment may be continued in the form of oral tablets. Additional treatment may also be needed if there is an infection in the teeth.

If the swelling does not improve despite antibiotic treatment, surgery may be necessary to drain the abscess fluid.

Complications

Some submandibular abscess complications are serious and life-threatening, such as:

• Sepsis, a widespread body infection that spreads through the bloodstream
• Septic shock, a decrease in oxygen supply to tissues and organs due to sepsis
• Lung infection with pus
• Suffocation, a condition of oxygen deficiency due to airway obstruction. Patients usually feel like they are choking.
• Inflammation or infection of the heart
• Blood clots in the neck vessels
• Aneurysm in large arteries near the neck. An aneurysm is a bulge in a blood vessel caused by weakening of the vessel wall. The bulge can easily rupture, causing severe bleeding and life-threatening conditions.

The above complications can even cause early death because infections can spread quickly and obstruct airflow. Prompt treatment is the best course of action to prevent the abscess from worsening.

Prevention

You can reduce the risk of submandibular abscess by:

• Maintaining oral hygiene
• Regular dental check
• Seeking proper treatment for dental and oral infections

If you plan to pierce your tongue, make sure the procedure is done by a professional using clean and sterile equipment. Consult a doctor immediately if you experience excessive bleeding or persistent swelling.

Brush your teeth twice a day and use mouthwash with antiseptic solution once a day. Do not ignore gum or tooth pain. See a dentist if there is a foul odor coming from your mouth or if there is bleeding from the tongue, gums, or teeth.

Pay close attention to any problems in your mouth area. Consult a doctor if you have immune system disorders or have recently experienced trauma to the mouth, including tongue piercing. If you have a mouth injury, be sure to see a doctor for examination.

When to See a Doctor? 

Seek medical attention immediately if you have symptoms of submandibular abscess as mentioned above. Proper diagnosis and treatment will prevent worsening symptoms and prevent life-threatening complications.

If emergency symptoms such as chest pain or shortness of breath occur, immediately call emergency services or ask someone to take you to the emergency room.