Rapidly progressive bilateral submandibular swelling with airway compromise

§Chief complaint

Severe swelling under the jaw and difficulty swallowing for 2 days

§Medical & dental history

• 01Poorly controlled type 2 diabetes
• 02No known allergies
• 03Toothache from a carious 47 for 3 weeks, self-medicated with analgesics

§Clinical examination

• 01Bilateral, board-like, tender submandibular swelling; skin tense and erythematous
• 02Raised floor of mouth, tongue elevated and pushed posteriorly
• 03Drooling, muffled 'hot potato' voice, inspiratory stridor
• 04Temperature 39.1 C, pulse 118, mouth opening 14 mm

§ figuresFigures (3)

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Ludwig's Angina figures pending faculty review.

§Differential diagnosis

§Final diagnosis

Ludwig's angina of odontogenic origin (47) with impending airway obstruction

Bilateral involvement of submandibular, sublingual and submental spaces with a board-like, non-fluctuant swelling and a raised tongue is the definition. The airway, not the abscess, is the emergency.

§Investigations

• 01Airway assessment first — flexible nasendoscopy
• 02Contrast CT neck and thorax — diffuse cellulitis, small collections, no mediastinal extension
• 03FBC, CRP, blood glucose, blood cultures, pus for culture and sensitivity

§Treatment plan

• 01Secure the airway — awake fibreoptic intubation or tracheostomy under local anaesthesia
• 02High-dose IV antibiotics covering anaerobes (co-amoxiclav plus metronidazole, or as per local policy)
• 03Urgent surgical decompression of all involved spaces
• 04Remove the source tooth in the same sitting; correct hyperglycaemia

§Surgical procedure

• 01Elective tracheostomy under local anaesthesia
• 02Bilateral submandibular and submental incisions, blunt decompression through mylohyoid into sublingual spaces
• 03Corrugated drains placed, extraction of 47

§Follow-up & outcome

• 01Decannulated day 7 after swelling resolved
• 02Antibiotics rationalised to culture (Streptococcus anginosus group, Prevotella)
• 03Discharged day 10; diabetes clinic referral

§Clinical pearls / learning points

• 01Never sedate or attempt blind oral intubation in Ludwig's angina.
• 02Absence of fluctuance does not mean absence of surgical disease — decompress the spaces.
• 03Check for descending mediastinitis with a CT that includes the thorax.

§Related diseases

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