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OMFS-0110InfectionadvancedSubmandibular and sublingual spaces

Rapidly progressive bilateral submandibular swelling with airway compromise

42-year-old male

Draft — educational study aid, pending faculty review.

§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)

Fig. 1Swelling in the submandibular area in a patient with Ludwig's angina. This made it difficult for the assessment of neck extension.

“Ludwig angina” · Anand H Kulkarni, Swarupa D Pai, Basant Bhattarai, Sumesh T Rao and M Ambareesha · CC BY 2.0 · Wikimedia Commons

Fig. 2Sexe du patient : inconnu. Âge du patient : inconnu. Année de prélèvement : 1931. Hôpital : Saint-Michel Archange. Pathologiste : inconnu.

“Macro Langue - Angine de Ludwig 55-o.apatho-260-langue” · Denis Desaulniers et Bernard Têtu · CC BY-SA 4.0 · Wikimedia Commons

Fig. 3Elevated tongue due to Ludwig's angina

“ElevatedTongueLA” · Doc James · CC BY-SA 4.0 · Wikimedia Commons

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

Ludwig's anginaBilateral submandibular + sublingual + submental cellulitis, raised tongue
Submandibular space abscessUnilateral, fluctuant, less airway threat
Necrotising fasciitisSkin crepitus, dusky discolouration, rapid systemic collapse
AngioedemaNon-tender, no fever, drug or allergic trigger

§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.

§References

  • Flynn TR. Principles of management of odontogenic infections.

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