Bilateral submandibular swelling with raised tongue and airway threat

§Chief complaint

Rapidly increasing neck swelling, drooling and difficulty breathing for 24 hours

§Medical & dental history

• 01Type 2 diabetes on metformin
• 02Neglected dentition
• 03Grossly carious 37 and 38 with pain for 2 weeks

§Clinical examination

• 01Brawny, board-like bilateral submandibular and submental swelling, non-fluctuant
• 02Raised, protruded tongue; floor of mouth elevated; drooling and muffled voice
• 03Trismus 15 mm, temperature 39.1 C, pulse 118, respiratory rate 26, SpO2 94%
• 04Stridor on exertion — imminent airway obstruction

§ 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 with impending airway obstruction

A rapidly spreading bilateral cellulitis of the submandibular, sublingual and submental spaces producing a board-like swelling with tongue elevation and voice change is Ludwig's angina — a clinical, airway-first diagnosis that must not wait for imaging.

§Investigations

• 01Immediate airway assessment — do not delay for imaging
• 02Bloods: FBC, CRP, glucose, blood cultures, blood gas
• 03Contrast CT neck and chest once the airway is secure, to detect collections and mediastinal extension

§Radiology

• 01CT neck — diffuse cellulitis of bilateral submandibular and sublingual spaces with small locules of gas, airway narrowed to 4 mm
• 02CT chest — no mediastinal extension

§Treatment plan

• 01Secure the airway first — awake fibreoptic intubation or tracheostomy
• 02Intravenous high-dose broad-spectrum antibiotics covering anaerobes
• 03Urgent bilateral surgical decompression of all involved spaces
• 04Extraction of the causative teeth; intensive care monitoring and glycaemic control

§Surgical procedure

• 01Elective awake tracheostomy under local anaesthesia
• 02Bilateral submandibular and submental incisions, blunt dissection through mylohyoid into the sublingual spaces, drains placed in all compartments
• 03Extraction of 37 and 38

§Follow-up & outcome

• 01Day 3 — swelling reducing, drains removed sequentially, CRP falling
• 02Day 7 — decannulated after a successful cuff-down trial
• 03Day 14 — discharged; dental rehabilitation planned

Outcome: Survived without mediastinal spread; full recovery with a planned dental clearance and diabetes optimisation.

§Discussion

• 01Ludwig's angina is a cellulitis, not an abscess, so early decompression is undertaken even when no discrete collection is seen.
• 02Mortality was over 50% before antibiotics and airway control; today it is under 10% with prompt management.
• 03Descending necrotising mediastinitis is the feared complication — image the chest.

§Clinical pearls / learning points

• 01Airway, airway, airway — then antibiotics, then surgery.
• 02Board-like bilateral swelling with a raised tongue is the diagnostic triad.

§Viva questions

§MCQs

§Related diseases

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