Probable Diagnosis: Ludwig's Angina (Most Likely) with key differentials

Clinical Analysis

• Fever + chills
• Runny nose + sore throat
• Marked swelling below the left jaw (submandibular region)

What is Ludwig's Angina?

• Brawny (woody, indurated, non-fluctuant) swelling of the submandibular region
• Inflammatory oedema of the floor of the mouth
• Putrid halitosis
• Tongue elevation and posterior displacement
• NO associated lymphadenopathy (spread is direct via fascial planes, not lymphatics)
• Rosen's Emergency Medicine, p. 3714: "Ludwig's angina is a rapidly spreading, woody induration or brawny cellulitis of the sublingual, submandibular, and submaxillary spaces, with the potential for airway obstruction."

Etiology / Source of Infection

• Streptococcus viridans, Klebsiella pneumoniae (most common aerobes)
• S. aureus, S. epidermidis, S. pneumoniae, E. coli, Haemophilus influenzae
• Anaerobes: Bacteroides, Peptostreptococcus
• Bailey and Love's Surgery, p. 1116: "The infection is often caused by a virulent streptococcal infection associated with anaerobic organisms."

Pathophysiology

1. Infection tracks deep to the mylohyoid muscle
2. Spreads via fascial planes (not lymphatics) - hence bilateral involvement without nodal enlargement
3. Tongue is displaced upwards and backwards - causes dysphagia and airway obstruction
4. If untreated: cellulitis extends beneath deep fascial layers → larynx → glottic oedema → fatal airway compromise
5. Can spread to the mediastinum (descending necrotizing mediastinitis) - a life-threatening complication

Clinical Features

• Brawny, non-pitting, woody induration below the jaw (submandibular region)
• Elevation and posterior displacement of the tongue above the lower teeth
• Trismus (difficulty opening the mouth)
• Odynophagia (painful swallowing)
• Drooling (unable to swallow secretions)
• High fever, chills, rigors, malaise
• Putrid halitosis

• Stridor
• Dyspnea / respiratory distress
• Inability to manage secretions
• Patient assumes "sniffing" or erect position
• K.J. Lee's Essential Otolaryngology, p. 2235: "Erect, drooling patient, with edema of tongue and floor of mouth; woody, indurated neck."

Differential Diagnosis

Investigation / Workup

Urgent / Immediate:

Treatment - Detailed

Step 1: AIRWAY - Immediate Priority

"Airway management is the first priority" - K.J. Lee's Otolaryngology

• The single most critical step is securing the airway before it is lost
• Options:
  • Awake fiberoptic nasotracheal intubation (preferred if airway is patent but at risk)
  • Tracheostomy under local anaesthesia (if severe oedema or trismus precludes intubation)
  • Never attempt blind oral intubation - high risk of total obstruction
• ICU admission with continuous monitoring

Step 2: IV Antibiotics (Broad-spectrum with anaerobic cover)

• Add anti-MRSA cover (vancomycin) if risk factors present
• Duration: minimum 10-14 days; switch to oral when clinically improving
• Bailey and Love's Surgery, p. 1126: "Antibiotic therapy should be instituted as soon as possible using intravenous broad-spectrum antibiotics, with anaerobic cover."

Step 3: Surgical Drainage (if antibiotics fail or pus is present)

• If no rapid improvement with antibiotics, or CT shows frank abscess formation:
  • Curved submental incision - drains both submandibular triangles
  • Incision of mylohyoid muscle - decompresses the floor of the mouth
  • Corrugated rubber drains placed in the wound (lightly sutured)
  • Bilateral submandibular and sublingual space drainage
• Preferred under general anaesthesia (controlled setting) - local anaesthesia is an alternative
• Bailey and Love's Surgery, p. 1127-1131: "A curved submental incision may be used to drain both submandibular triangles. The mylohyoid muscle may be incised to decompress the floor of the mouth."

Step 4: Dental Treatment

• Identify and treat the odontogenic source (extraction of offending tooth, root canal)
• Done only after the acute infection is controlled

Step 5: Supportive Care

• IV fluids and correction of electrolyte imbalance
• Analgesics (IV paracetamol, morphine if needed)
• Nutritional support (nasogastric feeding if swallowing is impossible)
• Blood glucose monitoring and control (hyperglycemia worsens outcomes)
• Proton pump inhibitor (stress ulcer prophylaxis)
• DVT prophylaxis

Complications (if untreated or delayed)

• K.J. Lee's Otolaryngology, p. 2227: "High mortality from asphyxia" if airway not secured.

Summary: Management Algorithm

Submandibular Swelling + Fever + Sore Throat
                ↓
        ASSESS AIRWAY FIRST
                ↓
    Secure airway (intubation/tracheostomy)
                ↓
    IV broad-spectrum antibiotics + anaerobic cover
                ↓
    CT neck with contrast (assess extent)
                ↓
    Abscess / no improvement?
         Yes → Surgical drainage
         No  → Continue IV antibiotics + monitor
                ↓
    Identify and treat dental source
                ↓
    Step-down to oral antibiotics + discharge