Series Editor: Herbert l. Fred, MD

Prepared by Ricardo Santayana, Jr, medical student, and Charlotte Derr, MD, FACEP, Attending Physician and Assistant Director, Residency Program, Division of Emergency Medicine, University of South Florida, Tampa

A 58-year-old woman presented with a 4-day history of progressive swelling of her neck and face (Figure), along with fever and pain on swallowing and speaking. She denied difficulty breathing, dental pain, or recent dental procedures. Physical examination showed her to be in no distress, with normal vital signs. She had trismus, as well as submandibular and sublingual erythema with induration. Laboratory studies showed neutrophilic leukocytosis. She soon had signs of respiratory distress and was admitted to the intensive care unit, where she was intubated and received intravenous (IV) antibiotics and surgical debridement of the affected tissues. After 10 days in the hospital, she had totally recovered and was sent home.

Points to remember: Ludwig’s angina is a rapidly spreading cellulitis involving the sublingual and submandibular spaces, with a life-threatening risk of airway obstruction. Most cases result from dental infections originating in the second or third mandibular molars. Mortality in patients treated with IV antibiotics and expectant airway management is less than 5%. A computed tomography scan of the neck can help determine the extent of infection. Surgical intervention may become necessary if an abscess forms, or if the response to medical treatment is poor.

Diagnosis: Ludwig’s angina.