What is the management for a patient with a tender fluctuant mass in the submandibular area, fever, and recent onset of symptoms potentially related to new ill-fitting dentures, to rule out Ludwig’s angina?

Management of Suspected Ludwig's Angina

This patient requires immediate airway assessment and protection, broad-spectrum intravenous antibiotics, and urgent surgical consultation for drainage, as Ludwig's angina is a life-threatening emergency with potential for rapid airway compromise.

Immediate Priorities

Airway Assessment and Protection

• Assess for signs of impending airway obstruction: stridor, dyspnea, inability to lie flat, drooling, trismus (late finding), and tongue elevation with sublingual edema 1, 2
• The "woody" or indurated floor of mouth with bilateral submandibular swelling is characteristic and indicates advanced disease 1
• Emergent consultation to anesthesia and otolaryngology is mandatory if any signs of airway compromise are present 1
• Flexible intubating endoscopy is the first-line approach for definitive airway if needed, with preparation for emergent surgical airway (tracheostomy) 1, 2
• Do not force the patient to lie supine if they cannot tolerate it, as this can precipitate acute airway obstruction 1

Immediate Medical Management

• Start broad-spectrum intravenous antibiotics immediately covering gram-negative anaerobes, streptococci, and staphylococci 3, 4, 1
• The infection spreads rapidly through fascial planes involving submandibular, sublingual, and submental spaces bilaterally 3, 4
• Remove the ill-fitting dentures immediately and examine the oral cavity for dental source of infection 5

Diagnostic Workup

Physical Examination Specifics

• Examine for bilateral cervical swelling, neck tenderness, elevation and posterior displacement of the tongue, restricted neck movement, and pooling of oral secretions 2
• Palpate for "woody" induration of the floor of mouth—this is pathognomonic 1
• Check for crepitus, which indicates gas-forming organisms and more severe infection 4
• Assess ability to handle secretions and presence of drooling 2

Imaging

• CT scan of neck soft tissue with IV contrast is the preferred imaging modality to determine extent of infection and identify drainable collections 1, 6
• However, only obtain CT if the patient can safely leave the ED and tolerate lying supine 1
• Point-of-care ultrasound can be useful adjunct, particularly in unstable patients who cannot lie flat 1
• Imaging should not delay antibiotic administration or airway management 1

Definitive Treatment

Surgical Intervention

• Surgical drainage of the infection source is mandatory in conjunction with antibiotics 3, 4, 1
• Early surgical decompression under antibiotic coverage is the standard protocol for advanced cases 3
• The American Academy of Pediatrics notes that Ludwig's angina requires systemic antibiotics AND surgical drainage of abscesses 5, 7

Disposition

• All patients must be admitted to the intensive care unit for close airway observation, even after initial stabilization 1
• The potential for rapid respiratory obstruction remains the greatest concern throughout the clinical course 4

Critical Pitfalls to Avoid

• Do not delay treatment for imaging if airway compromise is suspected 1
• Do not underestimate the speed of progression—this infection spreads rapidly and can cause death within hours 3, 4
• Trismus is a late finding, not an early one; its absence does not rule out severe disease 1
• Be aware of serious complications including sepsis, mediastinitis, pleural empyema, pericarditis, and pericardial tamponade 4
• The odontogenic source (dental infection) is the most common etiology, often related to poor dentition or recent dental trauma 1, 2