Importance of early recognition and intervention in Ludwig's angina by emergency medicine physicians to prevent life-threatening complications.

Abstract

Background: Ludwig's angina is a life-threatening cellulitis that can easily progress to airway compromise. Significant infection, often from periodontal abscesses of the molar teeth, may cause superior and posterior displacement of the tongue compromising patient's airways if not identified and treated promptly. Early recognition and clinical diagnosis, with or without imaging and blood cultures, and antibiotic treatment can help prevent rapid airway compromise, systemic infection and Le Mierre's disease (a rare life-threatening complication). Given that emergency departments are often the first point of contact, maintaining a high index of suspicion and acting decisively can significantly improve patient outcomes.

Case presentation: We report a case of a 79-year-old male presenting with a swollen neck progressing over the course of 24 h. This gentleman presented to our emergency department with a superior and inferior swelling to the mandible, a change in voice, and displacement of his tongue. Clinical examination showed a trismus of 1.5 cm, a superiorly and posteriorly displaced tongue, and a tender dental abscess of the lower molars. From examination a clinical diagnosis of Ludwig's angina was made, later confirmed on CT head and neck. A suspicious incidental finding of an internal jugular embolus on the background of dental infection was also suspicious for an early presentation of Le Mierre's disease. Intravenous antibiotics were promptly started. Intensive care team was contacted to support the patient's airway and facilitate transfer to our intensive care unit (ICU). Maxillofacial team was also notified and following antibiotics and tooth/abscess removal the patient made a full recovery and has no repeat presentation since.

Conclusion: This case highlighted and emphasised the importance of early recognition of neck swelling by emergency physicians to prevent progression of airway compromise and Le Mierre`s disease. Assessing emergency doctors must be able to identify, diagnose, treat and escalate Ludwig's angina secondary to periodontal abscesses prior airway compromise or systemic infection.