A 43-year-old man presented to the emergency department with complaints of dysphagia and fever. He has felt ill and unable to eat for 2 days. He has a history of type 2 diabetes and reports frequent alcohol use. On examination, he is noted to have poor dentition and is drooling. The floor of the mouth is firm, and the submandibular glands are enlarged and tender. Laboratory testing reveals a leukocytosis to 20,000. He is treated with ampicillin-sulbactam and clindamycin and admitted to the ICU. Over the next 4 hours, he complains of increasing tongue swelling and shortness of breath.
Which of the following is the more appropriate next step in management?
A. Proceed to the OR for intubation or tracheostomyCorrect Answer: A
This patient presents with an infection of the submandibular space (Ludwig angina). This acute condition can progress to critical airway compromise, making intubation extremely difficult. This bacterial infection often occurs after a tooth abscess but can also follow other mouth infections or injuries. It is more common in patients with diabetes and neutropenia. Common presenting signs and symptoms include dysphagia, mouth pain, drooling, and fever. The submandibular tissues are classically described as “woody,” not fluctuant, often without any true drainable collection. Typical pathogens include mouth anaerobes (Fusobacterium), streptococci, or Staphylococcus aureus, and initial antibiotics should broadly target all of these organisms, including MRSA. If untreated, the infection can progress with necrosis of the tongue, aspiration, and death from airway obstruction. If the airway becomes compromised, a surgical airway (tracheotomy or cricothyroidotomy) is typically recommended as first line for airway management. Direct laryngoscopy may be exceedingly difficult and attempting it in a resource-limited environment such as the ICU may lead to further complications. Bronchodilators are unlikely to relieve the airway obstruction. While drainage may be indicated, this patient is acutely decompensating, and the airway should be secured before attempting further procedures.
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