Ludwig’s Angina Complicated by a Massive Bilateral Deep Neck Abscess in a 26-Month-Old Boy: Multidisciplinary Airway and Surgical Management
4 affiliations
- 1Pediatric Emergency Medicine, Al Jalila Children's Speciality Hospital, Dubai, ARE
- 2Ear, Nose, and Throat, Al Jalila Children's Speciality Hospital, Dubai, ARE
- 3Pediatric Emergency Medicine, Dubai Medical University, Dubai, ARE
- 4Otolaryngology - Head and Neck Surgery, Mohammed Bin Rashid University, Dubai, ARE
Abstract
Ludwig’s angina is a rapidly progressive deep neck infection affecting the submandibular, sublingual, and submental regions. Although uncommon in children, it can be life-threatening due to sudden airway compromise. Early diagnosis, multidisciplinary airway planning, broad-spectrum antibiotic therapy, and timely surgical source control are essential in pediatric cases.
We report a previously healthy, unimmunized 26-month-old boy who presented with acute fever, rapidly progressive bilateral submandibular and submental neck swelling, poor feeding, vomiting, diarrhea, lethargy, inability to lie flat, and restricted neck movement. No drooling or stridor was present at presentation. Examination revealed massive fluctuant swelling throughout the submandibular and submental regions. Initial ultrasound demonstrated an extensive echogenic collection measuring approximately 15 × 4 cm, extending from the left submandibular region across the submental space to the right submandibular region. Contrast-enhanced CT demonstrated a large bilateral submandibular and submental abscess extending into the sublingual space and floor of the mouth, with mild airway mass effect but no intracranial extension. Due to the high risk of airway compromise, elective intubation was performed in the PICU before CT imaging and surgery. Urgent incision and drainage of the extensive bilateral submandibular, submental, and sublingual deep neck abscess was performed, yielding approximately 150 mL of purulent material, and a Penrose drain was placed. Two wound cultures grew methicillin-sensitive Staphylococcus aureus, and antimicrobial therapy was subsequently narrowed to flucloxacillin based on susceptibility results. After successful extubation, weaning to room air, and tolerating oral intake, the patient was discharged in stable condition to complete a 14-day course of antibiotic therapy.
This case highlights that pediatric Ludwig’s angina can progress rapidly and pose a significant airway risk even without drooling or stridor. Early multidisciplinary involvement, controlled airway management, cross-sectional imaging, prompt surgical drainage, and culture-directed antimicrobial therapy are crucial for a favorable outcome. A high index of suspicion and early airway planning are particularly important in children with rapidly progressive deep neck infections.
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BibTeX
@article{ismail2026ludwigs,
title = {{Ludwig’s Angina Complicated by a Massive Bilateral Deep Neck Abscess in a 26-Month-Old Boy: Multidisciplinary Airway and Surgical Management}},
author = {Razan Ismail and Khadejah Jamal and Rehaam Fathima and Safeena Kherani},
journal = {Cureus},
year = {2026},
month = sep,
doi = {10.7759/cureus.117232},
url = {https://europepmc.org/article/PMC/PMC13722086},
note = {CC BY},
}
RIS
TY - JOUR
TI - Ludwig’s Angina Complicated by a Massive Bilateral Deep Neck Abscess in a 26-Month-Old Boy: Multidisciplinary Airway and Surgical Management
AU - Razan Ismail
AU - Khadejah Jamal
AU - Rehaam Fathima
AU - Safeena Kherani
PY - 2026
DA - 2026/09/30
JO - Cureus
DO - 10.7759/cureus.117232
UR - https://europepmc.org/article/PMC/PMC13722086
AB - Ludwig’s angina is a rapidly progressive deep neck infection affecting the submandibular, sublingual, and submental regions. Although uncommon in children, it can be life-threatening due to sudden airway compromise. Early diagnosis, multidisciplinary airway planning, broad-spectrum antibiotic therapy, and timely surgical source control are essential in pediatric cases. We report a previously healthy, unimmunized 26-month-old boy who presented with acute fever, rapidly progressive bilateral submandibular and submental neck swelling, poor feeding, vomiting, diarrhea, lethargy, inability to lie flat, and restricted neck movement. No drooling or stridor was present at presentation. Examination revealed massive fluctuant swelling throughout the submandibular and submental regions. Initial ultrasound demonstrated an extensive echogenic collection measuring approximately 15 × 4 cm, extending from the left submandibular region across the submental space to the right submandibular region. Contrast-enhanced CT demonstrated a large bilateral submandibular and submental abscess extending into the sublingual space and floor of the mouth, with mild airway mass effect but no intracranial extension. Due to the high risk of airway compromise, elective intubation was performed in the PICU before CT imaging and surgery. Urgent incision and drainage of the extensive bilateral submandibular, submental, and sublingual deep neck abscess was performed, yielding approximately 150 mL of purulent material, and a Penrose drain was placed. Two wound cultures grew methicillin-sensitive Staphylococcus aureus, and antimicrobial therapy was subsequently narrowed to flucloxacillin based on susceptibility results. After successful extubation, weaning to room air, and tolerating oral intake, the patient was discharged in stable condition to complete a 14-day course of antibiotic therapy. This case highlights that pediatric Ludwig’s angina can progress rapidly and pose a significant airway risk even without drooling or stridor. Early multidisciplinary involvement, controlled airway management, cross-sectional imaging, prompt surgical drainage, and culture-directed antimicrobial therapy are crucial for a favorable outcome. A high index of suspicion and early airway planning are particularly important in children with rapidly progressive deep neck infections.
SN - 2168-8184
ER -