A 47-year-old man presented to our emergency department because of progressive swelling of the upper midline neck and dysphagia. Physical examination disclosed bilateral submandibular swelling and protrusion of the tongue. A lateral neck plain radiograph showed swelling of the submandibular region and the presence of free air (fig 1A, arrow). A subsequent contrast-enhanced CT scan showed soft tissue emphysema, fluid collection (asterisk) and fatty stranding of the mouth floor, submandibular gland, left masticator space and submandibular space (fig 1B). He was treated with surgical drainage and empirical antibiotic coverage consisting of ampicillin plus sulbactum and made an uneventful recovery.

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Figure 1 (A) Lateral neck plain radiograph showing swelling of the submandibular region and the presence of free air (arrow). (B) Contrast-enhanced CT scan showing soft tissue emphysema, fluid collection (asterisk) and fatty stranding of the mouth floor, submandibular gland, left masticator space and submandibular space.

Ludwig’s angina is an odontogenic infection of the submandibular and sublingual space. Dental disease is the most common cause of Ludwig’s angina. Treatments consist of airway safety, antibiotic treatment and surgical drainage. Metabolic control and fluid replacement are also important adjuncts. Fibreoptic nasotracheal intubation is the preferred method for airway control.