Intended for healthcare professionals

Endgames Case Review

Impending airway obstruction after dental extractions

BMJ 2015; 351 doi: (Published 06 October 2015) Cite this as: BMJ 2015;351:h5277
  1. Kemal Tekeli, specialist registrar in oral and maxillofacial surgery1,
  2. Guven Kaya, specialist registrar in radiology2,
  3. Samuel Grant, foundation year 1 doctor3,
  4. Michael Williams, consultant in oral and maxillofacial surgery1,
  5. David Howlett, consultant in radiology2
  1. 1Department of Oral and Maxillofacial Surgery, Eastbourne District General Hospital, Eastbourne, UK
  2. 2Department of Radiology, Eastbourne District General Hospital
  3. 3Eastbourne District General Hospital
  1. Correspondence to: K Tekeli kmt{at}

A 22 year old man presented to the department of oral and maxillofacial surgery with a five day history of sore throat, pain on swallowing, and low grade fever. He was previously fit and well with no medical history of note. His lower wisdom teeth had been extracted seven days before presentation. He was a non-smoker and non-drinker.

On examination, he looked unwell with tachycardia (120 beats/min) and a temperature of 37.2ºC. He was normotensive and mildly tachypnoeic (22 breaths/min).

Oropharyngeal examination was difficult owing to marked trismus, but a raised floor of the mouth was noted. He had a tender swelling in his upper neck extending to bilateral submandibular regions and a “hot potato” voice.

Initial investigations showed a raised white cell count of 29.9×109/L (reference range 4.5-11) and a C reactive protein (CRP) of 4343 nmol/L (0.76-28.5). Urgent contrast enhanced computed tomography of his head and neck was performed (fig 1).


  • 1. What is the likely diagnosis?

  • 2. What imaging modality should be used to investigate this patient?

  • 3. What are the red flags for impending airway obstruction?

  • 4. How should this patient be managed?


1. What is the likely diagnosis?

Short answer

Signs and symptoms suggest a fulminating infection of the neck. Elevation of the floor of the mouth and hot potato speech suggest involvement of deeper fascial spaces. The diagnosis is Ludwig’s angina.


The signs and symptoms are typical of Ludwig’s angina and impending airway obstruction. This condition was first described by Wilhelm Fredrick von Ludwig in 1836 as a rapidly evolving cellulitis around the neck originating from submandibular regions.1 It is a rare surgical emergency—among 365 cases of deep neck infections, the incidence of Ludwig’s angina was 4.1%.2 The incidence was higher in another series, at 8% among 112 cases of deep space neck infections.3 A …

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