Ludwig’s Angina Complicated by a Massive Bilateral Deep Neck Abscess in a 26-Month-Old Boy: Multidisciplinary Airway and Surgical Management

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, crosssectional 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.