‘Double Tongue’ Appearance due to Swelling of the Floor of Mouth

Image Source: The New England Journal of Medicine©

Spot diagnosis?

Hint: Swelling of the floor of mouth after a toothache?

A 68-year-old man presented to the emergency department with complaints of neck swelling for the past 2 days. The swelling was preceded by a history of toothache, fever, pain on swallowing, and progressive difficulty in swallowing both solids and liquids around 1 week back. The patient had no other complaints. His voice and breathing remain unaffected.

On examination of the oral cavity, the swelling was noted in the right submandibular and submental regions with marked edema of the floor of the mouth. Consequently, the tongue was displaced superiorly and posteriorly. Multiple dental caries and poor dentition were observed.

A flexible nasopharyngolaryngoscopy was performed, which showed patent airway, edema of the valleculae, and swollen epiglottis.

A diagnosis of Ludwig’s angina was made.

Broad-spectrum antibiotics were started intravenously. The patient was closely observed for any signs of airway obstruction. While the patient was under local anesthesia, the carious teeth were extracted

The patient had completely recovered at the 1-month follow-up, with no residual symptoms.

Ludwig’s angina is a rapidly progressive swelling of the submandibular space, which can subsequently displace the tongue and obstruct the airways, therefore a life-threatening emergency.
Thanks to the antibiotics and surgical techniques, the mortality of Ludwig’s angina has declined from 50% before the antibiotics’ era to as low as 8% in the current world.

Mostly it is secondary to odontogenic infections, the infection of the 2nd and 3rd molar teeth.

While other causes include: tongue piercing, peritonsillar/parapharangeal abscesses, neck trauma, mandibular fractures, sialadenitis, oral lacerations/piercing, and oral malignancy.

The patients may present with a history of toothache or infection followed by pain in throat, difficulty in swallowing and mouth opening, muffled voice, fever, displaced, protruded tongue, and bull neck appearance.

Are there any risk factors:

Yes, surely there are!

  • Diabetes mellitus
  • Recent dental treatment,
  • Dental caries
  • Alcoholism
  • Intravenous drug abuse
  • Malnutrition
  • Poor oral hygiene
  • Organ transplantation

Immediate and adequate treatment is indispensable. The patient should be observed for signs of airway obstruction. There is a high mortality rate of 50% due to asphyxia if not treated. Therefore, the management of the airway is the main therapeutic concern.
Other complications include sepsis and mediastinitis.

In some cases, needle drainage is necessary to avoid the spread of infection.


“Double Tongue” Appearance in Ludwig’s Angina. (2019, July 11). Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1814117

Nickson, D. C. (2019, April 23). Ludwig angina. Retrieved from LITFL: https://litfl.com/ludwig-angina-ccc/

Candamourty, R., Venkatachalam, S., Babu, M. R., & Kumar, G. S. (2012). Ludwig’s Angina – An emergency: A case report with literature review. Journal of natural science, biology, and medicine, 3(2), 206–208. https://doi.org/10.4103/0976-9668.101932

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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