Rapidly progressive Ludwig’s angina following self-extraction of a tooth with a nail: a Cannot-Intubate Possible-to-Ventilate scenario managed with LMA bridge to surgical tracheostomy — a case report

BACKGROUND: Ludwig's angina is a rapidly progressive, potentially fatal polymicrobial cellulitis of the submandibular and sublingual spaces, most commonly of odontogenic origin. Airway compromise may develop within hours, and securing the airway represents the most critical initial intervention. Lemierre's syndrome, septic thrombophlebitis of the internal jugular vein, may complicate deep neck infections and carries significant morbidity. We present a case in which both conditions converged with an extreme difficult airway scenario, managed according to Difficult Airway Society (DAS) guidelines in resource limited setting. CASE PRESENTATION: A 34-year-old previously healthy man presented with a 3-day history of rapidly progressive bilateral neck swelling, high-grade fever, dysphagia, drooling of saliva and respiratory distress after self-extracting a right lower molar tooth with a nail one week prior. On arrival, he had severe trismus, stridor, drooling, tachypnea to 40 breaths per minute and an oxygen saturation of 78% on room air. Direct laryngoscopy failed and video laryngoscopy was not available. A second-generation laryngeal mask airway (LMA) was successfully placed, establishing a Cannot Intubate, Possible to Ventilate (CIPV) scenario. Cricothyroidotomy was attempted but anatomically not feasible due to massive neck swelling. The patient was transferred immediately to the operating room where a surgical tracheostomy was performed while LMA ventilation was maintained. He subsequently developed septic shock, peri-procedural cardiac arrest with initial asystole converting to ventricular tachycardia (VTac) with wide-complex morphology requiring 200 J defibrillation after one CPR cycle and achieving return of spontaneous circulation. Ultrasound and CT of the neck confirmed Lemierre's syndrome with left internal jugular vein thrombosis. CONCLUSION: This case illustrates the lethal potential of rapidly progressive Ludwig's angina, underscores the importance of early structured airway management following DAS guidelines, and highlights Lemierre's syndrome as a serious complication of deep neck infection. LMA can be a life-saving bridge in the CIPV scenario when front-of-neck access fails.