Ludwig's Angina and Trismus

This case of Ludwig’s angina dates back to when I was in England. The patient aged 46 years, admitted for chronic dental abscess suddenly became acute and developed trismus. The resident anesthesiologist wanted to secure the airway under topical. My consultant was conducting a mitral valvotomy and left me to help these residents. She was very confident and said that the trismus disappears under Scoline and intubation will be possible. I smiled because in Bombay we were taught that a patient having Ludwig’s angina with difficulty in breathing should not be put to sleep. Since I smiled she knew that I disagreed. My next question was whether they are going to open the abscess from the skin or inside the mouth. She said that she is not aware but quoted a case from the medico-legal magazine where the anesthesiologist was blamed for not securing an airway. Anyway my reluctance was clear and I even asserted that I would not put this patient to sleep. She proceeded to conduct this case. She confidently gave Thiopentone and Scoline and to her amazement the jaw was only partially relaxed; she could not ventilate the patient. The laryngoscope did not reveal any anatomical landmark except a white wall in front. The residents in order of their seniority tried to intubate and failed. The last person to try was house surgeon and the patient by now was jet blue. Luckily he could see the chord separating and pushed the tube down. The dental surgeon opened the abscess which was pointing at the skin. The entire procedure could have been done under ethyl chloride spray locally.
When the consultant returned, and told me the whole story I asked her whether she had ordered a tracheostomy set in the ward by the bedside. She laughed and said the adults do not get laryngeal oedema and complete closure of the airway. Only four hours later the same patient was wheeled into the operation theatre and a stab tracheostomy was done to save his life.