In Ludwig's angina, what is the most immediate management step?

• A. CT of the neck.
• B. Intubation.
• C. Start IV penicillin.
• D. Incision and drainage.

Answer: (B)

Securing the airway is the immediate priority because Ludwig’s angina rapidly causes swelling in the floor of the mouth and neck that can suddenly block breathing. The quickest way to prevent a life-threatening airway collapse is to establish a protected airway now, typically with intubation. If the swelling makes intubation difficult or unsafe, an emergency tracheostomy may be required while maintaining spontaneous breathing as much as possible. Once the airway is secured, you can address the infection with IV broad-spectrum antibiotics and proceed with imaging or surgical drainage as the situation dictates. Imaging helps gauge extent and plan further management, but it cannot replace airway control in the acute setting. Starting antibiotics is important, but it should follow airway protection, and incision and drainage is not the initial step because this is a cellulitic infection rather than a discrete abscess requiring drainage.