Ludwig Angina

A 28-year-old man from rural India presents to the emergency department with severe bilateral submandibular swelling and difficulty swallowing for 3 days. He reports a history of poor dental hygiene and a painful lower molar tooth 1 week ago. On examination, his mouth floor is indurated and brawny, with elevation and posterior displacement of the tongue. Temperature is 38.9°C. Intraoral examination reveals a carious lower right first molar with purulent drainage. His neck is stiff, and he has difficulty opening his mouth. What is the most appropriate immediate management?

A 35-year-old woman presents to the ENT clinic 5 days after drainage of a submandibular abscess for Ludwig angina. She had received broad-spectrum antibiotics and underwent incision and drainage under general anesthesia. On follow-up, she complains of persistent fever (38.2°C), malaise, and new-onset chest pain on deep inspiration. Chest X-ray shows a widened mediastinum and bilateral pleural effusions. Blood cultures remain positive despite 5 days of antibiotics. What is the most likely complication, and what is the next step in management?