58 A 43-year-old woman was admitted to the hospital with chief complaints of hoarseness and sore throat after smoking crack cocaine roughly 4 hours before arrival. She describes her voice as being muffled. These symptoms had progressed rapidly, and her throat pain was increased with swallowing to the point that she was now unable to tolerate solid food or liquids by mouth. Additionally, she reported mild difficulty breathing without wheezing. She was otherwise healthy, without any significant medical history, including reflux, asthma, or heart disease, other than an adenotonsillectomy done about 30 years ago for chronic tonsillitis. The patient denied recent neck trauma, foreign body ingestion, or other caustic exposure. She denied recent fevers or illnesses preceding onset of her current symptoms. The patient’s immunization status was up to date. She was a 20-pack per year cigarette smoker and had a history of weekly crack cocaine and marijuana abuse. Other than acetaminophen for pain control, she was not taking any medications regularly. She had no known drug or environmental allergies. On physical examination, the patient was anxious and appeared to be in moderate distress. She was sitting erect but leaning slightly forward and was seen to be drooling. She was mildly stridulous, with a muffled voice, but was not tachypneic or retracting. She had a fever of around 102°F and was tachycardic but not hypotensive. Oral examination demonstrated no erythema or exudate and the absence of tonsils consistent with her prior surgery. The uvula was not edematous and was midline. Indirect mirror examination of the larynx revealed diffuse edema and erythema of the supraglottic structures, including the epiglottis, aryepiglottic folds, arytenoids, and false vocal cords. The true vocal cords were poorly visualized, and assessment of their mobility was subsequently limited. The neck was palpated and found to be tender anteriorly at the level of the larynx. Shotty bilateral cervical lymphadenopathy without overlying erythema or other skin changes was also appreciated. There was no thyromegaly. 1. Although tonsillitis in this patient is ruled out by her absence of tonsils, this patient’s sore throat could still be attributable to pharyngitis, or even possibly a deep neck infection. However, the onset of symptoms was quite rapid, decreasing the likelihood of a deep neck space infection, as well as other causes, such as malignancy. The history excludes other causes such as foreign body impaction or other trauma. The combination of fever, progressive odynophagia, and sore throat should therefore raise the suspicion of epiglottitis. 2. Until the early 1990s, epiglottitis was typically considered a disease of childhood, most commonly seen in children aged 2 to 7 years. However, after the introduction of the Haemophilus influenzae type B (HiB) vaccine in the 1980s, the incidence in children declined significantly. This disease is now more commonly observed in adults, with an incidence of 1 to 3.1 per 100,000 people. Adult mortality rates approach 7%, in many cases owing to a delay in diagnosis or adequate care. Therefore, a high index of suspicion should be maintained. 3. Physical examination is diagnostic and requires the use of either indirect mirror or fiberoptic laryngoscopy. Classically there is concern that performing such an examination in children may precipitate an acute airway obstructive event, so it is still recommended that a child with suspected epiglottitis be immediately transported to the operative suite to secure the airway. In adults several studies have demonstrated that indirect laryngoscopy is a safe maneuver in patients who are not in significant respiratory distress. Alternatively, one could obtain a lateral airway radiograph, which may demonstrate the “thumbprint” sign, indicative of severe epiglottic edema (Fig. 58.1). However, keep in mind that the sensitivity and specificity of this imaging study are relatively low (38% and 78%, respectively). Also note that in adults, the inflammation may involve not only the epiglottis, but other supraglottic structures as well, and may even extend toward the pharynx and uvula; in children, the infection tends to manifest as a swollen, cherry-red epiglottis.
Epiglottitis
History
Differential Diagnosis—Key Points
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