Adult Epiglottitis—Pitfalls of Management: A Case Report

Balaji Ramamourthy¹, Neemu Hage² https://orcid.org/0000-0002-2217-6010, Namit K Singh³ https://orcid.org/0000-0002-4290-6930

^1-3Department of ENT, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India

Corresponding Author: Balaji Ramamourthy, Department of ENT, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India, Phone: +91 9914402531, e-mail: drbala1991@gmail.com

Received on: 23 May 2024; Accepted on: 21 October 2024; Published on: 15 November 2024

ABSTRACT

Adult epiglottitis is inflammation of the epiglottis and adjoining supraglottis. Many times, it is misdiagnosed or diagnosed late. We present a 50-year-old male who presented with chief complaints of fever, difficulty in swallowing, and change in voice for 2 days. He was diagnosed with epiglottitis and managed with intravenous antibiotics, analgesics, and steroids. Oxygen supplementation was done. Airway intervention was avoided by vigilant monitoring and timely intervention. Patients presenting with airway risk factors such as tachypnea, tachycardia, decreased oxygen saturation, the “double thumb sign” on X-ray, and epiglottic abscess must be carefully monitored, and an airway management plan must be made. Because of its rapid progression and potential threat to airway, it is important for otolaryngologists to be familiar with this condition.

How to cite this article: Ramamourthy B, Hage N, Singh NK. Adult Epiglottitis—Pitfalls of Management: A Case Report. Int J Phonosurg Laryngol 2024;14(2):40-42.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Airway obstruction, Case report, Difficult airway, Epiglottis.

INTRODUCTION

Acute epiglottitis is the inflammation of the supraglottis with diffuse signs of infection.¹ Literature shows a growing incidence of epiglottitis in the adult population in the post-HIB (Haemophilus influenzae type b) vaccine era.² The incidence ranges between 1/1,00,000 and 4/1,00,000 in adults.¹ The mortality rate ranges from 1 to 20%.³ Similar to an upper respiratory infection, adults with epiglottitis usually experience a prodrome for 1–2 days.⁴ Patients may have a sore throat with or without dysphagia, dyspnea, hoarseness, and stridor. Fever may develop in the later stages.⁵ Owing to this, in the early stages of the disease, the diagnosis may be easily missed, and the patient ends up with an airway emergency. In this case report, we highlight the pitfalls in the diagnosis and management of an adult with epiglottitis and ways to avoid them.

CASE DESCRIPTION

A 50-year-old male presented to the otorhinolaryngology outpatient department with fever, difficulty in swallowing, and change in voice for 2 days. Fever was high grade and not associated with chills and rigors. Difficulty in swallowing was acute in onset, gradually progressive, more to solids than liquids. The patient also had odynophagia and change in voice but no difficulty in breathing. There was no history of any swellings or nasal and aural complaints. The patient had no similar episodes in the past and was a known case of hypothyroidism and hypertension on treatment. He was a chronic smoker and an alcoholic.

On examination, he was conscious, oriented, and febrile (100.8°F). His heart rate was 81 beats/min, and blood pressure was 106/70 mm Hg in the left upper limb in the sitting position. Respiratory rate was 24/min, and oxygen saturation was 97% on room air. He was using accessory muscles of respiration. He had adequate mouth opening, and oral and oropharyngeal examination was unremarkable. There were no swellings palpable in the neck; however, there was tenderness in the submental region. A 70° endoscopic examination of the larynx showed a congested edematous epiglottis completely obscuring the endolarynx (Fig. 1A). There was pooling of secretions in bilateral pyriform sinus. A diagnosis of acute epiglottitis was made, and 8 mg of dexamethasone and 100 mg of hydrocortisone were given. Oxygen supplementation was started, and the first shot of antibiotics was given after a test dose within the first 30 minutes of arrival (Fig. 1B).

Figs 1A and B: (A) Edematous epiglottis with pooling of secretions; (B) Normal epiglottis posttreatment with intravenous antibiotics and steroids

An X-ray soft tissue neck lateral view was done to confirm the diagnosis, which showed an edematous epiglottis and aryepiglottic folds (Fig. 2). His hemoglobin was 17.5 g/dL; white blood count was 23.4 × 10⁹/L; total bilirubin was 1.9 mg/dL; aspartate aminotransferase (AST) was 43 U/L; alanine aminotransferase (ALT) was 30 U/L; and the AST/ALT ratio was 1.4.

Fig. 2: X-ray neck lateral view showing “double thumb sign.” Edematous epiglottis indicated by red arrowhead; edematous aryepiglottic fold indicated by blue arrow

He was admitted and started on injection amoxicillin and clavulanic acid 1200 mg BD and metronidazole 500 mg TDS along with dexamethasone 8 mg BD. Analgesics and antipyretics were also started for symptomatic relief.

The patient became afebrile; respiratory rate normalized, and he was weaned off of oxygen. On day 4 of intravenous antibiotics, endoscopic examination was repeated, which showed a normal epiglottis. The patient was discharged on oral antibiotics. He was started on alcohol deaddiction after a psychiatry consultation.

DISCUSSION

Adult epiglottitis is of special interest to otorhinolaryngologists because of the risk it poses to the airway and the rapid progression. Men are more commonly affected than women, and the fourth and fifth decades of life are the ages at which they are affected.⁶ Our patient was a 50-year-old male with a chronic history of smoking and alcoholism.

Patients presenting with signs suggestive of dyspnea (respiratory rate >30/min, stridor, features of hypercapnia and hypoxemia, and supraglottic extension of edema) are more likely to require an airway intervention in the form of intubation or tracheotomy.⁷ Our patient had tachypnea and usage of accessory muscles of respiration at the time of presentation.

Epiglottic and aryepiglottic width >8 mm and 7 mm, respectively, on a lateral neck X-ray is strongly suggestive of epiglottitis in an adult patient.⁸ “Thumb sign” is the rounded thickening of the epiglottic shadow on the X-ray, giving it the appearance of an adult-sized thumb. When both epiglottis and aryepiglottic folds are involved, it gives an appearance of “double thumb,” indicating the severity.⁹ Our patient had a positive “double thumb sign.”

Epiglottic abscess (EA), one of the fatal complications of adult epiglottitis, is more frequently associated with airway obstruction. Patients with EA present with muffled voice and respiratory distress. Duration of hospitalization is doubled and these patients usually have a polymicrobial infection. Single or multiple low-density areas with rim enhancement and/or with internal gas collections are the usual computed tomography (CT) findings.¹⁰

CONCLUSION

Adult epiglottitis is often misdiagnosed and late diagnosed. In this case report, we present the successful management of a patient with epiglottitis and the pitfalls to look for to avoid an airway catastrophe.

The following patients must be under strict observation with an airway management plan:

Patients who present with increased respiratory effort like tachypnea, usage of accessory muscles of respiration, muffled voice, etc.
Presence of “double thumb” sign on soft tissue X-ray of the neck.
Presence of an EA with or without supraglottic edema at presentation or during hospitalization.

Though the use of intravenous steroids has no definitive evidence in preventing airway events, their use under antibiotic cover is beneficial in decreasing the respiratory effort.

ORCID

Neemu Hage https://orcid.org/0000-0002-2217-6010

Namit K Singh https://orcid.org/0000-0002-4290-6930

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