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Sri Lankan Journal of Anaesthesiology
ACUTE EPIGLOTTITIS COMPLICATED WITH PHARYNGEAL
ABSCESS AND RECURRENT ACUTE AIRWAY OBSTRUCTION IN
AN ADULT
*Mahesha Dabare
*Senior Registrar in anaesthesia and critical care, Base Hospital, Kanthale
*Corresponding author: [email protected]
Key words: Acute epiglottitis, Acute airway obstruction, Deep neck abscess
Acute epiglottitis is a common condition in children but is a rare entity in adults. Both in children and adults this is a life threatening condition as it can lead to complete airway obstruction. It is therefore vital that this condition is kept in mind when patients, both children and adults are admitted with severe airway obstruction to the emergency room. A case of adult acute epiglottitis complicated with abscess formation is described where timely intervention and correct diagnosis with appropriate treatment saved the life of the patient.
dexamethazone 8mg and nebulisation with
complained of a one day history of sore throat,
salbutamol. Patient was connected to an electro
odynophagia, dysphagia and fever. There was no
cardiac monitor (ECG) and pulse and a pulse
evidence of immune-suppression from the past
oxymeter. About one hour after admission the
medical history. He did not have recent weight
patient became restless with profuse sweating
loss and his appetite was fair. There was no
and developed a stridor. The saturation dropped
history suggestive of allergy, ingestion of
to 93%. He was brought to the intensive care
foreign body or any intraoral or extra-oral
On admission to the ICU patient was drowsy the
Physical examination revealed mild respiratory
SpO2 was 70% but it improved to 92% when
distress (respiratory rate: 22/min, SpO
supported with an ambu bag, tight seal mask and
air). He was restless but the glasgow coma score
oropharyngeal airway with 100% oxygen.
(GCS) remained 15. He was more comfortable
Securing the airway urgently was a necessity.
in the sitting position and was ill looking. Chest
The surgeon was summoned to be ready for
examination revealed few rhonchi and the air
emergency tracheostomy. A cricothyroidotomy
entry was reduced. The oropharynx was
puncture set was not available so it had to be
erythematous but no obvious oedema or
improvised to use as the plan B. Midazolam 5mg
asymmetry noted. Palpation of the neck revealed
was given and the ability to ventilate was
tender lymphadenopathy. His blood pressure
established and suxamethonium 100mg was
was 110/70 mm Hg and pulse rate was 110 beats
given. Significant oedema of the epiglottis and
per minute. He was admitted to the medical
ward for observation. Initial resuscitation
laryngoscopy. A size 7mm orotracheal tube was
entailed oxygen via face mask, intravenous
railroaded via a gum elastic bougie. He was
paralysed and ventilated for a few hours before
commencing SIMV mode. Further management
of the patient was carried out as acute
epiglottitis. Throat swab and blood culture was
Discussion
taken and intravenous cefotaxime 1g 8 hourly
Acute epiglottitis is a well recognized entity in
children but is rare in adults.1 Acute epiglottitis
nebulisation was also administered. The
in adults is often referred to as supraglottitis as
haemoglobin (Hb) was 14g/dl, white cell count
the inflammation is generally not confined to the
(WCC) was 10,300 mm3 with a 91% neutrophil
epiglottis but can also affect supraglottic
count. The chest x-ray antero-postero (AP) was
structures such as the pharynx, uvula, base of the
normal. The erythrocyte sedimentation rate
tongue, aryepiglottic folds or the false vocal
(ESR) was 18mm/hour, and renal and hepatic
cords. Overall mortality for adult epiglottitis is
function tests were normal. The C-reactive
higher around 4–7% 2,3 than in children (2–3%)
protein (CRP) was elevated. Unfortunately the
after the widespread immunization with HIB
microbiological specimens were not processed at
vaccine4. However the mortality in adults further
Trincomalee general hospital due to some
increases to 17% if complicated with airway
technical problems. The fever settled within
thirty six hours and the patient was extubated
after 2 days when a leak around the deflated cuff
The clinical presentation of the patient was
was observed. There was a good clinical
typical of acute epiglottitis with all the common
response and the patient was transferred to ward
symptoms like odynophagia, inability to
on the third day. Intravenous (IV) cefotaxime
swallow secretions, sore throat, dyspnoea, fever
was continued until the 6th day and he was
and tachycardia1. The rapid deterioration to
discharged from the hospital with oral penicillin.
upper airway obstruction within 12 hours of
onset, absence of obvious neck edema and
After 2 days the patient was readmitted to the
visualization of a swollen epiglottis and
emergency treatment unit (ETU) with stridor
perilaryngeal tissue led to the diagnosis of acute
and respiratory distress. The airway was secured
and he was sent to the ICU. The author was not
diagnosis of epiglottitis in children but in adults
directly involved with the intubation on this
it is controversial. Fiberoptic laryngoscopy is
admission and it was done in the emergency
performed safely in adults in contrast to children
treatment unit. Intubation was done with
and considered diagnostic 3,6. The lateral chest
midazolam and suxamethonium. Patient was
X- ray showing oedematous epiglottis (the
thumb sign) has a variable sensitivity.
Diagnostic investigations are not a priority in an
commenced with dexamethazone. A flexible
impending airway obstruction scenario.
laryngoscope was not available so the pharynx
was visualized with a paediatric gastroscope.
Stridor occurs when more than 50% of the
There was significant swelling in the left
airway is narrowed. There is no conclusive
pharyngeal wall and pyriform fossa. He was
evidence in the literature as to the best way of
transferred to the teaching hospital Kurunegala
for ENT opinion and drainage of abscess. Only
obstruction. Some experts suggest inhalational
an ulcer in the left pyriform fossa was noted on
induction and others claim that awake fiberoptic
flexible fiber optic assessment at Kurunegala so
intubation is optimal5. Inability to achieve
the ENT surgeon concluded that probably the
sufficient depth can be a disadvantage in
abscess would have ruptured during the journey.
inhalational induction but any episode of apnoea
Patient was transferred back to Kanthale ICU
may allow the patient to lighten and resume
and extubated after 3 days as planned. IV
spontaneous respiration which is the main
antibiotics were continued for 2 weeks. Naso
advantage. Awake fiberoptic intubation is the
gastric (NG) tube was kept in place for 6 days
other preferred choice and some studies quote a
until he could tolerate oral feeding. The patient
high success rate (98.8%) in experienced hands5.
was discharged after 2 weeks with oral
The technique requires equipment and skill to
antibiotics to review in the clinic.
contraindicated in suspected airway abscess. It
has infrequent success on the first pass and
Management of deep neck abscesses involve
increased trauma with repeated attempts
high dose intravenous antibiotics and
precipitating complete airway obstruction6. The
surgical drainage. If the size of the abscess
risk of general anaesthesia and muscle relaxation
is small and there are no imminent
is that if intubation is not successful, it may
complications, a trial of conservative
precipitate complete airway closure and make
management may be attempted. In our
patient the abscess ruptured spontaneously
necessitating an emergency airway7.In managing this patient the above risk was present but we
established the ability to ventilate before
necessary. Corticosteroids are added if there
administering suxamethonium. If such a
is no contraindication. The polymicrobial
situation came to light we were ready with plan
nature (β
-haemolytic Streptococcus,
Staphy-
lococcus aureus,
Bacteroides and
Neisseria
cricothyroidotomy followed by emergency
spp) of the infection calls for broad
tracheostomy. Gas induction would have been a
spectrum cover11.
better option but the ICU was not equipped with
an anaesthetic machine and it could have been
In the discussed case the seriousness of the
time consuming to import one from the
operating theatre (OT) in the limited time. We
underestimated at the time of admission
had neither the equipment nor the expertise for awake fiber optic intubation.
which led to the deterioration to acute
It is important to consider other differential
managed as acute epiglottitis in the ICU. He
was discharged on oral penicillin from the
(retropharyngeal,
medical ward before completing the full
tracheobronchitis,
reactions, foreign body aspiration and tumours7.
explanation for the recurrence of acute
Widening of the pre-vertebral space occur in
airway obstruction is worth discussing.
tomography (CT) is done only when the course
complicated with suppuration or we would
of illness is prolonged or when the diagnosis is
have misdiagnosed the first presentation. In
in doubt. Since the patient clinically improved
we did not consider transferring him to another hospital for CT.
discharged after adequate treatment with
broad spectrum antibiotics, ENT assessment
The treatment of acute epiglottis entails IV
and fiberoptic laryngoscopy. Perhaps a CT
antibiotics, humidified oxygen, steroids and
scan would have revealed the true extent of
nebulised adrenaline. IV antibiotics should cover
the infection and an alternate course would
haemophilus influenzae,
staphylococcus aureus,
have been pursued.
streptococcus
pneumococcus
(amoxicillin/clavulanic acid or a third generation
In summary, upper airway infections like
cephalosporin). Unlike in children in adults only
epiglottitis and deep neck abscesses can be life-
20% of epiglottitis is caused by
haemophilus
threatening. Airway compromise and the
influenzae8.
potential for abscess rupture are ever-present. A
randomised controlled trials are lacking but the
thorough evaluation of the airway is an absolute
available evidence does not show significant
necessity, and should include use of flexible
benefits to reduce the need for intubation and
fiberoptic laryngoscopy and CT scan when
shorten the clinical course9,10. Patients should be
necessary. A careful airway plan should be
extubated once a leak is detected with a deflated
established in the presence of a senior
anaesthetist and ENT surgeon in a limited time
frame which is challenging. Appropriate broad
retrospective review of 210 cases.
Ann Otol
spectrum antibiotics should be given for an
Rhinol Laryngol, 2001;
110: 1051–4.
7. Irani BS, Martin-Hirsch D, Lannigan F. Infection
microbiological diagnosis. Surgical drainage of
of the neck spaces: a present day complication.
J
Laryngol Otol 1992;
106:455–8.
abscess should not be delayed if significant and
8. Heeneman H, Ward K. Epiglottic abscess: Its
in the presence of airway obstruction.
occurrence and management
. J Otolaryngol
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Source: http://slja.sljol.info/article/10.4038/slja.v19i1.2872/galley/2302/download/
Institute of Agriculture and Animal Science Tribhuwan University An Assignment on Medicinal Plants Dr. Krishna Kumar Pant Associate Professor Department of Environment Science B.Sc. Ag. 5th semester Introduction to Medicinal Plants Medicinal Plants Medicinal plants have been identified and used throughout human history. Before the introduction of chemical medicines, man relied on the healing properties of medicinal plants. Some people value these plants due to the ancient belief which says plants are created to supply man with food, medical treatment, and other effects. There are nearly 2000 ethnic groups in the world, and almost every group has its own traditional medical knowledge and experiences. Plants have the ability to synthesize a wide variety of chemical compounds that are used to perform important biological functions, and to defend against attack from predators such as insects, fungi and herbivorous mammals. At least 12,000 such compounds have been isolated so far; a number estimated to be less than 10% of the total. Chemical compounds in plants mediate their effects on the human body through processes identical to those already well understood for the chemical compounds in conventional drugs; thus herbal medicines do not differ greatly from conventional drugs in terms of how they work. The use of herbs to treat disease is almost universal among non-industrialized societies, and is often more affordable than purchasing expensive modern pharmaceuticals. The World Health Organization (WHO) estimates that 80% of the population of some Asian and African countries presently use herbal medicine for some aspect of primary health care. Their use is less common in clinical settings, but has become increasingly more in recent years as scientific evidence about the effectiveness of herbal medicine has become more widely available. Medicinal and aromatic plants (MAPs) are an important part of the Nepalese economy, with exports to India, Hong Kong, Singapore, Japan, as well as France, Germany, Switzerland, the Netherlands, the USA, and Canada. These plants have a potential for contributing to the local economy, subsistence health needs, and improved natural resource management, leading to the conservation of ecosystem and biodiversity of an area. Nepal's ethnic diversity is also remarkable, so are the traditional medical practices. About 85% of total population inhabit in rural areas, and many of them rely on traditional medicines, mostly prepared from plants for health care. The majority of Nepal's population, especially the poor, tribal and ethnic groups, and mountain people, relies on traditional medical practices. A large number of products for such medical practices are derived from plants. The knowledge of such medical practices has been developed and tested through generations. In many cases this knowledge is transmitted orally from generation to generation and confined to certain people. In this paper, we will discuss about two particular medicinal plants, Aloe and Datura. Aloe vera is frequently cited as being used in herbal medicine since the beginning of the first century AD. Extracts from A. vera are widely used in the cosmetics and alternative medicine industries, being marketed as variously having rejuvenating, healing, or soothing properties. Datura, although widely known as weed, has be used significantly along the history owing to its deliric effects. It has been known to have been used in witchcraft, religious processions and more. Medically, it is used as anti-inflammatory drug. Because of its toxic property, it's used has be controversial among physicians for a long time. Let's explore these plants along with their cultivation practice, phytochemical properties and medical use in detail.
BETH TIKVAH C H A I L I G H T S PURIM 5776 MARCH 2016 FROM OUR RABBI There is a Jewish expression that says- "With the arrival of the comes to replace another one, until the other one comes back Jewish month of Adar, our happiness is greatly increased!" to replace the new one. And so on, and so on! The reference to "greatly increased happiness" is a reference to The story is told of a new rabbi officiating at his first religiousthe holiday of Purim celebrated on the 14th of Adar.