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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. 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