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Case of the Month 02/10

This 55 year old Broadway singer presented to the ED with a foreign body sensation in his throat after taking ibuprofen. He had had URI symptoms for 2 days and had been started on azithromycin by his PMD one day prior for presumptive pharyngitis.

His vitals were as follows: O2 Sat 99%, Resp rate 18, Pulse 110, Oral Temp 98.7 (likely higher core—skin felt hot to touch)
Hoarse voice, sitting up straight, and spitting and hacking (drool?)
Pharynx clear, lungs clear, no stridor.

The patient was sent for soft tissue lat c-spine.

Question 1: What's wrong with this picture?

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Answer 1:

Epiglottitis.
While the classic findings of epiglottitis in children (abrupt onset of high fever, sore throat, stridor, dysphagia and drooling) are fairly marked, in adults, the presentation is often much more subtle. Patients may present only with a severe sore throat, normal oropharyngeal exam and exquisite tenderness with movement of the hyoid. While lateral C spine films are a good first step, if clinical suspicion is high with negative films, the patient should undergo direct visualization of the epiglottis or CT imaging.

This x-ray demonstrates the classic “thumb sign” where the normally small, sharp appearing epiglottis has become very swollen. Compare it to the normal epiglottis (circled) in the x-ray below.

Question 2: Where do you go from here?

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Answer 2:

The airway needs to be secured in these patient by the most skilled provider available. Supportive measures include nebulized racemic epinephrine and heliox. Antibiotics should also be administered to cover H. flu and S. pneumo.

This patient was scoped in ED by ENT. When ENT could not see the cords, he patient taken to OR and fiberoptically tubed by anesthesia with thoracic surgery on standby.