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Questions Answered: 300

Final Score 76%

229
71

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Ear, Nose & Throat

Question 187 of 300

A 45 year old presents to the Emergency Department with a fever, dysphagia and sore throat. The triage nurse notes a stridor and moves the patient to the Resuscitation area. Shortly after transfer the patient collapses and you note paradoxical seesaw chest and abdominal wall movements. Your Consultant attempts intubation using a video laryngoscope (VL). You are able to see the above on the screen of the VL. What is the most likely diagnosis?

Answer:

The epiglottis is inflamed and oedamatous. Given the history of fever, sore throat and stridor this is in keeping with a history of epiglottitis.

Epiglottitis

Ear, Nose & Throat

Last Updated: 14th December 2023

Epiglottitis is a rapidly progressive cellulitis of the epiglottis and adjacent structures that has the potential to cause abrupt and complete airway obstruction.

Infectious agents

Following the introduction of the Haemophilus influenzae type b (Hib) vaccination in 1992, childhood epiglottitis has become rare, and more cases now occur in adults. However, children who are fully immunised can still get Hib culture positive epiglottitis. Other potential pathogens include Streptococcus pneumoniae, Staphylococcus aureus, and MRSA.

Clinical features

There is a rapid onset of pyrexia, sore throat, muffled speech, dysphagia, drooling and stridor. The child usually looks unwell in acute distress; sitting forwards, mouth open, drooling with tongue protruding.

No action should be taken that could stimulate a child with suspected epiglottitis (including examination of the oral cavity, starting intravenous lines, blood draws, or even separation from a parent) unless there are facilities for immediate intubation/tracheostomy because of the possibility of precipitating complete airway obstruction or cardiopulmonary arrest.

Investigations

Diagnosis is made on clinical grounds, and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected.

  • Fiberoptic laryngoscopy remains the 'gold standard' for diagnosing epiglottitis, as the epiglottis can be seen directly. Laryngoscopy in these patients should only be performed in areas such as operating theatres which are prepared for intubation or tracheostomy in the event of upper airway obstruction.
  • Lateral neck X-ray may be useful if laryngoscopy is not possible. Soft-tissue radiograph of the neck may show the 'thumbprint sign' (See below - left column normal, right column epiglottitis).
  • Throat swabs may be taken when the airway is secure, or when intubation/tracheostomy facilities are at hand.
  • Blood cultures may be taken if the patient is systemically unwell.
  • CT or MRI scans may be performed if abscess formation is suspected.

Lateral Neck X-ray Showing 'Thumbprint Sign' in Acute Epiglottitis. (Image by Med Chaos (Own work) [CC BY-SA 3.0 , via Wikimedia Commons)

Management

Management of this condition remains controversial. The cornerstone is not to distress the child as this can precipitate complete airway obstruction.

Oxygen should be administered if the child is hypoxic.

In the first instance, intravenous antibiotics should be administered, if intravenous access can be achieved without distress. Treatment choice is by hospital guideline with a third-generation cephalosporin being a reasonable choice.

Children under 6 years of age require urgent intubation, ideally in theatre by an experienced anaesthetist with an ENT surgeon present. If there is no time to transfer the child to theatre, then a difficult intubation trolley and cricothyroidotomy kit must be ready. In those over the age of 6 years, observation may be an option following consultation with an ENT and PICU consultant.

The average time for children to remain intubated is 48 to 96 hours. Extubation occurs when direct visualisation of the epiglottis confirms that the inflammation of the epiglottis and surrounding tissues has resolved.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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