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Sore throat.Sore throat in a 29-year-old male.
Sore throat in a 29-year-old male.
HISTORY OF PRESENT ILLNESSA 29-year-old male with a medical history significant for type I diabetes presented to the ED complaining of a sore throat,inability to swallow solids and fevers to 103◦F (39.4◦C) for two days. He noted a hoarse voice and was able to tolerate only small sips of liquids. He denied significant neck swelling or stiffness, and was able to tolerate his secretions. He had immigrated
to the United States from Mexico as a teenager, and his immunization status was unknown.
PHYSICAL EXAM
GENERAL APPEARANCE: The patient was a well-developed,nontoxic, moderately obese male who appeared slightly dehydrated,sitting upright and in no acute distress.
VITAL SIGNS
Temperature 103◦F (39.4◦C) ,Pulse 100 beats/minute,Blood pressure 145/85 mmHg,Respirations 22 breaths/minute,Oxygen saturation 100% on room air.
HEENT(HEAD, EYES, EARS,NOSE AND THROAT): Oropharynx was pink and moist, no erythema, exudates,tonsillar or uvular swelling noted.
NECK: Supple, anterior cervical lymphadenopathy noted, tenderness to palpation over cricoid cartilage noted.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm without rubs,murmurs or gallops.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
A peripheral intravenous line was placed and blood wasdrawn and sent for laboratory testing. Laboratory tests were significant for a leukocyte count of 24 K/μL (normal 3.5–12.5 K/μL) with 92% neutrophils (normal 50–70%). A softtissue lateral neck radiograph was obtained (Figure 1.1).
What is your diagnosis?ANSWER .The diagnosis is epiglottitis. The soft-tissue lateral neck radiograph demonstrates swelling of the epiglottis (“thumbprint” sign, Figure 1.2). The Ear, Nose and Throat (ENT) specialist was urgently consulted,and bedside nasopharyngoscopy demonstrated a swollen, red epiglottis with 90% obstruction of the upper airway. The patient received ceftriaxone 1 gm and decadron 10 mg intravenously, normal saline 1 liter IV bolus,and was admitted to the ICU for close monitoring and observation.The patient was discharged on hospital day #4 after his
symptoms had improved. Repeat nasopharyngoscopy demonstrated significant improvement of the epiglottic swelling. He was continued on cefpodoxime proxetil (VantinTM) orally for ten days following discharge.
Epiglottitis in adults.
Acute epiglottitis is a potentially life-threatening condition that results from inflammation of the supraglottic structures.1,2 Commonly considered a pediatric disease,thecurrent incidence of epiglottitis in adults is 1 to 2 cases per 100,000, which is presently 2.5 times the incidence in
children.1 Epiglottitis occurs most frequently in men in the fifth decade; the disease is more common in countries that do not immunize against Haemophilus influenzae type B. Currently,the most common cause of epiglottitis is infection,although sources such as crack cocaine use have also been
implicated.1 Common pathogens include H. influenzae (Hib),β-hemolytic streptococci and viruses.
The clinical presentation of adult epiglottitis may differ significantly from that of the classic drooling child seated in a tripod position. The most common symptoms in adults are sore throat, odynophagia and muffled voice.3 Sore throat is the chief complaint in 75–94% of cases, whereas odynophagia
may be present in as many as 94% of cases.4 The presence of stridor significantly increases the need for emergent airway intervention.5 Unlike children with epiglottitis, where emergency airway management is essential, most cases of adult epiglottitis do not require acute airway intervention due
to the greater diameter of the adult airway.The leukocyte count is greater than 10,000 in 80% of
cases of adult epiglottitis. Soft-tissue lateral neck radiography,which may show an enlarged, misshapen epiglottis(“thumbprint” sign), has a sensitivity of 88% in establishing the diagnosis.3 Patients who appear ill or are in extremis should not leave the ED for radiographs, and airway management in patients in extremis should be the first and foremost responsibility. Direct laryngoscopy is the most accurate investigation to establish a diagnosis of epiglottitis.3 Management
focuses on two important aspects: close monitoring of the airway with intubation (if necessary) and treatment with intravenous antibiotics.6 Antibiotics should be directed against Hib in every patient, regardless of immunization status. Cefotaxime,ceftriaxone or ampicillin/sulbactam are appropriate choices. Steroids are commonly used in the management of
KEY TEACHING POINTS
1. Acute epiglottitis is a potentially life-threatening condition resulting from inflammation of the supraglottic structures,with a current incidence of 1 to 2 cases per 100,000 adults in the United States.
2. Sore throat is the chief complaint in 75–94% of cases of adult epiglottitis, whereas odynophagia may be present in as many as 94% of cases.
3. Soft-tissue lateral neck radiography, which may show an enlarged, misshapen epiglottis (“thumbprint” sign), has a sensitivity of 88% in establishing the diagnosis.
4. The definitive diagnosis is made through direct laryngoscopic visualization of an enlarged, inflamed epiglottis.
5. Treatment of epiglottitis includes intravenous antibiotics and close airway monitoring in an ICU setting. Most clinicians treat acute cases with intravenous steroids.
HISTORY OF PRESENT ILLNESSA 29-year-old male with a medical history significant for type I diabetes presented to the ED complaining of a sore throat,inability to swallow solids and fevers to 103◦F (39.4◦C) for two days. He noted a hoarse voice and was able to tolerate only small sips of liquids. He denied significant neck swelling or stiffness, and was able to tolerate his secretions. He had immigrated
to the United States from Mexico as a teenager, and his immunization status was unknown.
PHYSICAL EXAM
GENERAL APPEARANCE: The patient was a well-developed,nontoxic, moderately obese male who appeared slightly dehydrated,sitting upright and in no acute distress.
VITAL SIGNS
Temperature 103◦F (39.4◦C) ,Pulse 100 beats/minute,Blood pressure 145/85 mmHg,Respirations 22 breaths/minute,Oxygen saturation 100% on room air.
HEENT(HEAD, EYES, EARS,NOSE AND THROAT): Oropharynx was pink and moist, no erythema, exudates,tonsillar or uvular swelling noted.
NECK: Supple, anterior cervical lymphadenopathy noted, tenderness to palpation over cricoid cartilage noted.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm without rubs,murmurs or gallops.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
A peripheral intravenous line was placed and blood wasdrawn and sent for laboratory testing. Laboratory tests were significant for a leukocyte count of 24 K/μL (normal 3.5–12.5 K/μL) with 92% neutrophils (normal 50–70%). A softtissue lateral neck radiograph was obtained (Figure 1.1).
What is your diagnosis?ANSWER .The diagnosis is epiglottitis. The soft-tissue lateral neck radiograph demonstrates swelling of the epiglottis (“thumbprint” sign, Figure 1.2). The Ear, Nose and Throat (ENT) specialist was urgently consulted,and bedside nasopharyngoscopy demonstrated a swollen, red epiglottis with 90% obstruction of the upper airway. The patient received ceftriaxone 1 gm and decadron 10 mg intravenously, normal saline 1 liter IV bolus,and was admitted to the ICU for close monitoring and observation.The patient was discharged on hospital day #4 after his
symptoms had improved. Repeat nasopharyngoscopy demonstrated significant improvement of the epiglottic swelling. He was continued on cefpodoxime proxetil (VantinTM) orally for ten days following discharge.
Epiglottitis in adults.
Acute epiglottitis is a potentially life-threatening condition that results from inflammation of the supraglottic structures.1,2 Commonly considered a pediatric disease,thecurrent incidence of epiglottitis in adults is 1 to 2 cases per 100,000, which is presently 2.5 times the incidence in
children.1 Epiglottitis occurs most frequently in men in the fifth decade; the disease is more common in countries that do not immunize against Haemophilus influenzae type B. Currently,the most common cause of epiglottitis is infection,although sources such as crack cocaine use have also been
implicated.1 Common pathogens include H. influenzae (Hib),β-hemolytic streptococci and viruses.
The clinical presentation of adult epiglottitis may differ significantly from that of the classic drooling child seated in a tripod position. The most common symptoms in adults are sore throat, odynophagia and muffled voice.3 Sore throat is the chief complaint in 75–94% of cases, whereas odynophagia
may be present in as many as 94% of cases.4 The presence of stridor significantly increases the need for emergent airway intervention.5 Unlike children with epiglottitis, where emergency airway management is essential, most cases of adult epiglottitis do not require acute airway intervention due
to the greater diameter of the adult airway.The leukocyte count is greater than 10,000 in 80% of
cases of adult epiglottitis. Soft-tissue lateral neck radiography,which may show an enlarged, misshapen epiglottis(“thumbprint” sign), has a sensitivity of 88% in establishing the diagnosis.3 Patients who appear ill or are in extremis should not leave the ED for radiographs, and airway management in patients in extremis should be the first and foremost responsibility. Direct laryngoscopy is the most accurate investigation to establish a diagnosis of epiglottitis.3 Management
focuses on two important aspects: close monitoring of the airway with intubation (if necessary) and treatment with intravenous antibiotics.6 Antibiotics should be directed against Hib in every patient, regardless of immunization status. Cefotaxime,ceftriaxone or ampicillin/sulbactam are appropriate choices. Steroids are commonly used in the management of
KEY TEACHING POINTS
1. Acute epiglottitis is a potentially life-threatening condition resulting from inflammation of the supraglottic structures,with a current incidence of 1 to 2 cases per 100,000 adults in the United States.
2. Sore throat is the chief complaint in 75–94% of cases of adult epiglottitis, whereas odynophagia may be present in as many as 94% of cases.
3. Soft-tissue lateral neck radiography, which may show an enlarged, misshapen epiglottis (“thumbprint” sign), has a sensitivity of 88% in establishing the diagnosis.
4. The definitive diagnosis is made through direct laryngoscopic visualization of an enlarged, inflamed epiglottis.
5. Treatment of epiglottitis includes intravenous antibiotics and close airway monitoring in an ICU setting. Most clinicians treat acute cases with intravenous steroids.
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epiglottitis,
Sore Throat,
