“Cherry Red Emergency”: Acute Epiglottitis Requiring Surgical Airway

Abstract

INTRODUCTION: Acute epiglottitis is an uncommon, rapidly progressive form of cellulitis of the epiglottis and adjacent structures that can result in complete and potentially fatal airway obstruction. Because of the danger of airway obstruction, acute epiglottitis constitutes a medical emergency. The diagnosis is often clinical, although direct fiberoptic laryngoscopy is frequently performed for culture and visualization. We present a case of a 43 year old male with acute epiglottitis that required emergent cricothyroidotomy. CASE PRESENTATION: Forty-three year old male with a 3 day history of pharyngitis, fever, malaise, odynophagia, and yellow sputum production. ENT evaluated the patient with direct fiberoptic laryngoscopy, which showed diffuse edema of the right oropharynx down to supraglottis with edema of the pyriform. Shortly after, the patient decompensated with stridor, hypoxemia and respiratory arrest. Endotracheal intubation was attempted by direct larnygoscopy, glidescope and bronchoscope by multiple subspecialists without success. An emergent surgical airway was obtained with a cricothyroidotomy. Patient received treatment with dexamethasone and IV antibiotics. Of the microbiologic data obtained, only the Rapid Strep test was positive. Repeat direct visualization 5 days later showed a purulent epiglottis with edema and erythema. The patient underwent a surgical tracheostomy. His oxygenation improved and he completed a course of intravenous antibiotic therapy. The patient was later discharged home with a tracheostomy and outpatient follow up. DISCUSSION: Epiglottitis is an uncommon disease with an incidence in adults of about 1 case /100,000 per year. Adult epiglottitis is most frequently seen in men in their fifth decade. Once considered as a pediatric disease, there has been a dramatic decrease in children since the introduction of the Hib vaccine. Adult cases have remained constant. With the decrease in Hemophilus infections, Streptococcus species are now the most common pathogens in this disease. Epiglottitis can lead to rapid deterioration and upper airway obstruction, thus involvement of ENT and Anesthesia early in patient care are key to successful management. CONCLUSION(S): Acute epiglottitis is a medical emergency and a multidisciplinary approach is part of management due to the complexity and potential complications. Antibiotic therapy should be broad to cover Hib and streptococcal species. If not suspected or identified promptly, obstruction of the airway can rapidly develop and be lethal. An emergent surgical airway is always a consideration in the setting of respiratory distress and an inability to obtain endotracheal intubation.