Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 33 (2015) 734.e5-734.e7

Epiglottic abscess?,??

Abstract

Epiglottic abscess is an uncommon complication of acute epiglottitis that occurs almost exclusively in adults. Because it is a potentially life- threatening condition, Prompt diagnosis and appropriate treatment are required. Keys to successful management include assessing the like- lihood of the need to secure the airway and potential for airway com- promise during intubation, as well as drainage and culture of abscess and institution of appropriate and timely antibiotic therapy. If the pa- tient is considered at risk for complete airway obstruction, prompt insti- tution of a pathway to securing the airway is crucial, including stabilization, notification of surgical and anesthesia teams, and safe transfer to the operating room. In this case report, we describe an other- wise healthy male patient with epiglottic abscess who required man- agement with awake upright fiberoptic intubation.

Epiglottic abscess is an uncommon complication of acute epiglottitis. A 2014 Pubmed search for the terms epiglottic abscess and its variations revealed only a few case reports in the United States [1-5]. Epiglottic ab- scess occurs almost exclusively among adults, and management of epiglottitis with abscess can be more complicated than epiglottitis alone, although studies report conflicting data regarding mortality. Ac- cording to a seminal case review in 1977, mortality in patients with epi- glottic abscess can be as high as 30%, although some more recent series report no fatalities [6-8]. Although the literature varies considerably in the estimation of its incidence and outcomes, epiglottic abscess is a po- tentially life-threatening condition that requires prompt diagnosis and appropriate treatment. Here, we present a case of an otherwise healthy male patient with epiglottic abscess necessitating management with awake fiberoptic intubation.

A 42-year-old man was transferred to the emergency department with a 4-day history of worsening throat pain associated with fever, chills, and malaise. He endorsed dysphagia with liquids and pills as well as a sensation of a “thick tongue.” He reported some minor night- time difficulty managing his secretions while supine and progressive muffling of his voice. The patient had a medical history of hypertension and hyperlipidemia for which he took medication, but was otherwise healthy. He had no prior history of abscesses or airway disease and only a 1.5-year remote smoking history. He denied any recent trauma. The patient’s vaccination status was unknown both to himself and the medical record.

On examination, the patient was hypertensive, mildly tachycardic (93 beats per minute), and febrile (38.4?C). He was mildly tachypneic

? Funding: This work was supported by internal funds only.

?? Acknowledgment: The manuscript was copyedited by Linda J. Kesselring, MS, ELS.

(24 breaths per minute) but was saturating well (SpO₂ 95%) on room air without obvious distress. He had a muffled voice and posterior oro- pharyngeal erythema. Flexible laryngoscopy done at the bedside re- vealed a bulbous, edematous, and inflamed epiglottis obstructing 90% of the hypopharynx and laryngeal inlet; when the scope was passed be- yond the epiglottis with moderate difficulty, the vocal cords were ob- served to be freely mobile and the airway appeared patent. A computed tomographic (CT) scan done prior to the patient’s arrival at our emergency department (ED) revealed marked diffuse edema throughout the free margin and body of the epiglottis and evidence of hypoattenuation, suggesting abscess formation, resulting in moderate to severe airway obstruction (Figs. 1 and 2).

Although he appeared comfortable and not in respiratory distress (normal respiratory rate, pulse oximetry remained within normal limits, and there was no stridor or tripod posture), because of concern for impending worsening edema and airway obstruction, the patient was taken to the operating room for controlled awake fiberoptic intuba- tion directed by anesthesia with ENT available for possible emergent tracheostomy. This was based on our concern about potential worsen- ing edema and potential airway obstruction based on CT and nasopha- ryngeal scope findings. Prior to the start of the procedure, the patient’s neck was marked, prepared, and injected with local anesthetic; and a surgical team was readied in anticipation of needing an urgent tracheos- tomy if the patient’s airway obstructed. The plans for steps to securing the airway were discussed between the anesthesia and surgical teams thoroughly. During this preparation, the patient was noted to be unable to tolerate supine positioning because of the visibly difficult breathing. Topical and aerosolized anesthetic was applied; and, in a seated posi- tion, the patient was successfully intubated with a fiberoptic scope and 6.0-mm endotracheal tube on the first attempt.

General anesthesia was induced, and the patient was moved to a su- pine position. Direct laryngoscopy was performed, and the epiglottis was visualized and found to be significantly enlarged and edematous. Biopsy forceps were used to obtain a specimen from the epiglottis to be analyzed for possible underlying malignancy. Upon completion of the biopsy, the epiglottis decompressed and copious purulent drainage was elicited. Cultures were requested.

The patient was transported to our surgical intensive care unit with continuing intubation and sedation. He received 1 dose of 10 mg dexa- methasone prior to arrival to our hospital, and he was given 2 additional 10-mg doses to decrease his upper airway edema. He was given a dose of ceftriaxone and initiated on intravenous vancomycin prior to arrival at our hospital; he was continued on intravenous vancomycin 1.25 g q12h with dosing managed by pharmacy and was given intravenous piperacillin-tazobactam, 3.375 g q6h. On postoperative day 3, the pa- tient was extubated after laryngoscopy confirmed near resolution of

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Fig. 1. Single sagittal contrast-enhanced CT image obtained near midline demonstrates marked diffuse edema throughout the epiglottis (white arrow), with resultant moderate to severe airway compromise at the level of the free margin of the epiglottis.

the edema and inflammation with only slight thickening of the epiglot- tis. Blood cultures remained persistently negative, and cultures from the abscess returned only mixed oral and anaerobic flora. The patient was discharged home on postoperative day 4 with a 10-day course of oral amoxicillin-clavulanic acid 875-125 mg twice a day. By the time of the 2-week follow-up, he had returned to his previous state of health.

Acute epiglottitis has bacterial, viral, fungal, and noninfectious causes but historically most commonly involved infection with Haemophilus influenza B [9]. Since the introduction of the Haemophilus influenza B vac- cine in 1985, the incidence of PEdiatric epiglottitis has decreased, whereas the incidence of adult epiglottitis has remained stable or has in- creased [10,11]. Other commonly implicated infectious agents include other serotypes of H influenzae, Streptococcus pneumoniae, ?-hemolytic streptococci, and Staphylococcus aureus [12,13]. In adults, blood cultures are negative 75% to 95% of the time [2].

Epiglottic abscess is a sporadically reported complication of epiglottitis that almost exclusively affects adults. This observation has been hypothesized to be due to the longer period of infection in adults, with epiglottic abscess manifesting as the end stage of epiglottic inflam- mation [14]. The treatment for both epiglottitis and epiglottic abscess involves airway management and antibiotics, but the presence of ab- scess may complicate airway management. Reported treatment modal- ities include artificial airway [8], incision and drainage [15-17], and spinal Needle aspiration [7], in addition to medical therapy and observa- tion (ie, Conservative therapy or watchful waiting). Clinical decision making regarding interventional vs conservative therapy is multifacto- rial and should consider the degree of obstruction and likelihood of de- veloping life-threatening airway compromise; the patient’s medical status and comorbidities; and, if conservative therapy is considered, the ability of caregivers to detect and respond to sudden-onset respira- tory distress. In the consideration of the latter, factors such as time of day, weekend coverage, and intensive care availability are paramount.

In our case, the decision was made to secure the patient’s airway based on the size of the epiglottis and amount of obstruction (near com- plete) during the initial flexible laryngoscopy examination. Because of

Fig. 2. Axial contrast-enhanced CT images extending from the free margin of the epiglottis

(A) inferiorly through the edematous, enlarged epiglottis (C) demonstrate subtle central hypoattenuation with peripheral enhancement compatible with abscess seen at direct lar- yngoscopy. Additional axial CT image more inferiorly demonstrates edema extending into the left aryepiglottic fold (D).

the risk of airway compromise during supine positioning or anesthesia, intubation was done under awake conditions with a fiberoptic scope and rapid postintubation sedation. In the event that Topical anesthetic or attempts at intubation caused laryngospasm or other airway compro- mise, the patient was also prepared for tracheostomy under local anes- thesia. Intubation was performed in the operating room with a surgical team and all necessary equipment present. After a short hospital course, the patient recovered completely without any sequelae or complica- tions of his disease.

The patient’s successful recovery and incident-free hospital course can be attributed to the rapid stabilization of the patient in the ED with expeditious transfer to the operating room. In addition, communi- cation between anesthesia staff and surgical team preceded any inter- vention and allowed for safe intubation and securing of airway with readily available options in need of emergent Surgical airway.

Epiglottic abscess is rare and often seems to arise in prolonged cases of epiglottitis. Keys to successful management include determining the need for urgent airway securement, drainage and culture of abscess, and institution of appropriate and timely antibiotic therapy. Once a patient is deemed at risk for airway obstruction, prompt institution of a path- way to securing the airway is crucial. If there is no emergent clinical need to place an airway in the ED (hypoxia, tripoding, or worsening stri- dor) and rapid destabilization is not anticipated, the patient may still re- quire invasive airway management. This may require rapid transfer to the operating or appropriate procedure room and notification and prep- aration of emergency medicine, surgical, and anesthesia teams to care for the patient in the ED, en route, and in the operating room.

J.K. Hsieh et al. / American Journal of Emergency Medicine 33 (2015) 734.e5–734.e7 734.e7

Anticipation of potential airway failure, especially in supine position when the epiglottis is edematous, bulbous, and could act as a ball valve and obstruct the airway completely, necessitates teamwork among multiple specialties including emergency medicine, otolaryngol- ogy, and anesthesia for management and best outcomes.

Jason K. Hsieh, BS

Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio Case Western Reserve University School of Medicine, Cleveland, Ohio

Michael P. Phelan, MD Emergency Services Institute, Cleveland Clinic, Cleveland, Ohio Corresponding author. 9500 Euclid Ave. E19 Cleveland, OH 44195

Tel.:+216 444 2188

E-mail address: [email protected]

Grace Wu, BS

Case Western Reserve University School of Medicine, Cleveland, Ohio

Aliye Bricker, MD

Department of Radiology, Cleveland Clinic, Cleveland, Ohio

Samantha Anne, MD

Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio

http://dx.doi.org/10.1016/j.ajem.2014.10.036

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