Again it’s a Sunday afternoon in minors and its busy…
You see a 40+ old male with a ‘sore throat.’ It's Winter and he's the third such you've seen. He tells you that he’s had a mild sore throat for the past 2-3 days which is getting worse. He finds it very uncomfortable to extend his neck and feels like his throat is closing over. Its also become increasingly difficult to swallow. He thinks it should be getting better by now. He wonders if he might have strained his neck at work a few days before. You confirm the absence of cough and recent viral illness but he does describe a subjective fever (despite being afebrile at triage with no recent antipyretic treatment).
On examination he is sitting with an upright posture and holds his head/neck rather stiffly due to pain. He has a soft "hot potato" voice but no stridor. His pharynx is completely unremarkable but palpation of the anterior neck produces pain. He has a borderline tachycardia.
What are your differentials? What are you going to do?
Well it could be any of these:
Tonsillitis, Pharyngitis, Peritonsilar Abscess (PTA) / Quinsy
Infectious mononucleosis / Glandular fever, Retropharyngeal abscess (RPA), Epiglottitis, Bacterial tracheitis, Ludwig’s Angina.
But there is no typical evidence of tonsillitis or pharyngitis on examination...You begin to think that you’re missing something and you can’t seem to get past epiglottitis as being top of the list, but only unvaccinated kids get this, right? And they all look really really sick? None of the text books seem to describe it in adults…
You treat it as if it's bad and call for an ENT opinion. Having nasendoscoped the patient the ENT registrar tells you this is supraglottitis. This and epiglottitis are separate but overlapping entities. In epiglottitis, the swelling is localised to the epiglottis which often looks like a red sausage rather than a thin flap. In supraglottitis, it is mainly the supraglottic tissues which are swollen with less localisation to the epiglottis. Muffled voice, drooling, absence of cough and tenderness over the larynx are all worryingly suggestive presentations.
If the patient is still maintaining his own airway and there is no threat of airway compromise (think stridor):
Broad spectrum antibiotics
Regular high dose IV steroids
PRN adrenaline nebs
IV fluid resuscitation
Transfer to specialist ENT ward or high dependency unit where there is airway support
Take home messages
With the advent of the Hib vaccination in 1992 in the UK, Epiglottis is now more common in adults than children (although it has recently started to rise again in under-5s, even when vaccinated). Adult epiglottitis has an incidence of between 1–4 per 100K per annum and has a mortality in adults of around 7%. Don't forget it when you see the drooling, hoarse voiced 40 year old!
Thanks again Aaron.
The Derrifoam Blog
Welcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy.....