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Sonographic diagnosis of epiglottal enlargement
  1. Firat Bektas,
  2. Secgin Soyuncu,
  3. Ozlem Yigit,
  4. Murat Turhan
  1. Akdeniz University, Acil Servis, Antalya, Turkey
  1. Correspondence to Firat Bektas, Akdeniz University, Akdeniz Üniversitesi Týp Fakültesi Hastanesi, Acil Servis, Antalya 07059, Turkey; fbektas{at}akdeniz.edu.tr

Abstract

The case is presented of epiglottal and pre-epiglottal oedema secondary to infection of the pharyngolaryngeal area. The purpose of this report was to assess the utility of ultrasonography to image epiglottal and pre-epiglottal oedema. Bedside emergency department ultrasonography could be a valuable tool to detect pathological enlargement of the epiglottis. Ultrasonography may be used in unstable patients for diagnosing epiglottitis because it is cheap, rapid, non-invasive and does not aggravate the patient's symptoms.

  • Airway
  • emergency care systems
  • emergency departments
  • imaging
  • ultrasound

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Acute epiglottitis is a life-threatening disease because of its potential for sudden upper airway obstruction. It is a well-known entity in children but it is uncommon in adults and therefore is often misdiagnosed.

We present the case of epiglottal and pre-epiglottal oedema secondary to infection of the pharyngolaryngeal area. The purpose of this case report was to assess the utility of ultrasonography to image epiglottal and pre-epiglottal oedema.

Case report

A 56-year-old man presented to the emergency department (ED) with a history of fever, sore throat and gradually increasing hoarseness, which had started 2 days previously. He had been followed up since March 2007 with nasopharyngeal cancer. The patient's last chemotherapy (cisplatine, doxitaxel and 5-fluorourasil) was 2 weeks earlier, and he had not been treated with radiotherapy since January 2008. His vital signs were as follows: blood pressure 98/64 mm Hg, pulse rate 112 beats/minute, respiratory rate 22 breaths/minute, oral body temperature 38.6°C and oxygen saturation 96% with pulse oxymeter at room air. Physical examination was normal except for a high body temperature, swelling on the anterior neck, pharyngeal erythema and epiglottal oedema on indirect laryngoscopy. This finding led us to think that the patient had epiglottitis. The patient was stable without any respiratory distress and he was suitable for ultrasound examination.

Ultrasonography was performed at the bedside, which revealed a hypoechoic structure with an increase in thickness (5.1 mm) of the echogenic pre-epiglottal space using a 10 MHz linear probe (Medison Digital Sonoace 5500; Medison America, Inc, Cypress, California, USA) (figure 1). Direct examination of the pharyngolaryngeal area was performed with the fibreoptic laryngoscope to confirm the diagnosis. On fibreoptic laryngoscopic examination, there was only moderate swelling of the epiglottal and laryngeal area (figure 2). The patient was admitted to the ear, nose and throat unit to be monitored for airway obstruction and to receive supportive treatment. He was treated with antibiotics, paracetamol and corticosteroids, and airway obstruction did not develop. He was discharged from hospital fully recovered 5 days later.

Figure 1

Epiglottis and pre-epiglottal space in transverse view. R-SCM=Right sternocleidomastoideus; L-SCM=left sternocleidomastoideus.

Figure 2

Epiglottal and pre-epiglottal oedema in the rhinoscopy view.

Discussion

The most useful diagnostic studies to detect epiglottitis are lateral radiography of the neck and direct laryngoscopy.1 Sonographic evaluation of laryngeal diseases in adults was first described by Böhme2 and called ‘echolaryngography’. In another study, Werner et al3 reported that bedside ultrasound is easy to perform and can accurately evaluate the epiglottis in the emergency setting. In their study, the average epiglottic thickness was found to be 2.39±0.15 mm in healthy volunteers. In our case report, epiglottic thickness and the pre-epiglottal space were found to be 3.2 mm and 5.1 mm, respectively. The diagnostic utility of bedside ED ultrasound to detect epiglottitis, epiglottal or pre-epilglottal oedema has not been determined in the medical literature, but especially in unstable patients ultrasound may be a useful technique to detect pathological enlargement of the laryngeal area. Other advantages of ultrasound are that it is cheap, non-invasive, non-ionising and easy to perform. As a result, ED ultrasonography may enhance the emergency physician's performance by shortening the length of stay in the ED, reducing the number of unnecessary tests to be ordered and hastening critical therapeutic interventions. However, this technique is dependent on the operator, affordability and skills training.

Conclusion

This case report shows that bedside ED ultrasonography could be a valuable tool to detect pathological enlargement of the epiglottis. Ultrasound may be used in unstable patients for diagnosing epiglottitis because it is cheap, rapid, non-invasive and does not aggravate the patient's symptoms.

References

Footnotes

    fn-1
  • Competing interests None.

  • fn-2
  • Patient consent Obtained.

  • fn-3
  • Provenance and peer review Not commissioned; not externally peer reviewed.