Case vignette

A 55-year-old male with a history of hypertension and peripheral vascular disease presents to the emergency department with a complaint of ‘noisy breathing.’ Two days prior to presentation, he began experiencing cough, subjective fever and a sore throat. His symptoms gradually worsened, developing into difficulty tolerating oral secretions and increased work of breathing. He is able to speak with a muffled voice and denies rash or recent changes in medication. He is currently taking amlodipine, hydrochlorothiazide, aspirin and simvastatin. His vaccination status is unknown. On examination, the patient is in moderate respiratory distress. His vitals signs show a heart rate of 111 beats/min, blood pressure of 111/71 mm Hg, respiratory rate of 17 breaths/min, temperature of 37.4 C and a pulse oximetry of 100%. Examination reveals notable stridor, a hoarse voice and tenderness over the anterior neck. His oral pharynx is clear. A lateral soft tissue neck x-ray is obtained (figure 1).

Key questions

1. Before looking at the x-ray, what is your differential diagnosis?

2. What does the x-ray demonstrate?

3. After looking at …