A Case of Epiglottitis in an Elderly Man

AFFILIATIONS

¹Department of Internal Medicine, Merit Health River Region Hospital, Vicksburg, MS
²Windsor Regional Hospital, Windsor, Ontario, Canada
³Department of Internal Medicine, Saint Peter’s University Hospital, NJ
⁴Department of Cardiology, Mayo Clinic, AZ

CITATION:

Yeruva K, Dave AD, Thota G, Mekala SR, Gudi TR. A case of epiglottitis in an elderly man: no age is an exception. Consultant. 2023;63(3):e8. doi:10.25270/con.2023.01.000003

Received September 12, 2022. Accepted November 21, 2022. Published online January 9, 2023.

DISCLOSURES

The authors report no relevant financial disclosures.

ACKNOWLEDGEMENTS

CORRESPONDENCE

Thulasi Ram Gudi, Department of Internal Medicine, Merit Health River Region Hospital, Vicksburg, MS (thulasiram.gudi@gmail.com)

Introduction. A 74-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented to the emergency department (ED) complaining of hoarseness of his voice and difficulty eating 2 days prior to his hospital admission.

Patient history. The patient noticed a change in his voice (being muffled) and difficulty swallowing food. The patient did not complain of barking coughs, sputum production, difficulty breathing, fevers, drooling or swelling of the neck, swelling of the lips or tongue, urticarial rashes, runny noses, or itchy eyes. There were no over-the-counter medications used. The patient was referred to an otolaryngologist by his primary care physician, who found swelling in the epiglottis on indirect laryngoscopy and referred the patient to the emergency room.                                                         

Physical examination. The physical examination revealed a man with class 1 obesity and no apparent distress, drooling, erythema of the uvula or the retropharyngeal wall, palatal tonsillitis, or enlarged lymph nodes, and a temperature of 99.4° F. His vital signs indicated a blood pressure of 151/69 mmhg, a pulse of 74 beats/min, and a saturation of 98% on room air.

Diagnostic evaluation. Blood cultures were drawn on admission. Laboratory studies showed a white blood cell count of 11.9 × 103/μL (reference 4.0-11.0 × 103/μL); a monocyte count of 0.9% (reference 0-10), and an absolute neutrophil count of 8.8 (reference 2.0-7.5 × 103/μL). His imaging included a lateral soft tissue neck x-ray, which showed a thickened epiglottis indicative of epiglottitis (Figure 1). Based on these findings, the patient was diagnosed with laryngoscopic epiglottis.

Figure 1. Lateral x-ray showing thumb sign of epiglottitis.

Treatment and management. The patient was intravenously (IV) administered ceftriaxone 2 g, clindamycin 900 mg, and dexamethasone 10 mg. He was admitted to the intensive care unit (ICU) so we could monitor his airway. The patient did not require any supplemental oxygen. The next day after admission, a flexible laryngoscopy was performed by an otolaryngologist which revealed a significantly less swollen epiglottis than the previous day and a much clearer definition of the vallecular space. On the day of discharge, the patient's muffled voice had returned to normal, he had no difficulty swallowing, and he was able to resume his normal diet.

Patient outcome. In the ICU, the patient was monitored for any signs of respiratory compromise and responded well to steroid therapy and IV antibiotics. The patient's final blood cultures were negative. He was discharged on a 5-day course of clindamycin 300 mg twice daily and cefpodoxime 200 mg once daily. The patient was instructed to follow-up with the otolaryngologist within 2 weeks.

Discussion. Epiglottitis is an inflammation of the epiglottis and surrounding supraglottic tissues. The incidence of acute epiglottitis in adults is increasing, with the reported annual incidence rising from 0.79 cases per 10,000 in 1986 to 1.8 per 10,000 in 1990, 2.02 per 10,000 in 1998, and 3.1 per 10,000 in 2000.¹ Generally, researchers cannot identify the pathogens in these cases. In immunocompromised patients, Pseudomonas aeruginosa and Candida species are prevalent.² Acute epiglottitis generally presents differently in adults and is often considered to be a distinct disease.³ Most patients with acute epiglottitis are aged 16 to 66 years, with few exceptions.⁴

For patients with laryngoscopic visualization of the epiglottis, the lateral neck films present an enlarged epiglottis protruding from the anterior wall of the hypopharynx (the "thumb sign"). There is a greater prevalence of non-Hib epiglottitis among adults which tends to develop slowly, involve more supraglottal tissues than the epiglottis, and cause less airway obstruction. It is recommended that patients with epiglottitis be monitored in an ICU because it is essential to examine the supraglottis daily to assess the response to therapy, any developing complications (such as epiglottic abscesses), and to monitor for delayed airway obstruction (if no artificial airway is used).⁵

Patient with epiglottis should be treated empirically with a third-generation cephalosporin (for example, ceftriaxone or cefotaxime) and an antistaphylococcal agent. Bronchodilators are not routinely recommended. Epiglottitis is commonly treated with parenteral glucocorticoids since swelling of the epiglottis results from edema and an accumulation of inflammatory cells in the potential space between the squamous epithelial layer and the epiglottis. Primary care physicians and internists are reminded in this case that preventing fatal outcomes is possible with an accurate diagnosis and timely intervention.