Epiglottic abscess.

A 43-year-old, previously healthy man complained of a 3-day history of sore throat, increasing odynophagia, dysphagia, headache, fever, nausea, vomiting, and decreased oral intake. He denied difficulty breathing, trauma, or foreign-body ingestion. The only antecedent event of note was that he had gone scuba diving 3 days prior to developing symptoms.

On examination, the patient was breathing quietly without stridor or stertor. His tonsils were 1+ and erythematous but without exudate. His lungs were clear on auscultation bilaterally. The patient had a mild "hot potato voice." Tender cervical lymphadenopathy was present bilaterally. A soft-tissue lateral neck radiograph showed an enlarged soft-tissue shadow on the epiglottis ("thumb-print sign").

Flexible fiberoptic laryngoscopy revealed a patent airway with an edematous and erythematous epiglottis and aryepiglottic folds without involvement of the glottis. The patient was diagnosed with acute supraglottitis/epiglottitis and was admitted to the intensive care unit for observation, monitoring, and intravenous antibiotics. Approximately 8 hours after admission, repeat flexible laryngoscopy showed an enlarged, yellow-red epiglottis with approximately 75% airway obstruction at the supraglottis. The patient was beginning to experience difficulty breathing while supine, although he had not developed stridor.

The patient was taken to the operating room for airway control and direct laryngoscopy. He was found to have an abscess involving the entire epiglottis, with purulent fluid draining from the right superolateral surface of the epiglottis after manipulation with the laryngoscope (figure). The abscess was incised and drained, and cultures were obtained. A tracheostomy was performed to avoid the need for prolonged orotracheal intubation. Cultures were positive for polymicrobial oropharyngeal flora. The patient was decannulated on postoperative day 7 and discharged home the next day.

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Acute epiglottitis was once more commonly a pediatric disease, but since the introduction of the Hemophilus influenzae type B vaccine in 1985, pediatric incidence has declined from 3.5 to 0.6 per 100,000 children per year; the adult incidence has remained stable at 1.8 per 100,000 per year. (1) Epiglottic abscess is an uncommon sequela of acute epiglottitis, occurring in up to 4% of cases in adults. (2) Fewer than 50 cases have been reported in the literature. Mortality from epiglottic abscess had been reported to reach as high as 30%, (3) but more recent studies reflect a significant decline, ranging from 0 to 7%. (4) Mortality occurs almost exclusively in adults and is three times more common in males than females. It is found most often on the free edge or lingual aspect of the epiglottis. Cultures are most often polymicrobial or grow Streptococcus spp. (5)

Adults presenting with acute epiglottitis and epiglottic abscess exhibit a variety of symptoms, but most have slowly progressive, severe odynophagia and dysphagia. The reason for the low incidence of dyspnea, stridor, and airway compromise in adults is that their airways are larger and more rigid than those of pediatric patients. (4)

Lateral neck soft-tissue radiographs and computed tomography can aid in the diagnosis of an epiglottic abscess, but flexible fiberoptic laryngoscopy is a safe and accurate means of quickly assessing the epiglottis. Epiglottic asymmetry, taut-appearing epiglottic mucosa, a prominent median glossoepiglottic furrow, and a yellow epiglottis are physical findings that should raise suspicion of an epiglottic abscess and warrant the patient' s transfer to the operating room for airway management, endoscopic evaluation, and drainage. (5) Securing the airway can usually be accomplished with endotracheal intubation, but in a few cases an operative airway has been necessary. (6)

In retrospect, after review of the literature, the tracheostomy performed on our patient was an aggressive means of further securing the airway to avoid prolonged orotracheal intubation. However, most reports indicate that extubation can be accomplished within 48 to 72 hours after drainage of the epiglottic abscess.

References

(1.) Frantz TD, Rasgon BM. Acute epiglottitis: changing epidemiologic patterns. Otolaryngol Head Neck Surg 1993;109:457-60.

(2.) Frantz TD, Rasgon BM, Quesenberry CP. Jr. Acute epiglottitis in adults. Analysis of 129 cases. JAMA 1994;272:1358-60.

(3.) Heeneman H, Ward KM. Epiglottic abscess: Its occurrence and management. J Otolaryngol 1977;6:31-6.

(4.) Fontanarosa PB, Polsky SS, Goldman GE. Adult epiglottitis. J Emerg Med 1989;7:223-31.

(5.) Stack BC, Jr., Ridley MB. Epiglottic abscess. Head Neck 1995;17:263-5.

(6.) Hawkins DB, Miller AH, Sach GB, Benz RT. Acute epiglottitis in adults. Laryngoscope 1973;83:1211-20.

>From the Department of Otolaryngology Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Wash. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army. Department of Defense, or the United States Government.