A 40-year-old man comes to the clinic due to runny nose, cough, and sore throat. He began having rhinorrhea 5 days ago and subsequently developed a cough that is worse at night. The patient has been taking an over-the-counter cough medication, but it has not improved his symptoms. Three days ago, he developed a sore throat, which he attributes to frequent coughing. Today, his throat is more painful, and he has been having difficulty swallowing liquids. The patient has hypertension and type 2 diabetes mellitus, for which he takes an antihypertensive and several medications for glycemic control. Temperature is 37.9 C (100.2 F), blood pressure is 148/90 mm Hg, pulse is 110/min, and respirations are 22/min. BMI is 35 kg/m2. Pulse oximetry shows 99% on room air. The patient winces when swallowing. Examination shows pooling of oral secretions. There are several dental caries. The posterior oropharynx appears mildly erythematous due to postnasal drip. The anterior neck is soft but tender to palpation. Lung examination reveals faint stridor with no crackles or rhonchi. Which of the following is the best next step for establishing the diagnosis in this patient?
Infectious epiglottitis | |
Epidemiology |
|
Clinical |
|
Diagnosis |
|
Treatment |
|
This patient's presentation raises suspicion for epiglottitis, a cellulitis of the epiglottis, aryepiglottic folds, and surrounding tissues. In adults, most cases are caused by Streptococcus pneumoniae or Haemophilus influenzae, with diabetes mellitus, obesity, and preceding upper respiratory infection (disruption of the respiratory epithelium creates a portal of entry for bacteria) increasing infection risk. Whereas children classically have abrupt onset of drooling, dysphagia, and distress (the "3 Ds"), initial manifestations in adults are more subtle and include sore throat, fever, and laryngotracheal tenderness to palpation. With worsening of the swelling, difficulty swallowing, pooled oral secretions, and respiratory compromise (eg, tachypnea, stridor) can develop, as seen in this patient.
The diagnosis is confirmed by direct visualization or soft-tissue lateral neck radiograph, which usually shows an enlarged epiglottis, loss of the vallecular air space, and/or a distended hypopharynx. Radiographs may also help exclude other conditions. Respiratory compromise is less common in adults but can progess quickly; therefore, patients with significant compromise (eg, hypoxia resistant to noninvasive intervention) require airway establishment prior to considering neck radiograph.
(Choices A and E) Chest x-ray and sputum Gram stain/culture are used to diagnose pneumonia. Although this patient has a cough, his pulse oximetry is normal, and his lungs have no evidence of intrapulmonary pathology (eg, crackles). The presence of stridor and pooled oral secretions makes an upper airway issue such as epiglottitis far more likely than pneumonia.
(Choice B) Diphtheria can cause slowly progressive sore throat, malaise, cough, stridor, hoarseness, low-grade fever, and a thick, white exudate (pseudomembrane) on the posterior pharynx. However, diphtheria is very rare in developed countries due to widespread vaccination; epiglottitis is more common.
(Choice C) Group A Streptococcus pharyngitis usually presents with acute-onset sore throat, tonsillar exudates, cervical lymphadenopathy, and no cough (Centor criteria). This patient's slow onset of sore throat, cough, pooled oral secretions, and stridor make epiglottitis far more likely.
Educational objective:
Epiglottitis should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions, and drooling. Risk factors include diabetes mellitus, obesity, and preceding upper respiratory infection. The diagnosis can be confirmed (in those with stable respiratory status) using lateral neck radiograph.