An 8-day history of severe dysphagia

CASE

The patient, a 66-year-old female, presented to the emergency department with an 8-day history of severe dysphagia. She reported that the dysphagia was intermittent but worsened after she administered ciprofloxacin (Ciloxin) eye drops, prescribed for bacterial conjunctivitis 2 days ago. She had a known allergy to penicillin. She had no history of recent dental work, trauma, or immune suppression.

HISTORY The patient had hypercholesterolemia, asthma, environmental allergies, and shingles. Her medications
included simvastatin (Zocor), montelukast (Singulair), and fexofenadine (Allegra), and she received immunotherapy for various allergens. She had had a total hysterectomy 15 years ago. Formerly a 5-pack-year smoker, the patient had quit smoking in the 1960s.

PHYSICAL EXAMINATION Findings included temperature, 100.9°F; BP, 138/81 mm Hg; and oxygen saturation, 99% on 2 L of oxygen via nasal cannula. Her eyes were round and reactive to light and accommodation. She had minimal mucoid discharge bilaterally with no photophobia. Nares were clear. Pharyngeal examination revealed firm sublingual edema with tongue elevation but no protrusion or drooling. Tonsils were of normal size, with the uvula in midline position without fullness of the soft palate. Voice was slightly muffled.

On neck examination, firm swelling in the submandibular region was noted but there was no overlying erythema or warmth. No stridor was heard, and the patient was not using her accessory muscles. No discrete lymphadenopathy was found. Range of motion was limited, but there was no nuchal rigidity. Laryngoscopy revealed that the base of the tongue and valleculae were grossly edematous. The entire epiglottis was swollen with a loss of contours, occluding a full view of the true vocal cords. Pooling of a green discharge was seen in the supraglottic region. Laboratory findings were WBC count, 22,800/μL; neutrophils, 85,700/μL.

WHAT IS YOUR DIAGNOSIS?

• Angioedema
• Supraglottitis
• Peritonsillar abscess
• Ludwig's angina

DISCUSSION

This patient had supraglottitis, a potentially fatal infection of the supraglottic region most commonly caused by Haemophilus influenzae type b (see Figure 1). Patients usually present with dysphonia, dysphagia, drooling, and sometimes stridor and may assume the tripod position with the tongue protruding in an effort to breathe easier. A high fever and an elevated WBC count with a left shift may be present. On lateral neck radiograph, the classic thumbprint sign may be evident. Epiglottitis is typically less acute in adolescents and adults than in children.¹ However, a higher mortality rate in adults (6% to 7%) than in children (1%) can be attributed to a difficult diagnosis.²

TREATMENT The patient was deemed not likely to need intubation and, therefore, safe to undergo observation. She was transferred to the ICU and treated with IV clindamycin (Cleocin), dexamethasone, and oxygen via nasal cannula. Twenty-four hours later, the patient reported a dramatic decrease in pain. Repeat laryngoscopy showed a significant decrease in airway edema. The true vocal cords were now clearly visible, and a patent airway was seen. She was transferred out of the ICU, and a soft diet was prescribed; IV clindamycin and dexamethasone were continued for an additional 48 hours. She was discharged on an oral fluoroquinolone. One week later, follow-up laryngoscopy showed that the larynx was entirely clear. The patient was referred to an immunologist to determine a possible immune cause.

COMMENT Airway patency is paramount in managing the patient with supraglottitis. In severe cases, patients should not be examined with a tongue depressor. A tracheostomy team should be available when performing a fiberoptic laryngoscopic examination because manipulation of the airway can provoke laryngospasm, further occluding the airway. Respiratory stridor, drooling, and an inability to saturate comfortably are indications for immediate intubation. The usual antibiotic choice is a beta-lactamase inhibitor. Clindamycin was chosen for this patient because she was allergic to penicillin and because clindamycin also offers coverage against streptococci, staphylococci, and anaerobes. JAAPA

Amelia Mohabir is a physician assistant in otolaryngology at St. Luke's Roosevelt Hospital Center, New York City, and a visiting faculty member at the Arthur Ashe Institute at SUNY Downstate, Brooklyn, New York. She has indicated no relationships to disclose relating to the content of this article.

1. Rubin MA, Gonzalez R, Sande MA. Infections of the upper respiratory tract. In: Kasper DL, Braunwald E, Hauser S, et al, eds. Harrison's Principles of Internal Medicine. Vol I. New York, NY: McGraw-Hill; 2005;27:192.

2. Jaffe JE, Hajdik RL. Epiglottitis, Acute. Emedicine from WebMD Web site. www.emedicine.com/radio/topic263.htm. Accessed November 7, 2007.