Do the clinical parameters provide the reliable indication of airway findings in adult patients with acute supraglottitis?

Airway management of adult patients with acute supraglottitis is challenging. The sign and symptoms of the disease may show marked variation in terms of severity and progression. Thorough evaluation is required before selecting any particular approach. We report the case of an adult patient with acute supraglottitis, in whom active airway intervention was planned. The clinical predictors were not suggestive of any airway compromise in our patient. However, the disease was found to have an unanticipated rapidly progressive course leading to the significant edema of the oropharynx and the surrounding structures as evidenced by the laryngoscope and computerized tomography scan findings.

Introduction

Acute supraglottitis is the inflammation of epiglottis and the surrounding structures.[1] The associated edema which may develop within an hour is the leading cause of potential life-threatening airway compromise. The disease may show variation in terms of its presentation and clinical course,[2] which needs to be addressed carefully before making any airway management plan. Literature is convincing both for the active as well as conservative approach of airway management depending upon the patient's clinical condition. The purpose of reporting this case is to highlight these issues in the management of adult patient with acute supraglottitis.

Case Report

A 52-year-old man presented in the emergency department with the complaints of sore throat for 1 day. The past medical history was unremarkable except the history of ischemic heart disease for which he was taking regular clopidogrel, losartan, and sublingual trinitrates as required. The oral examination revealed the enlarged uvula and bilateral swelling in throat. He was febrile with the temperature of 37.6°C, respiratory rate was 22 per minute, while the oxygen saturation on room air was 95%. There were no signs of airway obstruction including stridor, change of voice, and dyspnea related to change in position or lying down.

The initial management was started with humidified oxygen, intravenous dexamethasone, and adrenaline nebulization. The benzyl penicillin and cefotaxime were started empirically. An otorhinolaryngology consultation was requested for the further management. The fiberoptic nasolaryngoscopy showed the significant edema and inflammation of supraglottic region more on the right side as compared to the left. A provisional diagnosis of acute supraglottitis was made.

Anesthetic evaluation showed concern of sore throat only. He was quiet comfortable with the breathing and maintaining the oxygen saturation on Hudson mask. His Mallampati score was grade 3, and the neck seemed to be short. The rest of the physical and systemic examination was normal. On the basis of initial assessment, we thought that no airway intervention was required at the moment. However, consideration was given to nasolaryngoscopy findings and the fact that we did not have overnight otorhinolaryngology cover in our district hospital. It was also decided that conservative airway management of patient, either in our hospital or during shifting to the specialized unit, would be very high risk. We therefore planned prophylactic securing of airway.

Anticipating a difficult airway, all the preparations of difficult airway trolley were done according to our national guidelines. The otorhinolaryngology team was asked to standby for surgical tracheostomy (Plan B). The three anesthetists, out of whom two had consultant grades, were present for the case. The facilities for fiberoptic intubation and emergency crico-thyroidectomy were also available.

The routine American Society of Anaesthesiologists specified monitoring was done. Inhalational induction of anesthesia was done using sevoflurane in oxygen and air. Patient's was kept on spontaneous ventilation with the help of nasopharyngeal airway connected to the main circuit via 15 mm outer diameter connector. Conventional and fiberoptic laryngoscopy attempts failed to show any glottic view. The subsequent three attempts by both the consultant anesthetists were also failed. A surgical tracheostomy was done after infiltration of local anesthesia while the patient was kept anesthetized on inhalational anesthetic on spontaneous breathing pattern.

The patient remained stable throughout the procedure and shifted to the intensive care unit on completion of the procedure. He was kept sedated overnight. The unanticipated rapidly progressive course of the disease was confirmed by the computerized tomography scan of the neck done after 24 h, which showed the marked swelling of oropharynx reducing the size of airway to not more than a pin hole [Figure 1]. Patient was shifted to specialized center on the first postoperative day where he was treated medically. Tracheostomy was decannulated after 5 days. Rest of the course in the hospital was uneventful and then he was discharged home. No organism was grown in the cultures done at the time of presentation.

Figure 1

CT scan image of the airway at the level of cricoid cartilage

Discussion

Acute supraglottitis is the cause of potential airway compromise in adults. The reported incidence in this population group is 1–2.9/100,000 annually and is higher than that in the pediatric population.[3] Signs and symptoms at the time of presentation show variation among the patient group involved. Sore throat, dysphagia, and change in voice are the common findings in the adults while the children usually present with the cardinal signs of airway obstruction as stridor, drooling, and dyspnea.[4]

The securing of airway is the most important but controversial aspect of the management. The current literature supports the conservative approach for the patients in which no airway compromise is suspected.[5] Patients having a rapid progressive course, diabetes, or symptoms of impending airway obstruction like stridor or muffled voice are likely to be managed with the active airway intervention.[6]

We recommend that before taking any decision on the approach to a patient, it is very important to consider the type of health care setup and facilities available. The disease process may show marked variation in terms of symptoms and progression as it was happened in our patient. Our patient presented with sore throat and he did not have any sign or symptoms of respiratory distress but still had rapid onset of massive airway edema. A retrospective review of nine healthy adults found that the signs of upper airway obstruction are characteristically absent in early phase of potentially fatal supraglottitis.[7]

Fiberoptic nasolaryngoscopy is gold standard to establish the diagnosis.[8] It also aids in tracking the disease progress and the response to medical treatment. Severe swelling of the epiglottis and its extension to the arytenoids are the two factors strongly associated with the airway intervention.[6] The management of our patient was based on the nasolaryngoscopy finding at the time of presentation which showed the clinically significant edema of oropharynx.

Air way manipulation in such high risk patients should be done in the operation theatre with a surgeon ready for emergency tracheostomy. The anesthetic options, inhalational induction using sevoflurane or awake trachesotomy, should be individualized according to the patient condition and clinical expertise available.

In adult patients having acute supraglottitis, clinical parameters are not the reliable indicators of the airway condition, which may deteriorate rapidly. A multidisciplinary approach involving the otorhinolaryngologist and anesthesiologist is of prime importance for the management of airway. Either the prophylactic or conservative approach may be used depending upon the patient condition and the health care facilities available. It is also very important to anticipate the difficulty and all the preparations for an emergency tracheostomy should be there for securing of airway.