Managing supraglottitis in the COVID-19 era.

Discussion

The value of a lateral cervical radiograph to evaluate the upper aerodigestive tract cannot be discounted. It has diagnostic utility not only in radio-opaque foreign bodies, but may also demonstrate infective conditions such as acute epiglottitis, supraglottitis, or retropharyngeal abscesses. During COVID-19 pandemic, a patient who presents with respiratory symptoms needs to be carefully triaged and maybe be sent to a controlled area if at high risk for COVID-19 infection.

Medical personnel with full personal protective equipment (PPE) would take a polymerase chain reaction (PCR) swab. Then the relevant teams also in PPE will assess the patient in a specialized cordoned area. As such, a fiberoptic laryngoscopy evaluation may not be done immediately due to its aerosol-generating procedure nature. Thus, a radiograph has an increased clinical relevance as it can visualize supraglottic structures without the risk of aerosol generation. However, the patient should be adequately assessed for signs of respiratory distress before being sent for imaging to avoid a complicated resuscitation away from the Emergency Department.

In the event that the triage or evaluation of a suspected COVID-19 patient in a specific cordoned area patient may not be available (for example, many places do not have access to full PPE and other testing modalities, PCR is justifiably used due to more rapid results or increased accessibility.

Visual case discussion

A 68-year-old male, with underlying hypertension and dyslipidemia presented with three-day history of sore throat, swallowing and breathing difficulty, which acutely worsened over the past few hours. He denied any neck swelling or pain. He has no COVID-19 contact. There was no history of allergy, upper respiratory tract infection, or recent tooth extraction.

On examination, he was afebrile with normal vital signs. Soft inspiratory stridor was present and the voice was weak. Oral hygiene was fair, with no peritonsillar fullness or raised floor of the mouth. A lateral neck radiograph was done to rule out any radio-opaque foreign bodies or “thumb sign” as a sign of epiglottitis. It showed grossly enlarged arytenoid shadows (Fig. 1 ). Looking at their positions in the lateral view neck radiograph can differentiate the epiglottis and arytenoids pathologies. As anatomical location of the arytenoids is at the posterior part of the glottis, the opacity will be seen coming from the opposite to the anteriorly located epiglottis. The streak of air lucency in between these two structures is the patent airway left (Fig. 1).

Fig. 1

Enlarged arytenoids shadows suggestive of gross edema (white arrow). The streak of lucency indicates the patent airway left (blue arrow). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.).

This was corroborated by flexible nasopharyngolaryngoscopy (FNPLS), which demonstrated pooling of secretions, with edematous arytenoids and a mildly enlarged epiglottis. The airway was significantly narrowed at supraglottic region but patent (Fig. 2 ). The importance of FNPLS is to see the patency of airway in order to anticipate the degree of difficult intubation if the patient requires any. Hence, after FNPLS done the patient has been referred to anesthesia team anticipating difficult intubation if in case the patient collapsed. COVID-19 swab was done and it was negative.

Fig. 2

FNPLS view of the larynx showing oedematous epiglottis (black arrow) and swollen bilateral arytenoids (white arrow).

A contrast-enhanced computed tomography (CECT) neck was obtained immediately to rule out supraglottic or deep neck abscesses, besides underlying malignancy. CECT neck showed gross swelling of supraglottic structures with effacement of pyriform sinuses and valleculae. He was treated initially with intravenous (IV) unasyn 3 g QID for 3 days however repeated scope done showed no improvement. Hence, the antibiotic changed to IV ceftriaxone 1 g BD and IV metronidazole 400 mg TDS.

The patient showed improvement after the change of antibiotics and eventually was discharged home well to complete oral antibiotic for a week. A week later during follow up in our clinic, he was comfortable and no stridor heard. A repeat FNPLS showed the edematous supraglottic structures was resolving and the airway can be well visualized. Two weeks later during follow up, he was well and comfortable. The edematous supraglottic structures have completely resolved.

Questions and answers with brief rationale true & false and / or multiple-choice questions

Question 1: The presenting features and clinical course of acute supraglottitis in adult are similar to epiglottis in the pediatric age group.

True

False

Explanation: False. Acute supraglottitis in adult usually presents with a slower onset, fewer severe respiratory symptoms and pharyngeal symptoms such as sore throat and odynophagia. They may occasionally have dysphonia and inspiratory stridor.

Question 2-:

A pathognomonic radiographic finding of epiglottitis is the:

Steeple sign

Hourglass sign

Thumb sign

Pencil tip sign

Explanation: (C) Thumb sign. Thumb sign is the edematous epiglottis shown on the lateral neck radiograph. The only way to differentiate it from the epiglottic abscess is with imaging (CT scan) .

Steeple is the sign of acute laryngotracheobronchitis or croup, seen on anteroposterior view of neck radiograph. The subglottic and upper tracheal narrowing is seen as the church steeple. Pencil tip sign is the other name. Hourglass sign is a finding of tracheal stenosis on chest axial CT scan.