Diagnosis: Acute adult epiglottitis
The lateral soft-tissue view of the neck demonstrates marked enlargement of the epiglottis (FIGURE 3, arrow) in comparison with the patient’s normal epiglottis from films taken the year before for neck pain (FIGURE 4, arrow); this is indicative of acute adult epiglottitis. The epiglottis occupies most of the supraglottic space and displays the classic “thumbprint sign,” which is pathognomonic for epiglottitis.
FIGURE 3
Enlargement of the epiglottis
FIGURE 4
The same patient a year before
Differential diagnoses
Given the patient’s fever, sore throat, odynophagia, and shortness of breath, other diagnoses to consider are pharyngitis, tonsillitis, peritonsillar abscess, retropharyngeal abscess, and angioedema.
Pharyngitis and tonsillitis can easily be evaluated by visualizing the oropharynx. If epiglottitis is suspected, however, a tongue depressor should not be used as it may precipitate loss of the airway.
A retropharyngeal abscess will result in enlargement of the prevertebral soft tissues on the lateral soft tissue view of the neck. Diagnostic confirmation of a retropharyngeal abscess is made with a contrast enhanced computed tomography scan of the neck, demonstrating rim-enhancing fluid collections within the retropharyngeal space.
Angioedema may be associated with cutaneous manifestations, such as urticaria, and sometimes an inciting agent can be identified.
Epidemiology and pathophysiology of acute epiglottitis
Acute epiglottitis is a rapidly progressive supraglottic infection that can lead to life-threatening airway obstruction. Although it is becoming less common in pediatric populations secondary to the Haemophilus influenzae type b vaccine, the adult incidence of approximately 1.8 per 100,000 persons remains stable, if not increasing.1
As in childhood epiglottitis, H influenzae is the most common causative agent in acute adult epiglottitis. Other causative agents include Streptococcus pneumoniae, Group A Streptococci, Staphylococcus aureus, viruses, and caustic agents. Patients most often present with nonspecific symptoms of odynophagia, dysphagia, sore throat, and a muffled voice. In more serious cases, adults will present with respiratory complaints, indicating that the supraglottic infection is jeopardizing the patient’s airway. The mortality rate for acute adult epiglottitis is approximately 7%.2