No abstract

Acute epiglottitis is well recognised in children. In adults the condition is comparatively rare but the outcome may be equally serious. We present four cases emphasising the importance of early consideration of the diagnosis in adults with relatively common symptoms and recognising the necessity for urgent action in airway management. Case historiesCase I-A 43 year old previously fit man presented to the accident and emergency department with a history of sore throat, fever, and increasing dysphagia for five days and respiratory difficulty for the past hour. On admission he gave his own history; he was feverish and had pharyngitis and mild stridor. One hour after admission he was transferred to the ear, nose, and throat ward for assessment, where he was still able to talk and give his own history. His only treatment at that stage was humidified oxygen. Soon after arrival in the ward he developed complete upper airway obstruction and suffered a hypoxic cardiac arrest. Laryngoscopy showed an immense red, swollen epiglottis with no other recognisable laryngeal structure consistent with a diagnosis of acute epiglottitis. Oral intubation was impossible, and a minitracheotomy tube (Mini-Trach, Portex) was inserted through the cricothyroid membrane followed by a conventional emergency tracheostomy. Despite full cardiorespiratory resuscitation it became evident that the patient had suffered irreversible cerebral hypoxia during this period, and 48 hours later the criteria for brain stem death were fulfilled.Case 2-A previously fit 57 year old man drove himselfto the accident and emergency department and gave a history of increasing dysphagia and mild dyspnoea for four hours. He sounded hoarse, and 20 minutes after arrival inspiratory stridor became evident. Indirect laryngoscopy by an ear, nose, and throat surgeon showed epiglottitis and he was taken directly to the theatre. With an ear, nose, and throat surgeon present, he was anaesthetised with halothane in oxygen. Laryngoscopy confirmed severe epiglottitis and showed pronounced deformity ofthe laryngeal anatomy. The first attempt at intubation failed and a bronchoscope was therefore passed through the cords allowing a bougie to be inserted; this was used to guide the insertion of a 7-5 mm endotracheal tube, which was subsequently changed to a nasotracheal tube. Intravenous chloramphenicol and metronidazole were begun and the patient transferred to intensive care, where he was sedated with fentanyl and midazolam, spontaneously breathing humidified 30% oxygen. His fever settled and resolution of the epiglottic oedema was monitored regularly using the fibreoptic laryngoscope. Four days after admission the laryngeal anatomy appeared normal and the patient was extubated. He made a rapid and complete recovery. Throat swab culture grew a non-haemolytic streptococcus. Case 3-A previously fit 16 year old youth presented to the accident and emergency department with a six hour history of increasing dyspnoea and inspiratory stridor. Temperature was 38°C, there was inspiratory s...