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Four cases of acute epiglottitis with a peritonsillar abscess
Auris Nasus Larynx 38 (2011) 284–288 www.elsevier.com/locate/anl
Four cases of acute epiglottitis with a peritonsillar abscess Keiko Ito a,*, Hiroko Chitose a, Masamichi Koganemaru b a
Department of Otorhinolaryngology, Kumamoto Central Hospital, 955 Muro, Ozu-machi, Kikuchigun, Kumamoto 869-1235, Japan b Department of Radiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan Received 4 February 2010; accepted 11 June 2010 Available online 25 August 2010
Abstract We report four cases of acute epiglottitis with a peritonsillar abscess originating from the inferior pole of the palatine tonsil. All cases were male, and presented with acute onset of sore throat and dysphagia. Flexible laryngoscopy revealed swollen epiglottis and swelling at the base of tongue along the edge of the epiglottis in all cases. Computed tomography (CT) revealed the position and extent of a peritonsillar abscess. Surgical drainage was not performed. Abscesses decreased in size following intravenous antibiotics and corticosteroids. We surmise that inflammatory exudates extending widely in the pre-epiglottic space cause epiglottic swelling from oropharyngeal infection, the latter of which is thought to produce a peritonsillar abscess. We recommend CT examination for patients with a stable airway and swollen epiglottis, even if the swelling is mild. This will allow for exclusion of deep neck abscess and determination of the most effective treatment including intravenous antibiotics against anaerobe, incision and drainage of an abscess. # 2010 Elsevier Ireland Ltd. All rights reserved. Keywords: Epiglottitis; Peritonsillar abscess; Computed tomography; Pre-epiglottic space
1. Introduction
2. Case report
Acute epiglottitis is a bacterial infection of supraglottic structures that results in the symptom complex of sore throat, stridor, odynophagia, muffled voice, and high fever. It is a serious infection and may be fatal secondary to sudden airway obstruction. Epiglottic abscess is a rare complication of acute epiglottitis [1]. A rise in the incidence of acute epiglottitis along with a concomitant rise in the number of epiglottic abscesses has been recently noted [1,2]. Some patients with epiglottitis have concurrent peritonsillar abscesses [3] and/or deep neck abscesses [3,4]. We report four cases of acute epiglottitis with a peritonsillar abscess. We recommend CT examination for all patients with a stable airway and swollen epiglottis, even for mild swelling. CT scan will allow for exclusion of deep neck abscess and determination of the most effective treatment, including intravenous antibiotics against anaerobe, incision and drainage of the abscess.
2.1. Case 1 A 64-year-old man presented with a 3-day history of sore throat, dysphagia, fever (37.8 8C), and mild hoarseness. Flexible laryngoscopy revealed swollen erythematous epiglottis with involvement of the left arytenoid, bilateral salivary pooling in the piriform recesses, and swelling at the base of tongue along the left edge of the epiglottis (Fig. 1). White blood cell count was 18,500 cells/mm3 and C-reactive protein was 13.9 mg/dl. Throat swab culture was not performed. CT scan revealed an epiglottic abscess and a left-sided peritonsillar abscess (Fig. 2). Treatment with broad-spectrum intravenous antibiotics (carbapenem), clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 7 days after presentation. 2.2. Case 2
* Corresponding author. Tel.: +81 096 293 0555; fax: +81 096 293 2562. E-mail address: [email protected] (K. Ito).
A 34-year-old man presented with a 1-day history of sore throat and dysphagia. He complained of anterior neck
0385-8146/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2010.06.004
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K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
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improvement of clinical status and he was discharged 7 days after presentation. 2.3. Case 3
Fig. 1. Direct laryngoscopy revealing an epiglottic abscess (A) and the wall of a peritonsillar abscess (W) on admission of the patient in case 1.
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tenderness over the hyoid bone. He was afebrile. Flexible laryngoscopy revealed an erythematous oropharynx. White blood cell count was 11,300 cells/mm3 and C-reactive protein was 3.1 mg/dl. Throat swab culture revealed growth of a-Streptococcus. He returned the following day given that his symptoms did not improve with oral antibiotics. The patient was found to be febrile (37.9 8C) and repeat flexible laryngoscopy revealed swollen epiglottis. Swelling at the base of tongue along the left edge of the epiglottis was also seen (Fig. 3). White blood cell count was 11,800 cells/mm3 and C-reactive protein was 11.8 mg/dl. CT scan revealed enhancement of the base of tongue and a left-sided peritonsillar abscess (Fig. 4). Treatment with broadspectrum intravenous antibiotics (carbapenem), clindamycin, and hydroxycortisone sodium succinate resulted in rapid
A 41-year-old man presented to an outside emergency room with a 1-day history of sore throat, dysphagia, and fever (37.3 8C). He had an erythematous oropharynx and was given oral antibiotics. His symptoms had not improved and he presented to our clinic the following day. Flexible laryngoscopy revealed swollen epiglottis, bilateral salivary pooling in the piriform recesses, and swelling at the base of tongue along the left edge of the epiglottis (Fig. 5). White blood cell count was 16,900 cells/mm3 and C-reactive protein was 16.9 mg/dl. Throat swab culture was not performed. CT scan revealed a left-sided peritonsillar abscess and enhancement of the base of tongue (Fig. 6). Treatment with intravenous 3rd generation cephalosporin, clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 5 days after presentation. Follow-up examination 3 weeks later showed a normal epiglottis and a CT scan demonstrated complete resolution of the peritonsillar abscess. 2.4. Case 4 A 27-year-old man presented to an outside emergency room with a half-day history of sore throat, dysphagia, and fever (37.1 8C). He had an erythematous oropharynx and was given oral antibiotics. His symptoms had not improved later the same day, so he visited a different emergency room. Examination revealed erythematous oropharynx and rightsided anterior neck tenderness. Acute epiglottitis was suspected and lateral neck radiographs were obtained. No thickening of epiglottic tissue was noted on the radiograph; he was given an anodyne suppository and referred to an otorhinolaryngologist. He presented to our clinic the
Fig. 2. (A) Axial contrast-enhanced CT scan of the patient in case 1 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar (arrowhead) abscess on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar (arrowhead) abscess.
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K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
Fig. 3. Direct laryngoscopy revealing edema of the epiglottis (E) and the wall of a peritonsillar abscess (W) on day 2 of admission of the patient in case 2.
following day. Flexible laryngoscopy revealed swollen epiglottis and swelling at the base of tongue along the right edge of the epiglottis (Fig. 7). White blood cell count was 22,400 cells/mm3 and C-reactive protein was 7.3 mg/dl. Throat swab culture was not performed. CT scan revealed a right-sided peritonsillar abscess and enhancement of the base of tongue (Fig. 8). Treatment with broad-spectrum intravenous antibiotics (penicillin), clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 5 days after presentation.
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Fig. 5. Direct laryngoscopy revealing swelling of the epiglottis (E) and the wall of a peritonsillar abscess (W) on day 3 of admission of the patient in case 3.
3. Discussion Acute epiglottitis is a relatively rare, yet potentially lifethreatening condition. The most common symptoms in adults are odynophagia and dysphagia. Other symptoms include a muffled voice, drooling, cough, and fever. Dyspnoea occurs in a third of patients. Acute epiglottitis is diagnosed by direct laryngoscopy in most cases. CT imaging may be used to confirm the diagnosis when adequate laryngoscopic examination cannot be performed
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Fig. 4. (A) Axial contrast-enhanced CT scan of the patient in case 2 demonstrating enhancement of the base of tongue (arrow) and peritonsillar (arrowhead) abscess on day 2 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
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K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
287
Fig. 6. (A) Axial contrast-enhanced CT scan of the patient in case 3 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead) on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead). (C) Coronal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
[4]. Imaging should be considered only in patients with a stable airway, as the supine position required for CT or MRI increases the risk of acute respiratory distress. In case 3 and 4, although direct laryngoscopy showed mild swelling of the epiglottis, CT scan revealed a peritonsillar abscess. We recommend CT examination for all patients with swollen epiglottis, even if the swelling is mild. Smith et al. [4] described the appearance on CT and complications of supraglottitis in three adult patients. In that study, the most common CT findings were thickening of the epiglottis, aryepiglottic fold, false and true vocal cords, obliteration of pre-epiglottic fat, and thickening of subcutaneous tissue and muscles. Multiple loculated fluiddensity collections consistent with abscess were seen in one 35-year-old patient. In this patient, white blood cell count was 11,300 cells/mm3, and culture of the epiglottis grew blactamse-negative Haemophilus influenzae. These abscesses extended along the facial planes of the neck. Dominant collection extended from the submandibular space inferiorly
[(Fig._7)TD$IG]
Fig. 7. Direct laryngoscopy revealing partial swelling of the epiglottis (E) and the wall of a peritonsillar abscess (W) on admission of the patient in case 4.
along the sternocleidomastoid muscle. Abscesses were also seen anterior to thyroid cartilage, anterior to strap muscles, and in the supraclavicular region with extension into the mediastinum. This patient was directed to obtain appropriate surgical management. Although patients in case 3 and 4 did not have dyspnea nor remarkable swelling of the epiglottis, CT scan revealed a peritonsillar abscess. This CT finding suggested that swelling of the epiglottis occurred secondary to a peritonsillar abscess and excluded deep neck abscess caused by severe epiglottitis. This is consistent with Hafidh et al. [2], who reported 10 cases of acute epiglottitis in adults admitted to a tertiary referral center over a 6-month period. Two patients had concurrent acute tonsillitis and one had a peritonsillar abscess, which required incision and drainage. Degree of supraglottic swelling in these patients was mild, suggesting that it occurred secondary to oropharyngeal infection. CT findings in our cases included diffuse thickening of the epiglottis, aryepiglottic folds, and a peritonsillar abscess that originated from the inferior pole of the palatine tonsil. Two patients had both epiglottic and peritonsillar abscesses. Direct laryngoscopy revealed diffuse erythema with edema of the epiglottis, aryepiglottic folds, salivary pooling in the piriform recesses, and swelling at the base of tongue along the edge of the epiglottis. This swelling was thought to be the wall of an abscess. Epiglottic abscess is a rare sequela of acute epiglottitis. Berger et al. [1] reported that epiglottic abscess was evident in 24% of adult patients (28/118) studied with epiglottitis. Twenty-one abscesses were located along the lingual surface of the epiglottis, one along the laryngeal surface, and 6 were not localized to either surface. Punch biopsies of abscess walls were obtained at drainage from 6 patients. One biopsy revealed an infected mucus retention cyst (mucopyocele) at the base of tongue that reached the lingual aspect of the epiglottis and caused bacterial infection of supraglottic structures. Epiglottic abscesses may generally be diagnosed by direct laryngoscopy, as abscesses are frequently found on the free edge or lingual side of the epiglottis. There are some published reports of swelling of the epiglottis accompanied by acute tonsillitis or peritonsillar
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K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
Fig. 8. (A) Axial contrast-enhanced CT scan of the patient in case 4 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead) on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead). (C) Coronal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
abscess. Ozanne et al. [5] reported MRI findings in an adult with epiglottitis. In this case, MRI was performed the day after admission to exclude an abscess. Obvious swelling of the suprahyoid epiglottis and left aryepiglottic fold were noted on MRI. Surrounding fat planes were obliterated. The left tonsil was swollen, without abnormal signal or enhancement. The epiglottis and aryepiglottic folds were normal on inspection 3 weeks later, but the left tonsil was still enlarged and purulent after palpation. Tonsillectomy was performed 2 weeks later. Ebisumoto et al. [3] reported six cases with epiglottic abscess. Five cases were accompanied by inflammation of the inferior pole of the palatine tonsil and one case had a peritonsillar abscess. These reports did not mention any causal relationships between swelling of the epiglottis, acute tonsillitis, and peritonsillar abscess. In our cases, diagnosis of the peritonsillar abscess by oropharyngeal inspection was difficult. Since the abscess was located around the inferior pole of the palatine tonsil, diagnosis was ultimately made by CT scan. We believe that swelling of the epiglottis in our cases occurred secondary to oropharyngeal infection. Common infectious agents include H. influenzae in children, and Group A and Group F bhemolytic Streptococcus pyogenes, Staphylococcus aureus, or Klebsiella pneumoniae in adults. Cultures of epiglottis and abscess often show normal flora or are negative. In our cases, culture study was performed only in case 2, in which throat swab culture revealed normal flora. Michaels reports that in acute epiglottitis, not only dose the epiglottis show signs of acute inflammation but the adjacent tongue and pharyngeal structure are also swollen at autopsy [6]. The aryepiglottic folds are swollen and the laryngeal inlet is greatly narrowed. Microscopic sections show in all cases an acute inflammatory exudate with neutrophils, and infiltration by red blood cells and fibrin in the anterior part of the epiglottis deep to the squamous epithelium. The actual airway obstruction is related to deep extension of acute inflammation in the larynx and not to the epiglottis itself. In our cases, CT scans showed not only the swollen epiglottis, but also enhancement of the base of tongue and lingual side of epiglottis. It is thought that as the epiglottis swells, the above-mentioned infectious agents
gain entry to the submucosal tissue through the pharyngeal epithelium, possibly through a crypt of the lingual tonsil. This induces severe pharyngitis and eventually occludes laryngeal inlet tissues. Oropharyngeal infection is thought to produce lymphadenitis of the peritonsillar space, probably around inferior pole of palatine tonsil, that becomes phlegmonous inflammation. This phlegmonous inflammation leads to abscess of the neck. Meanwhile, an acute inflammatory exudate comprised of neutrophils, red blood cells, and fibrin from the pharyngeal epithelium infiltrates the anterior part of the epiglottis deep to the squamous epithelium. This inflammatory exudate extends widely in the pre-epiglottic space, but never penetrates the epiglottic cartilage posteriorly. This exudate is thought to cause swelling of the epiglottis [6]. Recent developments in CT technology afford us with high resolution, 3D reconstruction images, and multiplanar reconstructed images. Additionally, active application of multidetector-row CT using a higher concentration of contrast material can more effectively detect lesions not found by endoscopy. We recommend CT examination for patients with a stable airway and swollen epiglottis, even if the swelling is mild to exclude a deep neck abscess. If CT scan reveals a peritonsillar abscess, treatment should include antibiotics against anaerobe. Incision and drainage of the abscess should also be considered.
References [1] Berger G, Laudau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003;24:374–83. [2] Hafish MA, Sheahan P, Keogh I, Walsh PM. Acute epiglottitis in adults: a recent experience with 10 cases. J Laryngol Otol 2006;120:310–3. [3] Ebisumoto K, Hara H, Orita H, Ymasaki A, Miyauchi Y, Yamashita H. Acute epiglottitis and epiglottic abscess: varying risk of airway obstruction. Koutou 2006;18:19–22. [4] Smith SS, Mukherji SK, Thompson JE, Castillo M. CT in adult supuraglottitis. AJNR 1996;17:1355–8. [5] Ozanne A, Marsot-Dupuch K, Ducreux D, Meyer B, Lasjaunias P. Acute epiglottitis: MRI. Neuroradiology 2004;46:153–5. [6] Michaels L. Acute epiglottitis. Ear, nose and throat histopathology. Berlin/Heidelberg: Springer-Verlag; 1987. p. 317–9.
Four cases of acute epiglottitis with a peritonsillar abscess Keiko Ito a,*, Hiroko Chitose a, Masamichi Koganemaru b a
Department of Otorhinolaryngology, Kumamoto Central Hospital, 955 Muro, Ozu-machi, Kikuchigun, Kumamoto 869-1235, Japan b Department of Radiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan Received 4 February 2010; accepted 11 June 2010 Available online 25 August 2010
Abstract We report four cases of acute epiglottitis with a peritonsillar abscess originating from the inferior pole of the palatine tonsil. All cases were male, and presented with acute onset of sore throat and dysphagia. Flexible laryngoscopy revealed swollen epiglottis and swelling at the base of tongue along the edge of the epiglottis in all cases. Computed tomography (CT) revealed the position and extent of a peritonsillar abscess. Surgical drainage was not performed. Abscesses decreased in size following intravenous antibiotics and corticosteroids. We surmise that inflammatory exudates extending widely in the pre-epiglottic space cause epiglottic swelling from oropharyngeal infection, the latter of which is thought to produce a peritonsillar abscess. We recommend CT examination for patients with a stable airway and swollen epiglottis, even if the swelling is mild. This will allow for exclusion of deep neck abscess and determination of the most effective treatment including intravenous antibiotics against anaerobe, incision and drainage of an abscess. # 2010 Elsevier Ireland Ltd. All rights reserved. Keywords: Epiglottitis; Peritonsillar abscess; Computed tomography; Pre-epiglottic space
1. Introduction
2. Case report
Acute epiglottitis is a bacterial infection of supraglottic structures that results in the symptom complex of sore throat, stridor, odynophagia, muffled voice, and high fever. It is a serious infection and may be fatal secondary to sudden airway obstruction. Epiglottic abscess is a rare complication of acute epiglottitis [1]. A rise in the incidence of acute epiglottitis along with a concomitant rise in the number of epiglottic abscesses has been recently noted [1,2]. Some patients with epiglottitis have concurrent peritonsillar abscesses [3] and/or deep neck abscesses [3,4]. We report four cases of acute epiglottitis with a peritonsillar abscess. We recommend CT examination for all patients with a stable airway and swollen epiglottis, even for mild swelling. CT scan will allow for exclusion of deep neck abscess and determination of the most effective treatment, including intravenous antibiotics against anaerobe, incision and drainage of the abscess.
2.1. Case 1 A 64-year-old man presented with a 3-day history of sore throat, dysphagia, fever (37.8 8C), and mild hoarseness. Flexible laryngoscopy revealed swollen erythematous epiglottis with involvement of the left arytenoid, bilateral salivary pooling in the piriform recesses, and swelling at the base of tongue along the left edge of the epiglottis (Fig. 1). White blood cell count was 18,500 cells/mm3 and C-reactive protein was 13.9 mg/dl. Throat swab culture was not performed. CT scan revealed an epiglottic abscess and a left-sided peritonsillar abscess (Fig. 2). Treatment with broad-spectrum intravenous antibiotics (carbapenem), clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 7 days after presentation. 2.2. Case 2
* Corresponding author. Tel.: +81 096 293 0555; fax: +81 096 293 2562. E-mail address: [email protected] (K. Ito).
A 34-year-old man presented with a 1-day history of sore throat and dysphagia. He complained of anterior neck
0385-8146/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2010.06.004
[(Fig._1)TD$IG]
K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
285
improvement of clinical status and he was discharged 7 days after presentation. 2.3. Case 3
Fig. 1. Direct laryngoscopy revealing an epiglottic abscess (A) and the wall of a peritonsillar abscess (W) on admission of the patient in case 1.
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tenderness over the hyoid bone. He was afebrile. Flexible laryngoscopy revealed an erythematous oropharynx. White blood cell count was 11,300 cells/mm3 and C-reactive protein was 3.1 mg/dl. Throat swab culture revealed growth of a-Streptococcus. He returned the following day given that his symptoms did not improve with oral antibiotics. The patient was found to be febrile (37.9 8C) and repeat flexible laryngoscopy revealed swollen epiglottis. Swelling at the base of tongue along the left edge of the epiglottis was also seen (Fig. 3). White blood cell count was 11,800 cells/mm3 and C-reactive protein was 11.8 mg/dl. CT scan revealed enhancement of the base of tongue and a left-sided peritonsillar abscess (Fig. 4). Treatment with broadspectrum intravenous antibiotics (carbapenem), clindamycin, and hydroxycortisone sodium succinate resulted in rapid
A 41-year-old man presented to an outside emergency room with a 1-day history of sore throat, dysphagia, and fever (37.3 8C). He had an erythematous oropharynx and was given oral antibiotics. His symptoms had not improved and he presented to our clinic the following day. Flexible laryngoscopy revealed swollen epiglottis, bilateral salivary pooling in the piriform recesses, and swelling at the base of tongue along the left edge of the epiglottis (Fig. 5). White blood cell count was 16,900 cells/mm3 and C-reactive protein was 16.9 mg/dl. Throat swab culture was not performed. CT scan revealed a left-sided peritonsillar abscess and enhancement of the base of tongue (Fig. 6). Treatment with intravenous 3rd generation cephalosporin, clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 5 days after presentation. Follow-up examination 3 weeks later showed a normal epiglottis and a CT scan demonstrated complete resolution of the peritonsillar abscess. 2.4. Case 4 A 27-year-old man presented to an outside emergency room with a half-day history of sore throat, dysphagia, and fever (37.1 8C). He had an erythematous oropharynx and was given oral antibiotics. His symptoms had not improved later the same day, so he visited a different emergency room. Examination revealed erythematous oropharynx and rightsided anterior neck tenderness. Acute epiglottitis was suspected and lateral neck radiographs were obtained. No thickening of epiglottic tissue was noted on the radiograph; he was given an anodyne suppository and referred to an otorhinolaryngologist. He presented to our clinic the
Fig. 2. (A) Axial contrast-enhanced CT scan of the patient in case 1 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar (arrowhead) abscess on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar (arrowhead) abscess.
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Fig. 3. Direct laryngoscopy revealing edema of the epiglottis (E) and the wall of a peritonsillar abscess (W) on day 2 of admission of the patient in case 2.
following day. Flexible laryngoscopy revealed swollen epiglottis and swelling at the base of tongue along the right edge of the epiglottis (Fig. 7). White blood cell count was 22,400 cells/mm3 and C-reactive protein was 7.3 mg/dl. Throat swab culture was not performed. CT scan revealed a right-sided peritonsillar abscess and enhancement of the base of tongue (Fig. 8). Treatment with broad-spectrum intravenous antibiotics (penicillin), clindamycin, and hydroxycortisone sodium succinate resulted in rapid improvement of clinical status and he was discharged 5 days after presentation.
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Fig. 5. Direct laryngoscopy revealing swelling of the epiglottis (E) and the wall of a peritonsillar abscess (W) on day 3 of admission of the patient in case 3.
3. Discussion Acute epiglottitis is a relatively rare, yet potentially lifethreatening condition. The most common symptoms in adults are odynophagia and dysphagia. Other symptoms include a muffled voice, drooling, cough, and fever. Dyspnoea occurs in a third of patients. Acute epiglottitis is diagnosed by direct laryngoscopy in most cases. CT imaging may be used to confirm the diagnosis when adequate laryngoscopic examination cannot be performed
[(Fig._4)TD$IG]
Fig. 4. (A) Axial contrast-enhanced CT scan of the patient in case 2 demonstrating enhancement of the base of tongue (arrow) and peritonsillar (arrowhead) abscess on day 2 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
[(Fig._6)TD$IG]
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287
Fig. 6. (A) Axial contrast-enhanced CT scan of the patient in case 3 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead) on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead). (C) Coronal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
[4]. Imaging should be considered only in patients with a stable airway, as the supine position required for CT or MRI increases the risk of acute respiratory distress. In case 3 and 4, although direct laryngoscopy showed mild swelling of the epiglottis, CT scan revealed a peritonsillar abscess. We recommend CT examination for all patients with swollen epiglottis, even if the swelling is mild. Smith et al. [4] described the appearance on CT and complications of supraglottitis in three adult patients. In that study, the most common CT findings were thickening of the epiglottis, aryepiglottic fold, false and true vocal cords, obliteration of pre-epiglottic fat, and thickening of subcutaneous tissue and muscles. Multiple loculated fluiddensity collections consistent with abscess were seen in one 35-year-old patient. In this patient, white blood cell count was 11,300 cells/mm3, and culture of the epiglottis grew blactamse-negative Haemophilus influenzae. These abscesses extended along the facial planes of the neck. Dominant collection extended from the submandibular space inferiorly
[(Fig._7)TD$IG]
Fig. 7. Direct laryngoscopy revealing partial swelling of the epiglottis (E) and the wall of a peritonsillar abscess (W) on admission of the patient in case 4.
along the sternocleidomastoid muscle. Abscesses were also seen anterior to thyroid cartilage, anterior to strap muscles, and in the supraclavicular region with extension into the mediastinum. This patient was directed to obtain appropriate surgical management. Although patients in case 3 and 4 did not have dyspnea nor remarkable swelling of the epiglottis, CT scan revealed a peritonsillar abscess. This CT finding suggested that swelling of the epiglottis occurred secondary to a peritonsillar abscess and excluded deep neck abscess caused by severe epiglottitis. This is consistent with Hafidh et al. [2], who reported 10 cases of acute epiglottitis in adults admitted to a tertiary referral center over a 6-month period. Two patients had concurrent acute tonsillitis and one had a peritonsillar abscess, which required incision and drainage. Degree of supraglottic swelling in these patients was mild, suggesting that it occurred secondary to oropharyngeal infection. CT findings in our cases included diffuse thickening of the epiglottis, aryepiglottic folds, and a peritonsillar abscess that originated from the inferior pole of the palatine tonsil. Two patients had both epiglottic and peritonsillar abscesses. Direct laryngoscopy revealed diffuse erythema with edema of the epiglottis, aryepiglottic folds, salivary pooling in the piriform recesses, and swelling at the base of tongue along the edge of the epiglottis. This swelling was thought to be the wall of an abscess. Epiglottic abscess is a rare sequela of acute epiglottitis. Berger et al. [1] reported that epiglottic abscess was evident in 24% of adult patients (28/118) studied with epiglottitis. Twenty-one abscesses were located along the lingual surface of the epiglottis, one along the laryngeal surface, and 6 were not localized to either surface. Punch biopsies of abscess walls were obtained at drainage from 6 patients. One biopsy revealed an infected mucus retention cyst (mucopyocele) at the base of tongue that reached the lingual aspect of the epiglottis and caused bacterial infection of supraglottic structures. Epiglottic abscesses may generally be diagnosed by direct laryngoscopy, as abscesses are frequently found on the free edge or lingual side of the epiglottis. There are some published reports of swelling of the epiglottis accompanied by acute tonsillitis or peritonsillar
288 [(Fig._8)TD$IG]
K. Ito et al. / Auris Nasus Larynx 38 (2011) 284–288
Fig. 8. (A) Axial contrast-enhanced CT scan of the patient in case 4 demonstrating enhancement of the base of tongue (arrow) and a peritonsillar abscess (arrowhead) on day 3 of admission. (B) Sagittal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead). (C) Coronal contrast-enhanced CT scan demonstrating a peritonsillar abscess (arrowhead).
abscess. Ozanne et al. [5] reported MRI findings in an adult with epiglottitis. In this case, MRI was performed the day after admission to exclude an abscess. Obvious swelling of the suprahyoid epiglottis and left aryepiglottic fold were noted on MRI. Surrounding fat planes were obliterated. The left tonsil was swollen, without abnormal signal or enhancement. The epiglottis and aryepiglottic folds were normal on inspection 3 weeks later, but the left tonsil was still enlarged and purulent after palpation. Tonsillectomy was performed 2 weeks later. Ebisumoto et al. [3] reported six cases with epiglottic abscess. Five cases were accompanied by inflammation of the inferior pole of the palatine tonsil and one case had a peritonsillar abscess. These reports did not mention any causal relationships between swelling of the epiglottis, acute tonsillitis, and peritonsillar abscess. In our cases, diagnosis of the peritonsillar abscess by oropharyngeal inspection was difficult. Since the abscess was located around the inferior pole of the palatine tonsil, diagnosis was ultimately made by CT scan. We believe that swelling of the epiglottis in our cases occurred secondary to oropharyngeal infection. Common infectious agents include H. influenzae in children, and Group A and Group F bhemolytic Streptococcus pyogenes, Staphylococcus aureus, or Klebsiella pneumoniae in adults. Cultures of epiglottis and abscess often show normal flora or are negative. In our cases, culture study was performed only in case 2, in which throat swab culture revealed normal flora. Michaels reports that in acute epiglottitis, not only dose the epiglottis show signs of acute inflammation but the adjacent tongue and pharyngeal structure are also swollen at autopsy [6]. The aryepiglottic folds are swollen and the laryngeal inlet is greatly narrowed. Microscopic sections show in all cases an acute inflammatory exudate with neutrophils, and infiltration by red blood cells and fibrin in the anterior part of the epiglottis deep to the squamous epithelium. The actual airway obstruction is related to deep extension of acute inflammation in the larynx and not to the epiglottis itself. In our cases, CT scans showed not only the swollen epiglottis, but also enhancement of the base of tongue and lingual side of epiglottis. It is thought that as the epiglottis swells, the above-mentioned infectious agents
gain entry to the submucosal tissue through the pharyngeal epithelium, possibly through a crypt of the lingual tonsil. This induces severe pharyngitis and eventually occludes laryngeal inlet tissues. Oropharyngeal infection is thought to produce lymphadenitis of the peritonsillar space, probably around inferior pole of palatine tonsil, that becomes phlegmonous inflammation. This phlegmonous inflammation leads to abscess of the neck. Meanwhile, an acute inflammatory exudate comprised of neutrophils, red blood cells, and fibrin from the pharyngeal epithelium infiltrates the anterior part of the epiglottis deep to the squamous epithelium. This inflammatory exudate extends widely in the pre-epiglottic space, but never penetrates the epiglottic cartilage posteriorly. This exudate is thought to cause swelling of the epiglottis [6]. Recent developments in CT technology afford us with high resolution, 3D reconstruction images, and multiplanar reconstructed images. Additionally, active application of multidetector-row CT using a higher concentration of contrast material can more effectively detect lesions not found by endoscopy. We recommend CT examination for patients with a stable airway and swollen epiglottis, even if the swelling is mild to exclude a deep neck abscess. If CT scan reveals a peritonsillar abscess, treatment should include antibiotics against anaerobe. Incision and drainage of the abscess should also be considered.
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