My relief had arrived, and we were just starting sign-outs. The resident broke in, "This guy with the sore throat. I think he's sick!" Glancing up from the computer, she continued. "He's barely talking. He has inspiratory stridor. And he is sweaty."
The resident had me at inspiratory stridor. Diaphoresis on a chilly morning in our ED was just icing on the cake. Intrigued and concerned (we did not have ENT or an open OR at that time in our shop), I followed my oncoming colleague to the bedside. The experience was just as sphincter-tightening as the description. The 20ish-year-old man sitting bolt upright and holding on to the bed rails could not even count to one. The back of his throat was normal, and the bedside soft tissue lateral neck radiograph provided no reassurance.
Decision: immediate intubation. This was going to be tough. Few airways get tougher than this. All hands on deck (anesthesia, surgery, respiratory, CCU). All resources readied, including a scalpel and bougie.
The first look down was disorientingly frightening. It looked like a cervix. The swollen epiglottis and aryepiglottic folds allowed only a tiny opening still available for plastic to pass. With amazing skill, luck, and perhaps some prayer, a 6.0 ET tube made it through that tiny passageway into the trachea.
The patient was whisked away to the CCU, and we had time to debrief and review. The patient's lateral neck image was placed beside a normal one on the computer screen.
The epiglottis (red arrow on normal x-ray; cross our patient) had the telltale appearance of an epiglottitis thumbprint sign. Our patient also had a vallecula sign, a shallow vallecula seen with epiglottitis. The aryepiglottic folds (white cross) were more prominent than I had ever seen them. The extremely narrowed glottic opening (green line) explained the bizarrely ballooned hypopharynx; the patient had done everything he could to get air into his lungs. Staring at the images, we all knew that this would be one that would be imprinted on our brains for the rest of our careers. Adult epiglottis carries a mortality of seven to 20 percent. This patient was at the verge of meeting death that morning, and was pulled back from the edge.
Tips to Remember:
-Always respect inspiratory stridor and diaphoresis.
-The epiglottis always bisects the hyoid bone anteriorly. Follow the base of the tongue down into the vallecula, eventually reaching the hyoid. The usually narrow epiglottis (approximately 3 mm) should appear to spring up from the hyoid like a flower immediately posterior to the vallecula.
-Look for the thumbprint and vallecula sign when considering epiglottitis.
1. Ames WA, Ward VMM, et al. Adult epiglottitis: An Under-Recognized, Life-Threatening Condition. Br J Anaesth 2000;85(5):795.
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