Epiglottitis in a 68-Year-Old Woman With Type 2 Diabetes Mellitus

January 1, 2007

A 68-year-old woman with type 2 diabetes mellitus presented with a sore throat of 3 days' duration and progressively worsening dysphagia to both solids and liquids, including her own saliva. She denied consumption of steak or fish with bones. Attempts to swallow caused her to grimace. Her voice was normal and her airway was clear, but tenderness was noted when the larynx was moved side to side.

 

A 68-year-old woman with type 2 diabetes mellitus presented with a sore throat of 3 days' duration and progressively worsening dysphagia to both solids and liquids, including her own saliva. She denied consumption of steak or fish with bones. Attempts to swallow caused her to grimace. Her voice was normal and her airway was clear, but tenderness was noted when the larynx was moved side to side.

A lateral soft tissue radiograph demonstrated diffuse swelling of the epiglottis (E) and an abnormal density at the level of the vallecula (V) (A). The white blood cell count was 24,800/µL with a left shift, and the serum glucose level was 127 mg/dL.

Scott Pullen, MD, of Knoxville, Tenn, diagnosed epiglottitis pending the results of tests to rule out a neoplastic process. Laryngoscopy revealed moderate edema of the epiglottis and arytenoids, with normal vocal cords and subglottic space. Contrast-enhanced CT scans of the neck showed circumferential thickening of the soft tissues of the airway (B, arrows) from the level of the thyroid cartilage to just above the vocal cords. These findings confirmed the initial diagnosis.

Epiglottitis can occur at any age. In adults, the incidence is about 1 to 4 per 100,000 per year.1,2 Mortality in adults is about 7% and has been reported to be as high as 20%.1 Infection with Haemophilus influenzae type B or group A streptococci is the most common cause. Adults usually present with sore throat and painful dysphagia; drooling and stridor are infrequent.1 Epiglottitis is essentially a clinical diagnosis, with support from laryngoscopy. Lateral soft tissue radiographs may show thickening of the epiglottis, known as the "thumbprint sign," which is pathognomonic for epiglottitis.

Epiglottitis is managed with immediate intravenous antibiotic therapy that covers the most common causative organisms. This patient was treated with levofloxacin, 500 mg/d IV, and clindamycin, 600 mg IV q8h. Intravenous methylprednisolone (125 mg for 1 dose, then 60 mg q6h) was also given. She was hospitalized for observation because of potential airway obstruction. Her hospital course was uneventful.

References:

REFERENCES:1. Carey MJ. Epiglottitis in adults. Am J Emerg Med. 1996;14:421-424.
2. Solomon P, Weisbrod M, Irish JC, Gullane PJ. Adult epiglottitis: the Toronto Hospital experience. J Otolaryngol. 1998;27:332-336.