A 54 year old female with no past medical history presented to the emergency room complaining of “sore throat” for the past two days. She described it as throat tightness and fullness and was associated with mild dyspnea, dysphagia and low-grade fever. Her vital signs were stable with O2 saturation of 92% on room air. Examination of the oropharynx revealed erythema of the tonsils and the surrounding oropharyngeal area. No stridor or wheezing was appreciated. Rapid Group A Strep was negative. Laboratory was significant for WBC of 21.9 cells/mm3 with 15% bands. Electrolytes, renal and hepatic panels were all unremarkable. Chest xray was normal. CT scan of the neck revealed edema along the aryepiglottic folds and the arytenoids. She was evaluated by Otolaryngology and subsequently performed a flexible laryngoscopy that demonstrated generalized erythema and edema over the arytenoids, the aryepiglottic folds as well as the laryngeal surface of the epiglottis consistent with acute supraglottitis. Airway was patent. She was admitted for close airway monitoring and initiated on IV dexamethasone, IV ampicillin/sulbactam. She remained stable without need for invasive airway management and was discharged with resolution of symptoms.
Discussion:
Acute supraglottitis is a serious and potentially fatal infection owing to its risk for sudden upper airway obstruction. It is characterized by inflammation of the epiglottis, aryepiglottic folds and arytenoids that can swell precipitously once infection begins. Infectious causes are broad but Haemophilus influenzae type B accounts for 3-14% among identified pathogens. The main presenting features are sore throat and/or odynophagia which occur in 90% to 100% of cases but can have varying presentations making diagnosis challenging. The severity of sore throat can be occasionally out of proportion to examination findings. A strong suspicion and making a definitive diagnosis are crucial. Although radiographic imaging such as x-ray and/or CT are used, fiberoptic laryngoscopy is the gold standard for diagnosis. Medical therapy involves antibiotics active against Gram-positive organisms and Haemophilus influenzae type B. The use of steroids remains controversial but a short course (in the absence of contraindication) may reduce airway inflammation.
Conclusions:
This case aims to increase awareness of this potentially life-threatening infection. Because it is uncommon in adults, it can easily be misdiagnosed and managed inappropriately. Its varying presentations make it challenging and can mimic a number of upper airway infections. A high index of suspicion is critical as airway obstruction in these cases can be rapidly progressive and thus, warrants hospitalization. An aggressive approach from recognition to diagnosis is paramount as delay in management can prove fatal.