Epiglottitis

On oral board exams, we are often tested on challenging clinical cases, and epiglottitis is a prototype. One night, we get a call that a 50 year old hypertensive diabetic adult has the diagnosis and is in danger of losing his airway. As this is one of the more frightening anesthetic cases, all the anesthesiologists had a pow-wow, and we found that our collective experience in managing epiglottitis was quite small, and everyone who had seen a case had only seen it in children (where it is more common).

The epiglottis is the horse-shoe shaped fold of tissue that protects the windpipe when one swallows. When intubating a patient, we have to lift it up and navigate around it. In epiglottitis (shown on the right), the epiglottis becomes so angry and swollen it can be difficult to see where the vocal cords are.

The classic presentation of epiglottitis in a child is one of extremis. The child can barely breathe, tripoding himself by leaning forward onto his arms trying to catch air. With any disturbance, the epiglottis may close off, and the patient may die. Even placement of an IV can tip a child over. Here, luckily, the patient had IV access and could talk in two word sentences. He had a hoarse voice and was drooling, signs that things were getting worse. His airway needed to be protected while the antibiotics cleared the infection.

The ENT surgeons had slipped a tiny nasal camera in and they couldn't see anything. We talked about our options with them; we could keep the patient awake and try to navigate a larger camera through the vocal cords with the advantage of preserving the patient's spontaneous breathing. But if the ENT surgeons had no luck with a small camera, we weren't sure whether we'd be successful (and touching the vocal cords or epiglottis could cause irreversible spasm). If we put the patient to sleep, burning our bridge of spontaneous breathing, we had no guarantee we could intubate him.

In the end, we had the ENT surgeons prepare to do a surgical airway; they were ready to cut into the neck if everything we did failed. I put the patient to sleep rapidly then looked with a video laryngoscope. All I could see was purulent drainage and angry red tissue. When I identified the epiglottis, it looked pretty similar to the picture above (left: normal; right: epiglottitis). No matter what I did, I could not see vocal cords; the epiglottis was simply too swollen. But I blindly aimed the endotracheal tube where I expected the cords to be. When we ventilated the patient, we heard breath sounds, got end-tidal carbon dioxide, and confirmed we were in the right place. The surgeons didn't have to cut. The patient's vital signs never budged. It was one of the more nerve-wracking intubations I've had to do, and I'm glad I got the experience.

Image shown under Fair Use, from UpToDate.