Acute Supraglottitis Causing Airway Obstruction in Adults – A Case Series

Abstract

Acute adult supraglottitis is a serious and potentially life-threatening condition marked by inflammation of the supraglottic structures, posing a significant risk for rapid airway compromise. This case series highlights the varied presentations and management challenges associated with adult supraglottitis. The four cases involve adult males, most with uncontrolled diabetes mellitus, presenting with symptoms such as difficulty breathing, sore throat, dysphagia, and voice changes. Diagnostic approaches included soft-tissue neck radiographs and video laryngoscopy, with common findings of an edematous epiglottis and “thumbprint” sign. Management strategies ranged from conservative treatment with antibiotics and steroids to emergent airway interventions like tracheostomy. These cases underscore the importance of early diagnosis, close monitoring, and tailored treatment to prevent severe outcomes. The series emphasizes the need for high clinical suspicion and prompt action in cases of adult supraglottitis, especially given its potential for rapid deterioration and significant morbidity.

Introduction

Adult supraglottitis is a severe and potentially life-threatening emergency characterized by inflammation and swelling of the supraglottic structures of the larynx, such as the arytenoids, false vocal cords, laryngeal ventricles, aryepiglottic folds, and epiglottis. Its nonspecific and variable clinical presentations make diagnosis challenging. Patients with supraglottitis can rapidly experience airway compromise due to the swelling, potentially leading to respiratory arrest [1]. With the advent of immunizations against Haemophilus influenzae serotype b, the incidence of epiglottitis in the pediatric population has significantly declined over the past several decades. As a result, the majority of epiglottitis cases now occur in adults [2].

The annual incidence of adult supraglottitis ranges from 1.1 to 4.7 per 100,000 [1]. Acute epiglottitis, or supraglottitis, is definitively diagnosed by visualizing an edematous, cherry-red epiglottis through direct or indirect laryngoscopy. Lateral neck radiographs will show an enlarged epiglottis with ballooning of the hypopharynx and prevertebral soft tissue swelling [3].

Accurately identifying epiglottitis is critical, as it may require immediate intervention. Treatment is tailored to the degree of airway obstruction, with some patients improving with conservative measures and others needing an emergent artificial airway. Identifying risk factors for patients likely to require airway intervention is paramount [2].

Acute infectious laryngitis is characterized by inflammation of the larynx that usually accompanies upper respiratory tract infections with symptoms that may include cough, congestion, postnasal drip, mucus hoarseness, sore throat, odynophagia, dysphagia, dyspnea. This resolves within 3 weeks [4] which mimics similar to acute supraglottitis except a few impending signs which are more predominant in acute supraglottitis.

The differential diagnosis for epiglottitis includes benign conditions such as pharyngitis, laryngitis, viral syndrome, and influenza, as well as severe conditions causing airway obstruction, such as angioedema, anaphylaxis, foreign body aspiration, and caustic ingestion [2].

This case series holds significance in enhancing the importance of variable presentations of acute supraglottitis in adults and the challenges faced in treating them accordingly and managing airway emergencies.

Case Presentation

Case Series 1

A 35-year-old male who is a known case of Type − 2 Diabetes Mellitus, on irregular treatment presented to ENT OPD with complaints of difficulty in breathing for 1 day and a history of cough, throat pain, difficulty and painful swallowing, and voice change for 3 days. No history of noisy breathing. No history of smoking or alcohol consumption. On examination, the patient was afebrile (temperature − 36.4 C) and the rest of the vitals revealed a heart rate of 102/min, blood pressure – 140/90 mmHg, respiratory rate of 24 cycles/min, and oxygen saturation of 97% on room air, with elevated blood sugar values, with HbA1c – 9.2. A portable soft-tissue neck radiograph was obtained, which showed an enlarged and edematous epiglottis or “thumbprint “sign (Fig. 1A). Based on the severity of the findings mentioned above and concern for impending airway obstruction, the patient was shifted to the operating room, with tracheostomy consent and a Video laryngoscopy was done which showed congested and edematous epiglottis. Pus pointing was present over the lingual surface of the epiglottis (Fig. 1B). The airway was adequate. B/L Pyriform Sinus (PFS) -pooling of saliva present. A culture and sensitivity swab were taken from pus pointings over the lingual surface of the epiglottis and was reported as staphylococcus aureus. The patient was treated with a sensitive antibiotic - Intravenous Linezolid and a tapering dose of IV steroids, steroid nebulization, anti-inflammatory – trypsin–chymotrypsin analgesics, and anti-diabetic medications. Repeat video laryngoscopy was done after 48 hours and there was reduced edema of epiglottis. (Figure. 1C) The patient improved symptomatically and was discharged after 72 hours.

Fig. 1.

(A) : Congested and edematous epiglottis. Pus pointing is present over the lingual surface of the epiglottis. (B): On x-ray neck lateral view, the epiglottis is swollen and enlarged showing a classical “Thumb sign”. (C): Repeat video laryngoscopy was done after 48 h which revealed reduced edema of the epiglottis

Case Series 2

A 58-year-old male with a history of Type 2 Diabetes mellitus and on irregular medications presented to the Emergency Room with difficulty in breathing, noisy breathing, and change in voice for 1 day. On examination, the patient was afebrile (37.6 C) and other vitals revealed heart rate − 118/min, Respiratory rate – 23cycles/min, and blood pressure − 160/100 mmHg. Oxygen saturation was 90% in room air. Inspiratory stridor was heard. A portable X-ray soft tissue neck lateral view showed a “thumb sign” and an X-ray neck AP view showed a” steeple sign”(Figure. 2A, 2B). Because of the respiratory distress, the patient was given an injection of Hydrocortisone 100 mg IV stat, and steroid nebulization and immediately shifted to the operating room with emergency tracheostomy consent. Video laryngoscopy showed epiglottitis – congested and edematous, arytenoids - congested, edematous, and airway compromised with stagnant secretions (Fig. 2C). An emergency tracheostomy was done under Local anesthesia and the airway was secured. Post-operatively, the patient was shifted to the ICU for observation. The patient was treated with IV antibiotics, tapering doses of IV steroids, steroid nebulization, analgesics, and anti-inflammatory and anti-diabetic medications. The patient improved symptomatically, and a repeat Video laryngoscopy was done on postoperative day (POD)- 8 and was normal. Decannulation was done after spigotting for 48 h, blood sugars were controlled and the patient was discharged on POD#10.

Fig. 2.

(A): X-ray soft tissue neck lateral view showed a “thumb sign”. (B): X-ray neck AP view showed a” steeple sign”. (C): Video laryngoscopy showed epiglottitis – congested and edematous, arytenoids - congested, edematous, and airway compromised with stagnant secretions

Case Series 3

A 45-year-old male with a history of Type 2 Diabetes mellitus came to ENT OPD with complaints of difficulty in breathing, change in voice, pain while swallowing, and fever for 2 days. No history of noisy breathing. On examination, the patient was febrile (38.6 C) and other vitals revealed heart rate − 110/min, Respiratory rate – 24 cycles/min, and blood pressure 150/90 mmHg. Oxygen saturation was 90% in room air. A portable X-ray soft tissue neck lateral view showed a “thumb sign “– edematous epiglottis (Fig. 3A). Given suspicious airway compromise, the patient was shifted to the operating room with emergency airway equipment on the side and underwent a Video laryngoscopy which showed swollen epiglottis with edematous arytenoids and aryepiglottic fold. B/L pyriform fossa pooling of saliva was present, but the airway was adequate (Fig. 3B). The patient was kept in the ICU for observation and was treated conservatively with IV Ceftriaxone, tapering doses of IV steroids, Steroid nebulization, anti-inflammatory, and adequate control of blood sugar levels. Repeat video laryngoscopy was done after 3 days and was normal (Fig. 3C) and the patient was discharged.

Fig. 3.

(A): X-ray soft tissue neck lateral view showed a “thumb sign “– edematous epiglottis. (B) showed swollen epiglottis with edematous arytenoids and aryepiglottic fold. B/L pyriform fossa pooling of saliva was present, but the airway was adequate. (C) Repeat video laryngoscopy was done after 3 days and was normal

Case Series 4

A 38-year-old male with no comorbid illness came to ENT OPD with complaints of sore throat, shortness of breath, difficulty and pain during swallowing, and drooling of saliva for 2 days, with no history of noisy breathing. On examination, the patient was afebrile, and other vitals revealed heart rate − 105/min, Respiratory rate – 22 cycles/min, blood pressure 140/90 mmHg. Oxygen saturation was 98% in room air. Given the suspicious history and examination, an X-ray of neck soft tissue AP and lateral view showed edematous epiglottis. Despite the patient’s vitals being stable, the patient was admitted and shifted to the operating room for a video laryngoscopy to look for the status of the airway. Video laryngoscopy revealed stagnant secretions in the oropharynx, and edematous epiglottis with adequate airway (Fig. 4). A hemogram showed leukocytosis with neutrophil predominance. The patient was treated with IV antibiotics, IV steroids, and other supportive management. The patient improved symptomatically and was discharged after 4 days.

Fig. 4.

Revealed stagnant secretions in the oropharynx, and edematous epiglottis with adequate airway

Discussion

Acute adult supraglottitis (AAS) is indeed a serious condition primarily affecting the epiglottis and surrounding structures, with a significant risk of upper airway obstruction [1, 5]. This severity necessitates close monitoring in an intensive care setting.

The condition is more prevalent in males, with a male-to-female ratio of approximately 3:1, and typically affects individuals in their 40s and 50s [5]. The incidence of AAS in adults is relatively low, ranging from 0.97 to 3.1 cases per 100,000 people, but it has a notable mortality rate of around 7.1% [6].

The most frequently reported pathogen when an infectious agent is isolated is Streptococcus pneumoniae, however, Neisseria meningitides and Staphylococcus aureus have also been linked to infections. Non-bacterial causes, such as viruses, trauma, heat injury, irritating chemicals, recreational drugs, chemotherapy, and radiation therapy, are less frequently observed [1, 2, 8].

The literature lists several risk factors for the AAS, including diabetes mellitus, hypertension, obesity, smoking, alcohol misuse, pneumonia, and cancers.

[2, 5] In our case series, the majority had uncontrolled diabetes mellitus which could be a contributing factor for acute epiglottitis.

Many patients, nevertheless, do not have any risk factors at all. Airway intervention is thought to be strongly predicted by stridor and respiratory distress. On the other hand, it has also been demonstrated that more subdued indications and symptoms, such as tachypnea, tachycardia, and subjective dyspnea, can also serve as indicators for airway intervention [2].

Epiglottitis commonly manifests as an abrupt high fever, a severe sore throat, and trouble swallowing, necessitating sitting up and leaning forward to improve airflow. Drooling is typically caused by pain and difficulties swallowing. Generalized toxemia is typically the result of acute epiglottitis [6].

The study by Abdellah et al. states that odynophagia (100%), voice change (75%), and dysphagia (85%) are the most prevalent presenting symptoms in adults, Stridor is considered a warning indication for upper airway obstruction in adults. The rapid start of symptoms, tachycardia, tachypnoea, a “thumb-sign” shown on lateral neck X-rays in 79% of patients, and stridor are all strong indicators of impending airway compromise and rapid clinical deterioration [6].

Moreover, certain factors have been suggested as signs of impending airway obstruction. These include dyspnoea, drooling, a history of diabetes mellitus, Rapid onset of symptoms, and epiglottic abscess [7].

In this study, the thumb sign was positive in the majority of cases, where an X-ray soft tissue neck lateral view was done. Fiber optic nasopharyngeal endoscopy is the most reliable and diagnostic tool for supraglottitis [2, 3, 5]. the thumb sign provides a non-invasive diagnosis the result is that the thumb sign has a specificity of 89.2% and sensitivity of 92.2% [5].

A team approach is required for visualizing the epiglottis in the operating room with the Anaesthesiology and Otolaryngology departments when there are concerns about impending airway obstruction [2, 6].

Ultrasonography has been described as a method to investigate the epiglottis by visualizing the “alphabet P sign” in a longitudinal view through the thyrohyoid membrane [6].

Apart from X-ray one other imaging modality, Ultrasonography can be used to visualize epiglottis as an “alphabet P sign” in a longitudinal view through the thyrohyoid membrane [6].

CT imaging can be used in stable patients when suspecting conditions like retropharyngeal abscess. A CT scan is not routinely needed for diagnosis of supraglottitis. But it helps to diagnose complications that may cause infection to spread to the neck or chest forming multiple abscesses in the oropharyngeal area [2, 5]. Imaging modality should not delay airway intervention in patients presenting with respiratory distress [2].

In this case series, all the cases had variable presentations that needed an emergency assessment and appropriate way of management. Case 1 presented with infective etiology and was managed accordingly.

Case 2

presented with an airway emergency that required prompt intervention to secure the airway immediately. Case 3 was suspicious of an airway emergency which required a close follow-up in the intensive care unit. All the 3 cases had uncontrolled diabetes mellitus which needed crucial management for improvement. Case 4 was managed conservatively but had a suspicious history which required a close follow-up too.

Patients whose airway is reduced by more than 50% typically present with respiratory distress and require immediate intervention to secure the airway. Those with milder symptoms and mild to moderate edema need admission for close airway monitoring and the initiation of intravenous antibiotics and steroids. Signs of severe respiratory distress necessitate immediate airway establishment, either by tracheostomy or endotracheal intubation [7].

Induction may be performed with the patient sitting upright, as forcing the patient into a supine position may precipitate acute airway obstruction. Anaesthesia induction, achieving a deep level of anaesthesia while maintaining spontaneous ventilation, is the method of choice. The time required to produce deep anaesthesia using an inhalation induction may increase due to airway obstruction, potentially necessitating increased gas concentration. Capnography is useful in assessing the depth of anaesthesia with exhaled gas analysis. Muscle relaxants should be avoided, and spontaneous ventilation should be maintained [6].

Medical management, with empiric broad combination antibiotic therapy with 3rd generation cephalosporins and vancomycin is commonly recommended. Steroid plays a role in acute management. Steroid use is controversial, few studies suggest that steroid use reduces the duration of hospital stays in ICU . Bronchodilators, such as racemic epinephrine, are not effective in acute epiglottitis but may be considered in patients with impending airway obstruction while preparing for airway intervention [2].

Differential diagnoses include retropharyngeal or peritonsillar abscesses, bacterial tracheitis, thermal epiglottitis (scald burn from smoke or hot beverages), possibly angioneurotic edema, uvulitis, and diphtheria. Complications include epiglottic abscess and systemic bacteremia [3].

Although acute epiglottitis is now relatively uncommon due to widespread vaccination efforts, it remains crucial to maintain a high level of suspicion, and promptly recognize, and accurately diagnose epiglottic infection in adults to prevent rapid respiratory compromise and severe clinical decline [8]. This case series serves as an important reminder that any case presents with above-mentioned symptoms as in this case series requires appropriate management and to find impending airway cases and manage accordingly. Acute supraglottitis should be kept as one of the differentials in patients presenting with odynophagia, dysphagia, and stridor considering that these can become an airway emergency rapidly.

Conclusion

Acute supraglottitis is commonly considered a paediatric pathology, but it can also affect adults rarely, Early diagnosis and prompt treatment are crucial for achieving complete remission of the illness.

Author Contributions

All authors contributed to the research article. All authors read and approved the final manuscript.

Funding

No funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.

Declarations

Ethical Approval

Ethical committee approval was obtained to carry out this study.

Informed Consent

was obtained from the patient for investigations used in this manuscript.

Competing Interests

Authors have declared that no competing interests exist.