Treating A Sore Throat With Intubation. A case of Epiglottitis in an elderly patient. Sherif Yani, PGY3 St Joseph s FM Residency

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1 Treating A Sore Throat With Intubation A case of Epiglottitis in an elderly patient. Sherif Yani, PGY3 St Joseph s FM Residency

2 Outline H&P Diagnosis Management Discussion Take-Home Points

3 History 88 y/o F with history of HTN, T2DM, dementia brought in by her daughter to Urgent Care due to sore throat and poor PO intake over the past few weeks. She has been in and out of doctor s offices and ER with no improvement and no clear diagnosis. Patient was stable on exam with no acute abnormalities and discharged on empiric antibiotics. Patient brought to the SJH ER a few days later with no improvement and admitted to the hospital for further work-up.

4 What would you do What would you do if this lady came into your office? What would you look for on exam? When would you follow-up? Any urgent referrals or admission to hospital?

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6 Physical Exam Vitals: 146/75 mmhg, HR 62, 98F, O2 98% RA Frail elderly woman with dementia, she is AAO to person but not place or time (consistent with her baseline as reported by her daughter at bedside). She was noted to have difficulty swallowing when given her medications by nursing staff at bedside HEENT exam wnl. Oropharynx clear and moist with mild erythema otherwise no swelling/exudate/ LAD. Chest: RRR, no murmurs Lungs: CTA b/l, w/o rhonchi/rales/wheezing Abdominal exam: BS+, soft, nontender, no guarding/rebound tenderness or organomegaly Rest of exam fairly benign

7 What would you order? Labs? Imaging? Consults?

8 Diagnosis & Management CBC, CMP, TSH, B12, CXR wnl Blood cx and throat cx negative; Hemophilus influenzae Ig Ab positive SLP noted oral and pharyngeal dysphagia. MBS showed evidence of thickened epiglottis. She was started on modified diet. CT neck with IV contrast showed epiglottitis of acute inflammatory or infectious pathology. Challenging case given no ENT or ability for laryngoscope at SJH; attempted to transfer patient. Patient was started on empiric antibiotics with IV Ceftriaxone and Vancomycin Patient was placed under closer observation due to the need for potential intubation if her status declined. (PCU or even ICU is preferred) She stabilized over the course of the week and improved on IV empiric antibiotics without the need for intubation or O2 support.

9 Epiglottis width 6.4mm on admission (left); Epiglottis width 4.1mm s/p 1 week of IV antibiotics (right).

10 Discussion Acute Epiglottitis in the elderly can present with atypical presentations. Most cases of epiglottitis have negative blood and throat cx. If intubated then epiglottis cultures are useful Most common organisms: Hib, Strep pneumonia, GAS, MSSA/MRSA Traumatic causes (foreign body, caustic ingestion) 1.6 cases per 100,000 per year in USA (0.5 in children) Risk factors in adults: age/immunocompromised, DM, HTN, substance abuse

11 Discussion (continued) Important to notice need for intubation if unstable; oxygenate and intubate if emergent DDX: foreign body, peritonsillar abscess, angioedema, upper airway trauma. Empiric treatment with 3 rd gen cephalosporin and Anti-staph agent (Vancomycin) Evidence of benefit of using glucocorticoids is lacking (no reduced LOS and there is an increased risk for GI bleeds)

12 Discussion (continued) Retrospective study in Journal of Emergency Medicine 2017 showed that FN results on lateral neck XR are common. EW>6.3mm had best diagnostic accuracy, however prior antibiotic use is a risk factor. Retrospective study from Department of Otolaryngology from University S. California showed high risk criteria warranting more aggressive management using adults (mean age 53) presenting with dysphagia and sore throat. Patients with elevated blood glucose, CRP and history of prior episodes warrant more aggressive investigation as they are more likely to require ICU and intubation (p=0.005, n=358) Indication for airway intervention have not been established but findings of <50% of glottis visualized on laryngoscope is the most important factor. Other factors to consider are leukocytosis, dyspnea, odynophagia, hoarseness, drooling (Royal Belgian Society for ENT, 2016)

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14 Take-Home Points Prophylactic airway management is not necessarily indicated but close monitoring of airway in a controlled intensive care environment is recommended. Epiglottitis in adults is more common than previously appreciated. It is crucial to recognize important history and physical exam findings in order to initiate airway management if needed, as delaying this can be fatal. It is prudent to manage patients without dyspnea in a setting where intubation can be administered if needed. Improvement should be noted with empiric antibiotics otherwise consider alternative diagnosis.

15 References Shapira Galitz, Shoffel-Havakuk. Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention Sep;127(9): doi: /lary Epub 2017 May 11. Yen-Liang Chang MD,Shih-Hung Lo MD, Acute Epiglottits 2017 Japan-Taiwan Conference in Otolaryngology-Head and Neck Surgery, Tokyo, Japan, October 29-31, Lee SH, Yun SJ Do we need a change in ED diagnostic strategy for adult acute epiglottitis? /j.ajem Epub 2017 Apr 20. Shimizu Y, Mori E Airway intervention in cases of acute epiglottitis. B-ENT2016;12(4): Paul Hebert, Yadranko Ducic Adult Epiglottitis in Canadian setting 1998 in The Laryngoscope