A 58-year-old man presented to the emergency department after having had severe throat pain, hoarseness, and fever for 2 days. A physical examination revealed no stridor, respiratory distress, or drooling. The results of an oropharyngeal examination were unremarkable. A lateral soft-tissue radiograph of the neck showed a “thumb sign” (arrow) (a normal lateral soft-tissue radiograph of the neck is shown in the Supplementary Appendix (see below), available with the full text of this article at NEJM.org).
This radiographic sign is a manifestation of an enlarged and edematous epiglottis, and it suggests a diagnosis of acute infectious epiglottitis. Intravenous antibiotics were administered, and subsequent fiberoptic laryngoscopy confirmed that the epiglottis was swollen and inflamed. An apical epiglottic abscess was also present; it was not drained and was managed medically.
Countries with routine pediatric immunization for Haemophilus influenzae serotype b have witnessed a dramatic reduction in the incidence of epiglottitis in children, with the result that the majority of cases of infectious epiglottitis now occur in adults. Given the substantial risk of airway compromise, this patient was admitted to the intensive care unit for observation. No causative organism was identified in blood cultures. When his symptoms diminished, the patient was discharged to his home and instructed to complete a course of oral antibiotics.
Source: NEJM
Casey Grover, M.D.
Stanford University Medical Center, and Kaiser Permanente, Stanford, CA
cgrover@stanford.edu
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