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July 2008 Radiology Quiz
This patient is a 6 year old male who presents to the ED with sore throat and shortness of breath The following ray is shown.
Questions:
1. Describe what you see?
- Lateral x-ray shows a marked thickening of the epiglottis and narrowing of the laryngeal airway (Thumb Print Sign)
- Retropharyngeal swelling
2. Your differential includes?
- Croup
- Bacterial tracheitis
- Lingual tonsillitis
- Retropharyngeal abscesses
- Angioedema and foreign bodies cause a sudden onset of acute respiratory distress without antecedent illnesses
3. The most common organism is?
- Epiglottitis can be caused by bacteria (most commonly Haemophilus influenzae type b, Streptococcus species, Staphylococcus species), viruses, and fungi, although most frequently no organism can be isolated.
4. How do these patients present?
- They present with sore throat, fever, drooling, severe dysphagia, dyspnea, muffled or hoarse voice, and occasionally inspiratory stridor. Patients with severe respiratory distress assume the "tripod" position: sitting upright with the neck extended, arms supporting the trunk, and the jaw thrust forward. This position maximizes airway patency and caliber. Adults typically have an indolent course with a prodromal viral illness, but many children have a sudden onset and rapid progression to respiratory distress.
5. What would be your management for this patient?
- Patients with suspected epiglottitis require immediate otolaryngology consultation, and the emergency physician must be prepared to establish a definitive airway. The stable pediatric patient is treated with endotracheal intubation, preferably in the operating room. Patients with signs of impending airway obstruction can be treated with a bag-valve mask ventilation while preparing for a definitive airway. Orotracheal intubation can be attempted but will be difficult secondary to anatomic distortion. If intubation is unsuccessful, patients < 8 yrs may require needle cricothyroidotomy and those > 8 yrs may require surgical cricothyroidotomy. Once the airway is secured the patient should be given antibiotics such as: Cefuroxime 0.75–1.5 g IV q8 hrs is the recommended first-line treatment and should be initiated in the ED. Cefotaxime, ceftriaxone, or ampicillin/sulbactam is an acceptable alternative.
6. In acute somatic dysfunction is edema present?
Trivia: Where did Led Zeppelins last American concert of 1969 take place.
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