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Sore Throat and Difficulty Breathing



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Am Fam Physician. 2001 Jun 1;63(11):2255-2256.

A 36-year-old woman with no significant past medical history presented with a two-day history of sore throat, which had worsened progressively over the previous six hours, with associated odynophagia. She also complained of mild shortness of breath and the “feeling of a lump” in her throat. No symptoms of recent fever or chills were present. She had been unable to obtain relief from over-the-counter medications, because she could not swallow pills. She was, however, able to swallow secretions without difficulty. On examination, she was noted to be sitting upright and breathing without tachypnea, retractions or stridor. Her voice was slightly muffled. Examination of the throat revealed erythema of the posterior pharynx with no exudate. Bilateral lymphadenopathy of the neck was present. The patient's lung examination was unremarkable. A lateral neck roentgenogram of the soft tissue was performed (see the accompanying figure).

Question

Which one of the following conditions is the most likely diagnosis based on the patient's history and physical examination?

A. Croup.

B. Bacterial tracheitis.

C. Epiglottitis.

D. Retropharyngeal abscess.

E. Foreign-body aspiration.

Discussion

The correct answer is C: acute adult epiglottitis. The patient had acute epiglottitis with significant airway obstruction.

The characteristic barking cough of croup is uncommon in epiglottitis and, in cases of croup, the epiglottis is not as inflamed and edematous. Although adults contract upper respiratory infections from the same viral agents that cause croup in infants and young children, their larger airway diameter prevents the narrowing that causes the classic barking cough and inspiratory stridor. Neck radiographs in patients with croup typically show subepiglottic narrowing (steeple sign) and a normal-sized epiglottis.

Bacterial tracheitis (also called pseudo-membranous croup) is an uncommon infection that usually occurs in children and has a severe, rapidly progressive course. The onset is acute and associated with copious purulent secretions, high fever and stridor. Examination of the posterior pharynx typically reveals a gray-white pseudomembrane.

Retropharyngeal abscesses are also most commonly seen in young children and present as complications of infected retropharyngeal lymph nodes. This condition is unlikely in adults because the retropharyngeal lymph nodes have usually diminished or disappeared by adulthood. In children, infection (usually beta-hemolytic streptococcus) spreads to the lymph nodes from an infected middle ear, sinus passage, nose or adenoids. In adults, the unusual occurrence of retropharyngeal abscesses may be associated with perforation of the posterior wall by foreign bodies or instrumentation. The major manifestations are dysphagia, cervical lymphadenopathy, dyspnea and hyperextension of the neck without meningeal signs. Lateral neck radiographs show a widening of the prevertebral space. The actual abscess can often be seen on computed tomographic scans.

While aspiration of a foreign body should always be considered in cases of acute onset of dysphagia and respiratory obstruction, it is more likely to be associated with sudden-onset cough and choking with absence of a preceding upper respiratory infection.

Epiglottitis is a dramatic, rapidly progressive infection of the epiglottis that is potentially fatal because of sudden respiratory obstruction by the inflamed epiglottic and supraglottic structures. In adults, epiglottitis is often called supraglottitis because the inflammation is usually not confined to the epiglottis but may also occur in the structure above it. Haemophilus influenzae type b (Hib) is still the most common pathogen, although the incidence of H. influenzae is now much less common with use of the Hib vaccine. Other potential causes include streptococci and Staphylococcus aureus, as well as viral sources. In adults, successful treatment requires early recognition of epiglottitis.

Radiographic examination of the neck in epiglottitis shows an obviously enlarged epiglottis (thumb sign) and distension of the hypopharynx. Direct visualization of the epiglottis by laryngoscope, if attempted, reveals a beefy red, edematous epiglottis. Some cases of airway closure during examination have occurred, and there is controversy about whether it should be attempted. This patient received immediate antibiotic therapy, parenteral steroids and close monitoring in the intensive care unit with equipment readily available for rapid intubation.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or reflecting the views of the Navy medical department or the Navy service at large.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



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