A 2-year-old boy is brought to the emergency department at 2:30 a.m. complaining of throat pain, not drinking, drooling, difficulty swallowing, coughing, nasal congestion, and fever. The throat pain, difficulty drinking, and drooling started in the afternoon and have worsened over the night. He has had the coughing and nasal congestion for 3 days now. He was given some oral acetaminophen 45 minutes ago, but he could not swallow it. His past history is significant for frequent ear infections. His immunizations are "up to date."
At triage, the nurse notes that he is tired in appearance, but alert. He is given 14 mg/kg of acetaminophen rectally.
Exam VS T38.6 (rectal), P143, R28, BP not taken, oxygen saturation 100% in room air. He is active and alert. Not toxic. Not irritable. Drooling is noted but he is not tripodding. Eyes clear. TMs normal. Nose with thick mucus. Oral pharynx slightly red. The palate, gums, and oral mucosa were clear of any ulcers or petechiae. No tonsillar enlargement. No exudates. The epiglottis could not be seen. Neck supple, small nodes. Heart regular without murmurs. Lungs clear. No stridor. Good aeration. No retractions. He coughs occasionally and the sound of the cough is not croupy. Abdomen benign. Color and perfusion are good.
Although he does not look toxic and his airway function is assessed as being good, a lateral neck radiograph is ordered at 3:00 a.m. to look for a retropharyngeal abscess or epiglottitis.
The original radiograph displayed here was excessively dark. It was read with the assistance of a hot light. This scanned image shown here shows the radiograph scanned using standard light intensities and another view scanned using a hot light. Thus the image on the right shows the soft tissue structures better while overexposing the bony structures. The pre-vertebral soft tissue space is not widened. This essentially rules out a significant retropharyngeal abscess. The black arrow points to the tip of the epiglottis and the white arrow points to the pre-epiglottic space (vallecula).
The shape of the epiglottis is better seen on the overexposed (whiter) image on the right. The epiglottis should normally be thin or triangular in appearance. In this view, it appears to be rounded and somewhat thumb-like, which is similar to the classic radiographic description of epiglottitis. The pre-epiglottic space is fairly well preserved but it is slightly shallow. In epiglottitis, the pre-epiglottic space is obliterated or very shallow due to the inflammation of the epiglottis. The positioning of the patient does not show his neck well extended.
It was felt that this patient probably did not have epiglottitis, but the radiograph was suspicious enough to worry the physician. A tongue depressor was used to visualize the epiglottis, but it still could not be seen. He was sent back to the imaging department to repeat his lateral neck radiograph with better positioning.
This radiograph was again somewhat dark. The epiglottis still appeared to be enlarged (thumb-like) and the pre-epiglottic space was still shallow. At 3:30, it was decided to get a radiologist's consultation by teleradiology. The patient was given IM ceftriaxone while waiting for the radiologist's call. The radiologist reviewed both radiographs and agreed that they appeared to show epiglottitis.
The child continued to look good. No stridor was noted, but he continued to drool. VS at 3:40 a.m. T37.8 (rectally), P145, R40, BP not done, oxygen saturation 100% in room air.
The physician was still convinced that the child did not have epiglottitis. After a discussion with his mother, the physician looked at the epiglottis using a laryngoscope. The epiglottis was swabbed for a culture. The epiglottis was not enlarged, but it was slightly erythematous.
At 4:30 a.m., an ENT surgeon was called. He felt that it was satisfactory to hospitalize the child in a floor bed for observation. He did not feel that intubation was indicated, nor admission to a more advanced or intensive care unit for observation.
Although the epiglottis was somewhat erythematous, its anatomic shape and size were normal. How could a structurally normal epiglottis cast an abnormal radiographic shadow? One could only conclude that the examiner did not view the epiglottis correctly during laryngoscopy or that the radiographic appearance is due to some type of artifact that is appearing on two separate radiographs.
Over the next few hours, the patient did not worsen. The ENT surgeon reviewed the radiographs and agreed that the epiglottis appeared to be enlarged. Fiberoptic laryngoscopy carried out later that morning showed 3+ adenoid hypertrophy, mucopurulent discharge, a non-enlarged epiglottis, 3+ edema of the vocal cords, and a clear subglottic region.
A second radiologist who looked at the radiographs felt that both radiographs showed a normal epiglottis. The epiglottis can appear to be rounded if the lateral neck is taken at an oblique angle.
In this case, I thought that it would be very difficult to view the epiglottis with a laryngoscope in an awake 2-year-old without sedation. However, it was surprisingly easy. With the patient supine, it was only necessary to use the laryngoscope blade to push down the posterior aspect of his tongue. It was not necessary to insert the blade all the way to the epiglottis or the vallecula. He gagged a little, but it was so easy to see the epiglottis that it was not necessary to leave the laryngoscope blade in place as one would need to for intubation. The normal size and shape of the epiglottis on direct visualization in this case should have effectively ruled out epiglottitis. The slight erythema of the epiglottis may have been due to a viral infection such as laryngitis.