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\begin{document}

\title{Case Report: Adult Presentation of Acute Epiglottitis with Severe Airway
Complications -- Emergency Management and Surgical Intervention}



\author[1]{Ahmed Sajid}%
\author[1]{Muhammad Hamza Rafique }%
\author[1]{Farva Khan}%
\author[1]{arsal.22}%
\author[1]{ayesha.22}%
\author[1]{Zainab Khan}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
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\sloppy


\textbf{Introduction}

Epiglottitis refers to inflammation of the epiglottis and adjacent
supraglottic structures, primarily due to infection {[}1{]}. Without
treatment, epiglottitis can progress to life-threatening airway
obstruction. Historically associated with pediatric populations,
particularly causing emergency airway obstruction in young children
under the age of 6, the epidemiology of epiglottitis has shifted with
the widespread use of conjugate vaccines. In recent years, cases in
adults have become increasingly rare, making the presentation of
epiglottitis in the adult population an intriguing and uncommon
occurrence.

\textbf{Pathophysiology and Airway Obstruction in Children:}

The pathophysiology of epiglottitis involves inflammation of the
epiglottis and adjacent structures, often resulting from bacteremia or
invasion of epithelial layer by pathogenic agent {[}2,3,4{]}. In
children, this inflammation can lead to acute upper airway obstruction.
The proximity of the inflamed epiglottis to the airway makes it
particularly susceptible to swelling, potentially causing respiratory
distress {[}3,4{]}. This life-threatening complication emphasizes the
urgency of prompt diagnosis and intervention in pediatric cases.
Understanding the pathophysiological mechanisms is crucial for effective
management and prevention of severe outcomes.

\textbf{Unique Presentation in Adults -- Our Case:}

The epidemiological landscape of acute epiglottitis has evolved
significantly since the introduction of vaccines against H. influenzae
type b (Hib), but may still be isolated in completely vaccinated
children {[}5,6,7,8,9{]}. In the current post-conjugate vaccine era,
epiglottitis has predominantly shifted towards affecting adults, with an
estimated annual incidence ranging from 0.6 to 1.9 cases per 100,000
{[}10,11{]}and an overall mean age of onset between 45 to 49 years
{[}12,13{]}. Notably, our case report adds a unique dimension to this
evolving scenario. The 28-year-old male patient sought emergency medical
attention when he presented with severe respiratory difficulty, with a
history of sore throat and vomiting over three days, eventually leading
to the diagnosis of acute epiglottitis {[}14{]}. In contrast to the
typical course observed in adults, our case introduces an uncommon
complication -- acute upper airway obstruction. This deviation
challenges the established norms and highlights the dynamic nature of
epiglottitis in adult's post-vaccination. The patient's presentation
highlights the importance of vigilance in recognizing and managing
uncommon complications associated with this condition in the adult
population. Additionally, comorbid conditions such as hypertension,
diabetes mellitus, and other factors mentioned in the epidemiological
context contribute to noninfective causes of acute epiglottitis and its
management in adults {[}15,16,17,18{]}.

\textbf{Case Presentation:}

\textbf{Hospital Course:}

The 28-year-old male patient presented to the outpatient department with
a 3-day history of sore throat, vomiting, and fever. Upon arrival at
12:50 pm, he exhibited severe respiratory difficulty and stridor.
Clinical examination revealed a severely congested throat with bilateral
grade 2 tonsillar hypertrophy and follicles. Due to the emergent nature
of the situation, an emergency tracheostomy was performed. Prior to the
tracheostomy, the patient received immediate medical management,
including intravenous administration of Ceftriaxone 1g BD, Metronidazole
500mg TDS, Dexamethasone 4mg OD, Omeprazole 40 mg OD, and Paracetamol 1g
TDS.

Under aseptic measures, the patient was taken to the operating room. A
tracheostomy was performed under local anesthesia- confirmed by an
anesthesiologist. General anesthesia was administered, and a rigid
direct laryngoscope was passed which revealed a swollen
epiglottis\textbf{(Figure 1A)} . True and false vocal cords, bilateral
arytenoids, and aryepiglottic folds were normal, and the subglottic
region appeared normal. Bilateral pyriform was not visible due to
swelling. The patient was handed over to the anesthesia department with
oxygen saturation at 99\%.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

(\textbf{Figure 1A} - Imagine captured through video-laryngoscope
post-tracheostomy)

Per-operative findings during emergency tracheostomy followed by direct
laryngoscopy revealed a significantly enlarged epiglottis\textbf{(Figure
1A)} , providing insight into the cause of the severe congestion
observed during clinical examination. Hypertrophy of the epiglottis
confirmed the diagnosis of acute epiglottitis.

Laboratory investigations were undertaken to elucidate the diagnosis and
to understand the extent of the infection. A complete blood count (CBC)
was performed, and the results are depicted in \textbf{Table 1} . The
CBC revealed an elevated Total Leukocyte Count (TLC) indicating a
pronounced systemic response to infection. This marked leukocytosis is
often associated with bacterial infections and was suggestive of a
severe infectious process, corroborating the clinical suspicion of acute
epiglottitis. Further differentiation of the leukocyte profile, as
detailed in Table 2, showed a disproportionately high neutrophil
percentage of 92\%. This neutrophilia is a hallmark of an acute
bacterial infection, providing further evidence to support the
infectious etiology of the patient's epiglottitis. The differential
count, in conjunction with the elevated TLC, Highlights the body's
robust immunological response to the pathogenic insult.

These finding, combined with the comprehensive medical regimen
administered pre-tracheostomy contributed to the successful emergency
management of the patient's condition.

The patient was admitted to for close medical surveillance and
management. Serial laboratory investigations were integral to monitoring
the patient's progress. \textbf{Tables 1 and 2} illustrate the
trajectory of the Total Leukocyte Count (TLC) and the differential
leukocyte percentages across multiple time points.

A consistent decline in TLC was observed, indicating a favorable
response to the instituted medical regimen. Concurrently, there was a
noted decrease in neutrophil percentage, which further suggested a
resolution of the acute inflammatory state. These laboratory trends were
not only prognostic but also guided the clinical decisions regarding the
intensity of medical therapy and infection control measures.

The patient's clinical course, characterized by stabilization in vital
signs and symptomatic relief, mirrored the improvements seen in the
laboratory parameters. This congruence was indicative of a successful
post-operative recovery and an effective response to the medical
treatment.

\textbf{Investigations:}

\textbf{Blood complete Picture:}

\textbf{Blood Complete Picture}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Reference range} \textbf{DOA}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{TLC (10\textsuperscript{6}/l)}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{RBC ml/}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Hb (g/dl)}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{HCT (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\selectlanguage{greek}\textbf{Platelet count/µL}\selectlanguage{english}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4000-10000\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.5-5.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13-17\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
46-50\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
200000-550000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\textsuperscript{st}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24940\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.92\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
33.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
234000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\textsuperscript{nd}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10960\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12.7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
349000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\textsuperscript{th}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
17670\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12.3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
36.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
453000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9\textsuperscript{th}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13760\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6.46\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11.8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
36.1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
427000\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{(Table 1)}

\textbf{Differential TLC count:}

\textbf{Differential TLC count}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Date}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{TLC (10\textsuperscript{9}/l)} \textbf{Ref range:
4000-10000}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Neutrophils (\%)} \textbf{Ref range: 45-70}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Lymphocytes (\%)} \textbf{Ref range: 20-40}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1\textsuperscript{st}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
24940\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
92.2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2\textsuperscript{nd}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10960\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
84.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.6\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6\textsuperscript{th}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
17670\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
77.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
17.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9\textsuperscript{th}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13760\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
74.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{(Table 2)}

\textbf{Condition on Discharge:}

The patient was stable clinically and vitally, with successful
decannulation and dressing. No hoarseness or breathing difficulty was
observed.

\textbf{Medication advised on discharge:}

\begin{enumerate}
\tightlist
\item
  Tab Cefixime 400mg (1+0+0) per oral for 7 days
\item
  Tab Ibuprofen 400mg (1+1+1) per oral for 5 days
\item
  Cap Omeprazole 40mg (1+0+0) per oral for 10 days
\end{enumerate}

\textbf{Patient follow up in OPD 10 days after being discharged}

During a follow-up visit at the outpatient department, the patient
underwent a thorough physical examination, was unremarkable. The patient
appeared alert, was in no distress, and was otherwise in a good state of
health. To assess the condition of the epiglottis and the surrounding
airway structures, video laryngoscopy was performed. The procedure aimed
to evaluate the presence of residual inflammation and to ensure the
trachea remained unobstructed.

The findings from the video laryngoscopy were encouraging. There was a
marked reduction in the epiglottic inflammation (as demonstrated
in\textbf{Figure 2A} ), and the vocal cords were clearly visualized
without any signs of swelling or obstruction (\textbf{Figure 2B} ).
Additionally, the examination confirmed that the trachea was open and
fully patent, with the surrounding anatomical structures being normal in
appearance (\textbf{Figure 2C} ). These observations were indicative of
a positive response to treatment and a significant recovery from the
initial presentation.

\textbf{Direct visualization through VDL:}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

(Figure 2A- Imagine captured through video-laryngoscope on follow-up)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

(Figure 2B- Imagine captured through video-laryngoscope on follow-up)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

(Figure 2C- Imagine captured through video-laryngoscope on follow-up)

\textbf{Discussion} :

\textbf{Acute Epiglottitis in Adults:} The presented case highlights an
uncommon complication of acute epiglottitis, traditionally associated
with pediatric populations {[}19{]}. The post-conjugate vaccine era has
seen a shift in its epidemiology, with adults now occasionally
presenting with this once predominantly pediatric condition {[}12,13{]}.
While the incidence in adults has increased, the complications,
particularly acute upper airway obstruction, remain exceedingly rare.
This case challenges the prevailing understanding, emphasizing the
importance of vigilance in recognizing atypical presentations
{[}20,21{]}.

\textbf{Clinical Presentation and Diagnosis:} The patient's initial
symptoms of sore throat, vomiting, and fever are consistent with the
prodromal phase of acute epiglottitis {[}14{]}. However, the unique
aspect of this case lies in the rapid progression to acute upper airway
obstruction in an adult patient. Clinical examination revealed bilateral
tonsillar hypertrophy and stridor {[}20,21{]}, indicative of the
severity of the condition. The decision for emergency tracheostomy was
imperative to ensure a patent airway and avert a life-threatening
crisis.

\textbf{Surgical Intervention and Intraoperative Findings} : The
emergency tracheostomy, performed under local anesthesia, played a
crucial role in securing the airway promptly. Intraoperatively,
significant swelling of the epiglottis was observed {[}3,22{]}. Notably,
bilateral arytenoids, and aryepiglottic folds the true and false vocal
cords appeared normal, highlighting the localized nature of the
inflammatory process. The absence of visible pyriformis due to swelling
further contributed to the understanding of the extent of tissue
inflammation.

\textbf{Laboratory and Radiological Findings:} Laboratory
investigations, indicated an elevated platelet count and inflammatory
markers, reflecting the acute nature of the condition. Radiological
assessments, such as imaging of the neck or direct visualization through
fiberoptic laryngoscopy {[}2,23{]}, provided additional insights into
the extent of inflammation and supported the diagnosis as explicitly
mentioned in the case.

\textbf{Treatment and Outcome:} The patient responded well to the
instituted treatment regimen, including antibiotic therapy and
anti-inflammatory medications {[}24,25{]}. Absence of breathing
difficulties at discharge signify the effectiveness of the
interventions. The postoperative course was uneventful, highlighting the
importance of early recognition, prompt intervention, and appropriate
postoperative care.

\textbf{Conclusion and Implications} :

This case contributes to the limited literature on acute epiglottitis in
adults, emphasizing the need for heightened awareness among healthcare
providers. The rarity of complications in adults necessitates a thorough
understanding of atypical presentations to ensure timely and effective
management. Furthermore, the case highlights the importance of
considering acute epiglottitis in the differential diagnosis of
respiratory distress in adults, especially in the absence of typical
pediatric risk factors. Continued surveillance and reporting of such
cases will further refine our understanding of this evolving clinical
entity.

\textbf{Declarations:}

\textbf{Ethics approval and consent to participate}

This case report adheres to ethical principles governing medical
research and patient confidentiality. Informed consent was obtained from
the patient for the publication of this case report, including the use
of clinical data, images, and relevant medical history. All patient
identifiers have been removed or anonymized to protect confidentiality.
The report was conducted with integrity, honesty, and respect for the
patient's autonomy, dignity, and privacy. It aligns with the principles
outlined in the Declaration of Helsinki and other relevant ethical
guidelines. The authors declare no conflicts of interest or financial
disclosures related to this case report.

\textbf{Consent for publication}

Written informed consent was taken from the patient's legal guardians
based on the journal's policy. Consent for publication is also provided
by the patient's legal guardians abiding to the policy of the journal.

\textbf{Availability of data and material}

All data about this case is made available within the manuscript. Any
further data or information will be made available upon request.

\textbf{Competing interests}

The author(s) have no conflict of interest to declare

\textbf{Funding}

The project is not funded by any grant or organization.

\textbf{Authors' contributions}

AS, MHR and FZK contributed to conceptualization, data curation,
investigation, supervision, project administration, writing-original
draft, and writing review \& editing. AZ\textsuperscript{4},
AZ\textsuperscript{5}, ZZK, AK contributed to conceptualization,
writing-original draft, and writing review \& editing.

\textbf{Acknowledgements}

We would like to acknowledge the team of clinicians who managed this
case.

\textbf{Abbreviations:}

\begin{enumerate}
\tightlist
\item
  CBC - Complete Blood Count
\item
  TLC - Total Leukocyte Count
\item
  BD - Twice a Day (from the Latin ''bis in die'')
\item
  TDS - Three Times a Day (from the Latin ''ter in die'')
\item
  OD - Once a Day (from the Latin ''omne in die'')
\item
  DOA - Date of Admission
\item
  RBC - Red Blood Cell
\item
  Hb - Hemoglobin
\item
  HCT - Hematocrit
\item
  Hib - Haemophilus influenzae type b
\item
  OPD - Outpatient Department
\item
  VDL - Video-Direct Laryngoscopy
\end{enumerate}

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\end{enumerate}

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