The authors describe the case of a 30-year-old female patient who presented to the emergency department with a two days history of odynophagia and progressive severe dyspnea.Physical examination revealed an enlarged epiglottis. A neck CT scan to assess complications was performed, confirming epiglottitis and showing a mucosal pharyngeal space collection. Sudden spontaneous elimination of purulent sputum a few hours later confirmed the collection to be an abscess

Mesquita, Romeu

Reis, Alcinda

Sousa, Marta

Vilaverde, Filipa

English

Acta Radiológica Portuguesa

  49
Caso Clínico / Radiological Case Report
Correspondência
Filipa Vilaverde
Rua do Arinho, nº 6
4730-430 Vila Verde
e-mail: filipavilaverde@gmail.com
1Serviço de Imagiologia do Centro Hospitalar
de Entre o Douro e Vouga, Feira
Diretora: Dra Rosa Cardoso
Recebido a 09/12/2014
Aceite a 28/02/2015
ADULT EPIGLOTTITIS COMPLICATED WITH A PHARYNGEAL
MUCOSAL SPACE COLLECTION
EPIGLOTITE NO ADULTO COMPLICADA POR COLEÇÃO NO ESPAÇO DA
MUCOSA FARÍNGEA
Filipa Vilaverde1, Romeu Mesquita1, Marta Sousa1, Alcinda Reis
Resumo
Os autores descrevem um caso de uma mulher
de 30 anos que recorreu ao serviço de urgência
com uma história de odinofagia há 2 dias e
dispneia severa progressiva. O exame físico
revelou uma epiglote tumefacta. Foi realizada
TC cervical para avaliar complicações,
confirmando a epiglotite e mostrando uma
coleção do espaço mucoso faríngeo. A
eliminação espontânea de secreções purulentas
algumas horas depois confirmou que a coleção
se tratava de um abcesso.
Palavras-chave
Epiglotite; Abcesso; Espaço mucoso
faríngeo; TC.
Abstract
The authors describe the case of a 30-year-old
female patient who presented to the emergency
department with a two days history of
odynophagia and progressive severe dyspnea.
Physical examination revealed an enlarged
epiglottis. A neck CT scan to assess
complications was performed, confirming
epiglottitis and showing a mucosal pharyngeal
space collection. Sudden spontaneous
elimination of purulent sputum a few hours
later confirmed the collection to be an abscess.
Key-words
Epiglottitis; Abscess; Mucosal pharyngeal
space; CT.
ACTA RADIOLÓGICA PORTUGUESA
Janeiro-Abril 2015   nº 104 Volume XXVII   49-51
Case report
A previously healthy woman presented with a two days history
of odynophagia unresponsive to nonsteroidal anti-
inflammatory drugs, and progressive onset of severe dysphagia,
dyspnea and fever. Physical examination revealed neck swelling
and oropharyngeal erythema but no signs of respiratory distress.
Laboratory data showed leukocytosis and raised C-reactive protein.
The patient performed a chest X-Ray (not shown), which was
unremarkable. A neck CT before and after intravenous contrast
ruled out foreign bodies, and showed an enlarged edematous
epiglottis and enlargement of the aryepiglottic folds in the
supraglottic larynx, associated with thickening and hypodensity
of pharyngeal mucosal space (PMS) of the oropharynx and
hypopharynx (Figs. 1, 2, 3). The PMS involvement also showed
a central fluid collection with mild peripheral rim-like
enhancement suggesting the presence of  a collection (Fig. 4).
There was no marked narrowing of  the airway, extension to
parapharyngeal space, vascular complications or involvement
of the mediastinum. Mild reactive bilateral internal jugular chain
lymphadenopaties were found, namely in the level II.
The patient started intravenous antibiotics (clindamycin plus
ceftriaxone) and corticotherapy (dexamethasone), and wasn´t
immediately intubated but stayed at the hospital in closed
observation. A few hours later had a sudden onset of  cough
with spontaneous elimination of purulent sputum. She had
completely clinical recovery and repeated CT three days later,
which showed resolution of the previous findings. Blood
cultures were negative.
Fig. 1 - Epiglottitis. Axial contrast enhanced CT
above the hyoid bone level, shows an enlarged
and edematous epiglottis (white arrow), with mild
thickening of the pharyngeal mucosa (black
arrow) without extension to vallecula (*). Mild
reactive bilateral upper internal jugular chain
lymphadenopaties (level II) were also found
(black *).
50
Discussion
The differential diagnosis of an enlarged epiglottis and mucosal
pharyngeal edema should include infection, angioedema,
ingestion of  a caustic substances or foreign body, trauma and
thermal injury, and post-irradiation edema, the last five
hypotheses excluded by an adequate clinical history. Also,
angioedema usually occurs more suddenly with a history of
exposition to a potential offending antigen. In this particular
case, the clinical and laboratory findings support the infectious
etiology as the most likely.
Epiglottitis is an acute life-threatening disease often associated
with airway compromise mainly in children. The introduction
of Haemophilus influenza type b vaccinations programs led to a
drastic decrease in its incidence among children [1] and to a
demographic and etiologic shift, with more preva­lence in
adulthood, and non–Haemophilus influenza becoming the
dominant agent (2]. Non–Haemophilus influenza epiglot­titis
tends to involve the supraglottic structures to a much greater
extent [2], and 4%–25% of patients develop complications
such as necrotizing epiglottitis and epiglottic or deep neck abscess
[3]. The PMS abscess is one of these collections and is very
unusual, having the same serious complications as other deep
neck abscesses, such as spontaneous rupture into the pharynx
(risk of aspiration pneumonia and empyema).
The symptoms of  epiglottitis and its complications overlap,
and patients typically pre­sent with fever, abrupt onset of stridor
(more often in children) and dysphagia, shortness of breath,
sore throat and posturing with neck extension [5,6].
Epiglottitis is usually a clinical diagnosis. Imaging studies are
reserved for doubtful cases and to assess the extent and possible
complications. Lateral neck radiography is usually the first exam,
mostly in children, which reveals the typical “thumb sign” of
thickened epiglottis [5]. In adults the contrast-enhanced CT is
more useful, and shows a thickened, edematous epiglottis and
mucosal enhancement. The supraglottic larynx, tongue base,
and tonsils are often involved, and a phlegmonous collection
or even an abscess may be seen within the adjacent soft tissues
[5, 7]. In the presented case, there was also implication of the
PMS, an extremely rare finding, especially secondarily to
epiglottitis. The PMS includes the mucosal surface structures
of the nasopharynx, oropharynx, and hypopharynx, and extends
from the skull base to the cricoid cartilage [8-11].
One of  the greatest author´s struggles when faced with this
case was the assessment of the lesion to a specific space. As we
faced with a lesion predominantly involving the more posterior
compartments of the neck, the main spaces considered were
the PMS, the retropharyngeal and the prevertebral spaces. The
prevertebral muscles were normal, the collection involves almost
circumferentially the hypopharynx (Fig. 4) and the caudal
extension of the collection is in the neck, don´t extending further
to the mediastinum (Fig. 2). These findings make a PMS
collection most likely.
Conclusion
CT scan has an important role in evaluation of  epiglottis’s
possible complications, particularly in adults.
a b
c d
Fig. 4 - Pharyngeal mucosal space phlegmon/abscess. Axial pre (a, b)
and post contrast (c, d) enhanced CT at the level of the hyoid bone,
depicts marked thickening and hypodensity of the pharyngeal mucosal
space, extending laterally, beyond the retropharyngeal limits. There is
peripheral rim-like enhancement (arrow) although without a clearly
fluid collection (clinic evolution confirmed this was an abscess (apagar)).
PMS – parapharyngeal space; RPS – retropharyngeal space; PVS –
prevertebral space.
Fig. 3 - Supraglotic
extension. Axial
contrast enhanced CT
at the level of the
supraglottis shows the
extension of the
inflammation to the
floor of the mouth (*)
and to the aryepiglottic
folds, occluding the
pyriform sinus.
Fig. 2 - Epiglottitis.
Sagital reformatted
contrast enhanced CT
demonstrates the
edematous epiglottis
(white arrow) and
prevertebral(apagar)
soft tissue swelling
between cervical spine
and upper airway due
to pharyngeal mucosal
space collection (black
arrow). Note that a
retropharyngeal space
collection should
extend inferiorly to
the mediastinum.
  51
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Adult Epiglottitis Complicated with a Pharyngeal Mucosal Space Collection

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Adult Epiglottitis Complicated with a Pharyngeal Mucosal Space Collection

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