Acute epiglottitis

A 30 year old man presented to the emergency department with a two day history of fever, sore throat, and progressive difficulty in swallowing. He had no allergies and had taken one dose of benzylpenicillin, prescribed by his general practitioner, earlier that day. His medical history included recurrent tonsillitis, which had been treated with antibiotics; he smoked 15 cigarettes a day.

On initial examination he had tachycardia (115 beats/min) and fever (38.5°C). The remainder of his respiratory and cardiovascular examination was normal. Oropharyngeal examination showed a swollen uvula and enlarged red tonsils without pus. There was no lip or tongue swelling and no obvious rash.

Ten minutes later he developed progressively worsening stridor. He was unable to complete sentences and was drooling. His respiratory rate was 34 breaths/min and his oxygen saturation was 89% on 15 L oxygen. A wheeze was present throughout his chest. He was still tachycardic at 120 beats/min and his blood pressure had increased to 170/100 mm Hg. Administration of adrenaline nebulisers improved the stridor slightly. Blood cultures were taken and intravenous antibiotics and steroids administered. A working diagnosis of acute epiglottitis was made; an urgent anaesthetic and ear, nose, and throat (ENT) review was requested.