Viral supraglottitis in an adult: a case presentation and literature update

Herpes simplex laryngitis: Comparison between pediatric and adult patients

OBJECTIVES

Infection with herpes simplex virus (HSV) typically causes limited oral and genital symptoms, however HSV can also affect the larynx and result in severe aerodigestive symptoms. Due to the rarity of HSV laryngitis, the symptoms and clinical course of are not well understood. This study aims to more completely characterize HSV laryngitis in order to aid clinicians in understanding and recognition of HSV laryngitis.

METHODS

Comprehensive literature search of MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews to identify articles relating to HSV laryngitis. Patient demographics, presenting signs and symptoms, treatment and clinical course were extracted from the selected manuscripts.

RESULTS

There were 31 studies on HSV laryngitis that identified 36 patients (17 pediatric, 19 adult). The average age for pediatric patients was 11 months (9 M, 8F) and 52 years for adults (11 M, 8F). In the pediatric population, stridor was more common at presentation in comparison to the adult population (p < .01). Adults more commonly presented with dysphagia (p = .03) and dysphonia (p < .01) Adult patients were significantly more likely to undergo tracheotomy than pediatric patients (p = .047). The mean length of inpatient hospital stay was 21.2 days in pediatric patients and 15.8 days for adult patients.

CONCLUSION

HSV laryngitis has a unique presentation in pediatrics and adults, but is nonspecific in both populations leading to delays in diagnosis and treatment. HSV laryngitis is associated with significant morbidity including multi-week hospital stay and risk for needing tracheostomy in both adults and pediatric population which demonstrates need for clinical awareness of this complication of HSV infection.

Intubation decision criteria in adult epiglottitis

OBJECTIVES

To identify contributive criteria in decision-making for intubation in acute epiglottitis, based on clinical and endoscopic data in adult patients, and to study clinical and biological characteristics and management.

MATERIALS AND METHODS

Diagnosis was established by flexible endoscopy showing epiglottic edema in association with general signs of sepsis in 28 patients consulting into two French hospitals between 2005 and 2016. Retrospective univariate and multivariate analysis between patients managed by intubation (Group I) or surveillance (Group S) was performed on clinical and endoscopic data.

RESULTS

Ten patients were intubated (36%). On univariate analysis, 4 variables were suggestively associated with intubation. On multivariate analysis, associations remained suggestive for dyspnea (OR=50.6; 95% CI=[2.7; 940.1]) and supraglottic edema extension (OR=42.2; 95% CI=[2.2; 799.5]). The area under the curve identifying intubated patients on these 2 criteria was 90.8%, testifying to high discrimination.

CONCLUSION

Intubation must always be considered in epiglottitis. Dyspnea and supraglottic extension of the edema seem to be the two main criteria to be considered in airway control decision-making.

Disseminated Herpes Simplex Infection Presenting as Acute Supraglottitis in an Adult

Supraglottitis is a life-threatening, predominantly bacterial disease that is rarely caused by viral etiologies. Herpes Simplex Virus (HSV) supraglottitis has been infrequently reported, but its presentation can mimic that of bacterial supraglottitis or pharyngitis which may lead to delayed diagnosis and increased morbidity. We present a case of supraglottitis in an immunocompetent man initially thought to have bacterial epiglottitis. After receiving a tracheostomy due to impending airway compromise and failing to improve on antibiotic therapy, biopsy of the upper airway tissue revealed infection with HSV type 2. The patient improved after multiple weeks of systemic antivirals. HSV supraglottitis remains an unusual but important diagnostic consideration in patients with dysphonia, dysphagia, ulcerative supraglottal lesions, and acute supraglottic inflammation unresponsive to antibiotics.

CO2 laser supraglottic resurfacing for non-granulomatous chronic supraglottitis in two children

Chronic epiglottitis and supraglottitis are clinical entities that present with respiratory distress and are primarily associated with autoimmune disorders, gastroesophageal reflux disease, or angioedema. First described in adults with sarcoidosis in 2010, CO2 laser epiglottis resurfacing has been effective in reducing epiglottic edema. We present two cases of adolescent males with non-granulomatous chronic supraglottitis who were successfully treated with CO2 laser supraglottic resurfacing.

Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission

Objectives

(1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification.

Methods

A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007.

Results

The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care.

Conclusion

A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.

Case and Literature Review: Adult Acute Epiglottitis – Rising Incidence or Increasing Awareness?

Objective

The prevalence of adult acute epiglottitis is probably more common than is generally appreciated. A retrospective case review in a district hospital and a medical literature search may provide baseline information to guide future strategies.

Methods

Cases of acute epiglottitis in a period of 3 years and 4 months were traced from the hospital computer systems. Medical records were reviewed. Medical literature on “adult acute epiglottitis” was searched through Medline and EMBASE. Relevant full text articles were retrieved through hospital library network.

Results

From February 1998 to June 2001, 11 cases of acute epiglottitis were identified. The age range was 34–78 (mean 47.5, median 41). There was no paediatric case. The male to female ratio was 9:2. Eight presented with fever, sore throat and dysphagia, one presented with dyspnoea and two presented as foreign body in throat. Nine were treated successfully conservatively. Two were intubated prophylactically. There was no case fatality.

Conclusion

Adult acute epiglottitis has become much commoner than its paediatric counterpart. Acute epiglottitis should be suspected in all patients with a sore throat and dysphagia, especially if symptoms are out of proportion to the pharyngeal inflammation.

Herpes Simplex Virus Laryngitis Presenting as Airway Obstruction: A Case Report and Literature Review

OBJECTIVES

Herpes simplex virus (HSV) laryngitis is rare in adults. We add a case report to the literature and perform a literature review to further delineate the clinical presentation, course, and treatment of HSV laryngitis in adults.

METHODS

Case report and literature review using PubMed and Ovid databases.

RESULTS

Ten cases of diagnosed HSV laryngitis in adults were reported in the literature. It is more common in immunocompromised patients. The mean patient age was 51 years with a male to female ratio of 1:1. The clinical presentation and course of HSV laryngitis is variable. Patients may have mild chronic symptoms, such as dysphonia, or a fulminant course with rapid airway compromise. On laryngoscopic exam, the most common findings are a white exudate or ulceration. The most common treatment is with antiviral medication, such as acyclovir, which tends to be highly effective.

CONCLUSIONS

Herpes simplex virus laryngitis is rare. Clinical presentation of HSV laryngitis is variable, and its course may be indolent or fulminant. Treatment with antiviral medication tends to be highly effective.

The burden of epiglottitis among Japanese children before the Haemophilus influenzae type b vaccination era: an analysis using a nationwide administrative database

Epiglottitis is a potentially life-threatening disease and is largely preventable by vaccination against Haemophilus influenzae type b (Hib). Little is known, however, about the epidemiology of childhood epiglottitis in Asian countries, including Japan. Using a nationwide inpatient database, this study aimed to determine the burden of childhood epiglottitis before the introduction of Hib vaccine into Japan. The study period was between July and December in 2007 and 2008, when Hib vaccine was not available. We found 102 cases with epiglottitis among children ≤5 years old. The annual incidence of epiglottitis in children ≤5 years old was estimated to be 3.2 per 100,000 population per year. Among the 102 patients, 31 (30.4%) required respiratory support, including two cases with tracheotomy and one fatal case. Our study demonstrated the substantial burden of epiglottitis among Japanese children, highlighting that a routine Hib vaccination program is essential.

Should antiviral medications be considered preoperatively for microlaryngoscopy in patients with a history of recurrent herpes stomatitis?

Infectious complications following phonomicrosurgery are rare. Reports of herpetic laryngitis are in the literature but none following microlaryngoscopy. We present a case of a 55-year-old female who underwent microsurgical excision of a left vocal fold (VF) lesion and KTP ablation of bilateral vascular ectasias. Postoperative stroboscopy demonstrated severe bilateral VF edema, erythema, and ulcerations of the VFs, encompassing an area greater than the original surgical field. Initial management included voice rest, antibiotics, steroids, and aggressive reflux treatment. The patient experienced prolonged VF edema and poor voice outcome, which ultimately resolved over 6 months. Clinical diagnosis of herpetic laryngitis was presumptively made after the patient revealed a history of relapsing oral herpes incited by stress with a recent episode before microlaryngoscopy. This case highlights the importance of thorough review of a patient's medical history. A protocol for preoperative (prophylactic) antiviral therapy and appropriate timing of surgery is presented for patients with history of herpes infection.

Chronic non-granulomatous supraglottitis: a rare and difficult disease

OBJECTIVES

To examine chronic non-granulomatous supraglottitis, a rare disorder of uncertain aetiology with few reported cases in the literature.

CASE REPORTS

We describe two cases of chronic non-granulomatous supraglottitis that led to persistent respiratory compromise. Patients underwent extensive investigation that failed to reveal a definitive diagnosis.

CONCLUSION

In patients suffering from chronic inflammation of the supraglottic larynx without evidence of infection, neoplasm or granulomatous disease, many disorders must be ruled out in order to diagnose chronic non-granulomatous supraglottitis, which is a diagnosis of exclusion. We review the literature on this rare entity, discuss current management strategies, and suggest an algorithm for diagnostic investigation.

Severe parainfluenza virus type 2 supraglottitis in an immunocompetent adult host: an unusual cause of a paramyxoviridae viral infection

Parainfluenza virus is a major cause of respiratory illness in humans, manifesting from mild upper respiratory tract infection to bronchiolitis and pneumonia, especially in children. We report - to our knowledge - the first case of a nonimmunocompromised adult patient with human parainfluenza type 2 supraglottitis immediately after returning from China.

Acute herpes simplex laryngotracheitis: Report of two pediatric cases and review of the literature

Herpes simplex virus (HSV) is a rare cause of laryngotracheitis (LT) with only 22 previously reported and confirmed pediatric cases in the literature. It is often associated with immune deficiency states and presents with a severe acute upper airway obstruction commonly requiring intensive care management and artificial ventilation. We present two cases of atypical laryngotracheitis in which HSV was found to be the causative pathogen subsequent to laryngoscopy and microbiologic investigations. While the first case was a previously well 8-month-old girl, the second was a 22-month-old immunosuppressed boy. One-third of the total confirmed cases in the English literature required intensive care management eliciting the setting as a pointer to the diagnosis. Laryngoscopy is a readily available tool for rapid diagnosis and controlled securing of the airway. This step may avoid controversial and potential counter-productive use of systemic steroids in these cases.