DP27: DELAYED-ONSET POST-EXTUBATION LARYNGEAL EDEMA COMPLICATED BY EPIGLOTTITIS: A CASE REPORT
Cecilia K Nosti, MD1; Jeffrey U Valencia, MD1; Suset Almuinas de Armas, MD1; Claudia Larios, BS2; Yamil Selman, MD1; Dahlia A Blake, MD, MBA, FCCP1; Benjamin Houseman, MD, PhD, FASA3
1Memorial Healthcare System; 2Florida International University HWCOM; 3Envision Physician Services
Introduction: Post-extubation laryngeal edema (PELE) is a recognized complication of endotracheal intubation. Most cases are mild and self-limiting, but severe cases can be associated with dysphagia, hoarseness, and airway compromise. Here we describe a case of delayed onset PELE following elective hernia repair complicated by epiglottitis.
Case Presentation: A 73-year-old male with a history of asthma, GERD, prior tonsillectomy, and occasional tobacco smoking presented for elective hernia repair under general anesthesia. His preoperative airway exam was reassuring, and general endotracheal anesthesia was planned. Famotidine 20 mg IV, dexamethasone 8 mg IV, tylenol 1000 mg PO and midazolam 1 mg IV were administered preoperatively. Following induction of general anesthesia, rapid sequence endotracheal intubation was successfully performed on the first attempt and an orogastric tube was inserted uneventfully. He was extubated at the end of the procedure and discharged home without complication.
Late on postoperative day 1, the patient presented to the emergency department a severe sore throat, difficulty swallowing, and a hoarse voice. The patient stated that symptoms began in the morning. Vital signs on admission included a fever (38.5 degree C) and oxygen saturation of 99% on room air. Physical examination demonstrated tenderness to palpation in the anterolateral neck, and laboratory analysis was remarkable for neutrophilic leukocytosis, elevated CRP and procalcitonin. CT scan of the neck showed laryngeal edema extending to the epiglottis without airway stenosis.
Steroids and broad-spectrum antibiotics were initiated. On postoperative day 2, his dysphagia worsened, prompting admission to the ICU for observation despite adequate oxygenation and ventilation. Flexible laryngoscopy showed moderate edema of the arytenoids (right greater than left) and epiglottis. Vocal fold motion was normal with full abduction and adduction, and no lesions or masses were identified.The patient was treated with corticosteroids, antibiotics, and supportive care, including speech therapy and dietary modifications. He was discharged home on postoperative day 4, and his symptoms gradually improved over the next two weeks. Repeat laryngoscopy demonstrated normal vocal cord motion, mild erythema of the epiglottis, and cobblestoning of the hypopharyngeal mucosa, consistent with resolving epiglottitis and laryngopharyngeal reflux. The patient was prescribed omeprazole for management and scheduled for a follow-up evaluation by head and neck surgery.
Discussion: Our choice of general endotracheal anesthesia with rapid sequence induction for this operation was motivated by several factors, including the size of the hernia, surgeon request for relaxation, and GERD. The patient denied preoperative symptoms of upper respiratory infection or sick contacts, both before surgery and during admission.
Clinically significant PELE and epiglottitis following elective surgery is rare. The few reports available describe physical folding of the epiglottis by either an LMA or endotracheal tube [1]. While trauma from the endotracheal or orogastric tube in our case is certainly possible, the delayed onset, fever, leukocytosis, elevated procalcitonin, the extensive surface area of inflammation and asymmetrical arytenoid swelling favored an infectious etiology [2].
This case highlights the importance of early recognition, airway monitoring, and multidisciplinary management.
References:
1. 10.1093/bja/83.6.962.
2. 10.1016/j.anl.2020.06.00
Images:
Thumbprint Sign
Arytenoid Swelling
Epiglottic Swelling
