by Robert J. Lanz, LCSW
Epiglottitis is a kid’s disease, an inflammation of the epiglottis. It is serious at any age, but if you make it to adulthood without getting it, then you should be all right. Should is the operative word here. Your epiglottis is that little flap that goes over your trachea when something beside air is heading down your throat. Epiglottis open, air goes into lungs. Epiglottis closed, food, water etc. goes into your stomach. It’s pretty simple, but any malfunctions by this simple mechanism can have dire results. Fluids or solids in the windpipe cause choking and even death. To make things even worse, just small amounts of certain substances sucked inadvertently into your lungs can cause infection and then death. Your lungs, absolutely necessary for sustaining life, are fungi-warm and wet, kind of like a mushroom farm, and perfect for growing infections.
So, even if you survive a large quantity of the wrong stuff getting by that flap, the quality of the stuff could still kill you. That’s why your epiglottis is such a key element to your survival, and you definitely don’t want anything to go wrong with it. You especially don’t want it to get infected. Infection means inflammation. Inflammation means swelling. Swelling means that the perfectly fitted epiglottis that keeps stuff from your lungs becomes imperfect, and the swelling may actually close over your windpipe. That’s epiglottitis.
When the middle-aged guy showed up in the ER, he didn’t know that he had it. He complained of a sore throat and fever, but his breathing was all right and he seemed healthy otherwise. His wife was with him, and it seemed a rather simple presentation. He got a little Tylenol for fever. He got some blood work to confirm the infection and then he got ignored, pending results of the blood tests, which can take an hour or more to come back. About 45 minutes into that wait, the patient told his nurse he was having a little trouble breathing. When she asked him how much trouble, he replied that he thought his airway was closing.
A closing airway is a very bad sign, especially with a sore throat. The doctor came down to the ENT room and asked about the airway. The patient repeated that his airway was being compromised and a special soft tissue x-ray was ordered. The patient remained comfortable, but it was obvious that he was getting increasingly anxious. If you were about to lose your airway, you’d be anxious too.
By the time the x-ray came back, everyone was getting anxious. A large abnormality showed up and the doctor decided to take another look down the man’s throat. Had this patient been a small child, a deeper look would have been a normal part of the initial exam, but since epiglottitis is so rare in adults, that hadn’t been done. It’s pretty hard to look all the way down there, is very uncomfortable and intrusive, and is only done when there is significant suspicion. At this point, there was definitely significant suspicion and the ER doctor called out for the secretary to get the ear, nose and throat (ENT) specialist on call stat-stat, meaning as quickly as possible. The patient knew what that meant and didn’t seem to need a reminder. His anxiety level continued to rise. Luckily for him, the ENT doc wasn’t at a party or playing golf or off doing something that would delay his trip to the ER. He was there in seven minutes, long ones according to the patient.
The ENT guy tilted the man’s neck back and took a fiber-optic tube, shoved it up his nose then down to where the epiglottis would be and looked into his eyepiece. When an already anxious patient hears the specialist utter a vigorous, “Oh my God!” and then take a big step back, it doesn’t help his anxiety at all. Nevertheless, he remained calm as the ENT specialist called for some steroids, also stat. An IV was started with some stat antibiotics thrown in, too. The ER “crash cart” was placed at the patient’s bedside. A “crash cart” is essentially a toolbox like you might see in a mechanic’s shop except the “tools” in it are specifically designed to resuscitate a person who has stopped breathing. The cart includes a special tool called a laryngoscope that is only used to depress a patient’s tongue, push his vocal chords aside and expose the trachea so that a breathing tube can be placed there. That usually works for most folks, but if you have been in a fire and inhaled too much smoke, it may close off your airway. Or if you have an inflamed epiglottis, the same thing can happen.
Between the time the steroids were injected and the time they seemed to be reducing the badly swollen epiglottis, everyone got a little more anxious. The patient remained calm and finally he told the specialist he could feel his airway returning to normal. Everyone breathed a sigh of relief and the ER doctor who had been away from the room and missed the actual visualization of the swollen epiglottis wondered if she might take a peek. The specialist would have to stick that fiber-optic tube down the patient’s throat again if the ER doc was going to take that peek. Before giving consent, the patient told the specialist to call anyone else in who might want to have a look at this medical rarity so he could get all the procedures over with and go home.
“Hmmm,” said the specialist. “We can do that, except for the part about going home. With this diagnosis you’ll have to stay in the ICU for a bit. Maybe a day or two.”
Some patients don’t mind being in the hospital and some do. This patient had just had cancer surgery a couple of months before and had seen enough of hospital beds that year. In fact, there was some speculation briefly that the tube they put down his throat during cancer surgery may have been the source of infection that caused the epiglottitis. Needless to say, the patient wasn’t too happy, but what could he do?
When he got upstairs, they put him in a special bed, hooked him up to a special machine and put a mask over his face that would was designed to keep blowing steroids down his windpipe. He was not allowed to lie down due to his compromised airway. The crash cart was placed outside his room where he could see it clearly. Maybe the staff thought that would be reassuring. Let’s see, was there anything missing to make this a difficult experience?
His throat hurt. His specialist had jumped backwards and yelled “Oh, my God!”. He was a little claustrophobic and they had placed a mask over his face. The mask was loud and uncomfortable. The steroids would take care of the swelling, but they also packed the stimulating equivalent of a couple of Venti’s from Starbucks, so sleep was out of the question. Because of his diagnosis, he needed to be watched closely, so the lights were on in his room all of the time. To top it off, the ICU is never quiet. The patient laid awake and stared at the crash cart all night.
In the morning, he was scoped again by the same specialist and everybody in ICU who had never seen epiglotittis was invited to take a peak down the scope, too. Because of the rarity of the diagnosis, the infectious medicine specialist came up for a visit and asked a lot of questions about travel and surgery and recent illnesses. He ordered more lab tests. Up to this point, the patient hadn’t slept much.
The next twenty-four hours were much the same and on the second morning, the specialist returned for another scoping and thought things looked okay. The infectious medicine specialist came back and after looking at the lab work he concluded that, like most cases of epiglotittis in adults, the culprit was something as simple as Hemophilis B flu. He talked to the ENT specialist, who apparently thought everything was back under control and the patient could be discharged. Another medical mystery solved and controlled.
I was never so happy to leave the hospital and go home to get some rest. I had survived cancer and thought that was the worst thing that would ever happen to me, then had a near death experience with a little kid’s disease. Once again, it was clear to me that the edge we all live on was really obvious, and I didn’t like it much.
Luckily I wasn’t on a ski trip to Chile or hiking the John Muir Trail, racing in Baja or some other adventure. I wondered if I could actually do a necessary procedure, like a cricothyrotomy, with the stuff I had with me if I was in some far off place alone. I guess if I was turning blue I could. A lot better to work in an ER where you get to go to the front of the line and people believe what you say….Bob