Supraglottic Soft-Tissue Infection with Epiglottic Abscess: A Silent Threat to the Airway

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 Supraglottic Soft-Tissue Infection with Epiglottic Abscess: A Silent Threat to the Airway

Author: Elias Lee, Ph.D.(Medicine, Engineering)
Category: ENT | Radiology | Emergency Medicine
Estimated reading time: 5 minutes

Introduction

Supraglottic soft-tissue infection with epiglottic abscess formation is a rare yet life-threatening condition, especially in young adults. This infection involves acute inflammation and the potential formation of abscesses in the epiglottis and adjacent supraglottic structures. Timely recognition and airway management are crucial to prevent sudden respiratory compromise.

In this post, we explore a real case of a 19-year-old male who presented with a sore throat and dyspnea over several days, highlighting the diagnostic role of CT and the clinical implications of epiglottic abscess.

Clinical Case Summary

A previously healthy 19-year-old man presented with progressive sore throat and shortness of breath lasting 2–3 days. No recent trauma or known immunodeficiency was noted.

CT topogram and contrast-enhanced CT of the neck revealed:

  • Thickening of the epiglottis and aryepiglottic folds
  • Diffuse mucosal enhancement and edema involving the oropharynx, epiglottis, and supraglottic space
  • A low-attenuation, peripherally enhancing area consistent with epiglottic abscess, involving the lingual surface and right tonsillar region


 

Pathophysiology and Epidemiology

Acute epiglottitis and subsequent abscess formation can occur due to:

  • Direct mucosal infection
  • Spread from adjacent sites (e.g., tonsillitis, pharyngitis)
  • Minor trauma (e.g., intubation, foreign body)

In adults:

  • Most cases are now caused by non-Haemophilus influenzae organisms such as Streptococcus pneumoniae, Staphylococcus aureus, and Group A Streptococcus
  • Abscess formation is more common, occurring in up to 24% of adult epiglottitis cases
  • Rapid onset of symptoms: muffled voice, dysphagia, stridor, high fever

Imaging Pearls


Lateral CT Topogram:

  • Thumbprint sign (enlarged epiglottis)
  • Thickened aryepiglottic folds

Contrast CT of the Neck:

  • Swollen, edematous epiglottis with ring enhancement (abscess)
  • Involvement of supraglottic soft tissues
  • It may help differentiate abscess from cellulitis or mass

Treatment Strategies

  1. Airway protection is paramount.
    Early intubation or tracheostomy may be necessary if there is respiratory distress.
  2. Intravenous antibiotics targeting common pathogens:
    • Ceftriaxone or ampicillin-sulbactam
    • Consider MRSA coverage in high-risk cases
  3. Steroids (e.g., dexamethasone) to reduce edema
  4. Surgical drainage of abscess during direct laryngoscopy

Quiz

1. Which anatomical structures appear abnormal on the CT topogram?

A) Adenoid tonsils
B) Aryepiglottic folds
C) Epiglottis
D) Prevertebral soft tissues
E) B and C
F) A and D

Explanation: Both the epiglottis and aryepiglottic folds are thickened on imaging, consistent with acute epiglottitis and adjacent inflammation. These findings are typical of supraglottic infection.

2. Which structure is NOT located in the supraglottis?

A) Arytenoid cartilage
B) False vocal cords
C) Lingual surface of the epiglottis
D) Vallecula

Explanation: The vallecula lies superior to the supraglottic region and is part of the oropharynx. The other structures are within the supraglottic larynx.

3. What is the correct role of CT imaging in acute epiglottitis?

A) CT excludes complications like abscess formation
B) CT evaluates airway narrowing due to inflammation
C) Lateral neck X-ray alone is sufficient
D) Radiology plays no role in typical cases
E) None of the above

Explanation: While diagnosis is often clinical, CT scans are valuable for detecting complications, such as abscesses, which may require surgical intervention. It also delineates the extent of soft tissue involvement.

References

  1. Berger G, et al. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol. 2003;24(6):374-383.
  2. Capps EF, et al. Emergency imaging assessment of acute, nontraumatic conditions of the head and neck. Radiographics. 2010;30(5):1335-1352.
  3. Hindy J, et al. Epiglottic abscess as a complication of acute epiglottitis. Am J Otolaryngol. 2013;34(4):362-365.
  4. Mayo-Smith MF, Spinale JW, Donskey CJ. Acute epiglottitis in adults: an under-recognized problem. South Med J. 1995;88(9):915–919.
  5. Mayo Clinic Proceedings. Acute Supraglottitis in Adults. 2001;76(5):484–488.
  6. Chiang WC, et al. Clinical presentation and predictors of epiglottic abscess in adults. Am J Emerg Med. 2012;30(9):1676–1680.
  7. Pourmand A, et al. Acute epiglottitis in the ED: A review for emergency physicians. Am J Emerg Med. 2017;35(8):1166–1170.





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