difficult airway....

The patient had presented with an unusual complaint – throat pain which radiated to neck base. A young age male in his early 20s who noted with sudden onset of discomfort. The initial review had shown enlarge tonsil with some pus.

I had given him some pain killer and a parenteral dose of Augmentin. He had become better and discharged with oral medication.

He had returned to ED 5 hrs later in the morning c/o SOB and unable to swallow. I had a very bad feeling about it and started him on epinephrine inhalation. I had proceeded with a neck CT which revealed swelling over the epiglottis region.

A very unusual case as acute epiglottis is very rare in adult…. I am aware of the difficulty of intubating such patient and does not want to risk it even if it is an elective one. Since it is early in the morning, I had decided to hand him over to an expert for intubation.

I had called up our anesthesiologist CZ and he had gladly complied with my referral. He had come and seen my patient within minutes.

I thought he was going to take the patient up elsewhere for the intubation. However he said he would bring down his tools and do it in the ED.

He ordered large doses of diprivan (a full ampule ) with an ampule of succinylcholine. ( I would only use 1/4 of those most of the time). Before he started with the routine, I joked to him,” don’t treat here as yours house”…indeed, the equipment in the ED might not be as complete as it was in the OT.

After the fibrillation of muscle, he had started the insertion which ended into the oesophagus. The O2 sat had fallen to 50% then. Prior to the second attempt, the O2 sat had fallen to 30% and CZ had told me to relax as the patient is young….

The second attempt was successful and the SpO2 risen to a comfortable level within seconds and it was a real relief for me when I confirmed the position of the tube.

For me, anything which go wrong would be my responsibility as I was the patient’s attending physician.

CZ had told me that the epiglottis was actually ok but there was this large swelling at the tongue base which actually acted as the culprit. Well, a review of the history which was compatible to the diagnosis -> no barking cough but difficulty of speaking ( tongue base problem c normal epiglottis vs swollen epiglottis).

What ever is the diagnosis, I am happy with the outcome as the patient had improved after admission to the ICU….