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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 42-44

Idiopathic primary supraglottic laryngeal abscess


Department of Otorhinolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication22-Aug-2019

Correspondence Address:
Dr. Saurabh Varshney
Department of Otorhinolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_12_19

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  Abstract 


Laryngeal abscess is a suppurative submucosal connective tissue inflammation of the larynx. It is rare but can be life-threatening due to its potential for airway obstruction. The etiology and thus treatment has changed drastically from pre- to postantibiotic era. We are hereby reporting an interesting rare case of laryngeal abscess in this postantibiotic era. Current etiological factors and modes of presentation are also discussed in this article.

Keywords: Abscess, acute, antibiotics, laryngeal


How to cite this article:
Gupta S, Varshney S, Malhotra M, Tyagi AK, Kumar A. Idiopathic primary supraglottic laryngeal abscess. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:42-4

How to cite this URL:
Gupta S, Varshney S, Malhotra M, Tyagi AK, Kumar A. Idiopathic primary supraglottic laryngeal abscess. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Nov 19];3:42-4. Available from: http://www.aiaohns.in/text.asp?2019/3/1/42/265132




  Introduction Top


Laryngeal abscess is a suppurative submucosal connective tissue inflammation of the larynx. The incidence of laryngeal abscess ranges from 2% to 29%.[1] Laryngeal abscesses can be life-threatening due to the potential for airway obstruction. Historically, it has been classified on the basis of origin into primary and secondary types. The primary type may begin in the perichondrium, from either trauma or inflammation, leading to pus formation and the secondary type develops as a result of extension of infection from tonsillar or nasopharyngeal infections.[2] They have also been found to be associated with typhoid, measles, pyemia, and general sepsis.[2],[3] Other cases are along with tuberculosis or syphilis of the larynx.[2] In laryngeal abscess, the most common isolated organisms are Haemophilus influenzae, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, Meningococci, Haemophilus parainfluenzae, Klebsiella pneumoniae, Nocardia species, and Candida albicans.[1] Most of the abscesses occur in the epiglottis or preepiglottic space as a sequelae of acute supraglottitis. In the postantibiotic era, the etiology of laryngeal abscess formation has changed. It is now associated with recent airway manipulation and malignancies of the larynx.[3],[4],[5] It is characterized by a rapid deterioration in the size of the laryngeal inlet which needs urgent airway management. Appropriate workup and management of the airway are essential for optimizing outcomes in these patients.

In this article, we present an interesting rare case and management of a spontaneous idiopathic primary laryngeal abscess which was initially suggestive of a malignant growth clinicoradiologically.


  Case Report Top


A 45-year-old male patient presented to the ear, nose, and throat outpatient clinic at our institute with complaints of pain and difficulty in swallowing (both for solids and for liquids) associated with dysphonia for the past 15 days. The patient had no history of fever or dyspnea. The patient was a chronic smoker for the past 20 years. There was no significant past medical or surgical history. The patient was nondiabetic and nonhypertensive. There was no history of otalgia. The physical examination was significant for a rough and muffled voice without any stridor or respiratory distress. Ear and nose examination was within the normal limits. Neck examination showed no lymphadenopathy. Laryngeal crepitus was present. A clinical diagnosis of laryngeal malignancy was considered based on symptoms and examination. The contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) of the neck and larynx [Figure 1]a and [Figure 2]a showed poorly marginated heterogeneously enhancing hypodense lesion in the right supraglottis causing effacement of the preepiglottic space with thickening of epiglottis and extending on both sides of the midline with erosion of bilateral thyroid lamina and extension to strap muscles. Transnasal flexible laryngoscopy revealed a submucosal bulge over the right aryepiglottic fold and false vocal cord region [Figure 3]a. A direct laryngoscopy and biopsy from the suspected lesion was planned under general anesthesia and biopsy was taken. The histopathology revealed hyperplastic stratified squamous epithelium. Underlying subepithelium showed fibrocollagenous tissue and mild chronic inflammatory infiltrate [Figure 4]. No granuloma or atypical cell was identified. Hence, repeat biopsy was done, which again revealed only chronic inflammatory infiltrate. The patient was advised oral antibiotic amoxicillin + clavulanic acid 625 mg tds and oral metronidazole 400 mg tds along with chymotrypsin for 3 weeks. The patient was symptomatically relieved after 2 weeks. Clinical suspicion of inflammatory lesion was supported by histopathological findings. Thus, final diagnosis of an abscess was made. Negative biopsy, high total leukocyte count (14,500 cells/mm3), acute onset of symptoms, and symptomatic relief on antibiotic treatment favored the diagnosis. Repeat fiber-optic examination was done after 2 months' significant reduction in the size of lesion over the laryngeal surface of the epiglottis [Figure 3]b. The rest of swelling had subsided significantly. A repeat CT and MRI of the neck [Figure 1]b and [Figure 2]b done after 2 months showed the absence of swelling or growth as compared to previous scan. The patient was followed with endoscopy after 3 months and had no residual or recurrence of the disease.
Figure 1: (a) Pretreatment sagittal view of computed tomography scan showing hypodense lesion causing effacement of the preepiglottic space. (b) Posttreatment sagittal view of computed tomography scan showing no lesion or growth

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Figure 2: (a) Pretreatment axial view of scan showing hypodense lesion in the right supraglottis. (b) Posttreatment axial view of scan showing no lesion or growth

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Figure 3: (a) Pretreatment indirect laryngoscopy showing a smooth bulge in false vocal cord region. (b) Posttreatment indirect laryngoscopy showing a significant reduction in the size of lesion

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Figure 4: Histopathology of the lesion showing chronic inflammatory infiltrate

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  Discussion Top


In the preantibiotic era, primary laryngeal abscess was a result of a preceding event of catarrhal inflammation, trauma due to foreign bodies, overexertion of laryngeal muscles, or cauterization with alkalis or acids.[2] It was postulated that the abscess develops from an acute submucosal laryngitis that involves the perichondrium immediately. The perichondrium is separated from the cartilage with abscess formation.[6] The inflammatory process either compromises the airway or extends laterally to develop a subcutaneous abscess or fistula.

Secondary laryngeal abscess formation was described as an extension of an infection from tonsils, peritonsillar space, or the nasopharynx or as a complication of various diseases.[2],[3],[6]

In the postantibiotic era, the etiology of laryngeal abscess formation is associated with recent manipulation of airway and laryngeal malignancies.[4],[5] The cases of primary laryngeal infection and abscess are now associated with immunocompromised patients or, rarely, still as a result of acute sinusitis or tuberculosis.[7]

Acute laryngeal abscesses could be intra- or extralaryngeal. The intralaryngeal origin of abscess is usually in the epiglottis, thyroid, or cricoid cartilage, whereas extralaryngeal origin is on the anterior surface of the epiglottis, aryepiglottic folds, or pyriform sinuses.[8],[9] The extralaryngeal origin can be due to spread of abscess in the visceral space of the neck. The anterior visceral space extends beneath the strap muscles; encircles the thyroid gland, trachea, and esophagus; and communicates with the retropharyngeal space bordered posteriorly by the visceral fascia. Infection of the visceral space usually results from trauma to the upper airway tract or secondary to infected laryngocele, suppuration in prelaryngeal lymph nodes, or retropharyngeal space infection.[8],[9] The present case is a primary extralaryngeal abscess.

Multiple biopsies are recommended in all cases of laryngeal abscess. A high clinical suspicion of an underlying malignancy should always be associated with patients with no underlying etiological factors, as this is now the most common reason in patients who may develop a laryngeal abscess today. As in the present case, multiple biopsies ruled out any malignant growth.

Diagnosis of laryngeal abscess can be challenging and confusing. Patients with acute symptoms of short duration with no definitive growth and negative biopsy for malignancy from submucosal bulge should always be suspected and simultaneously treated for abscess as was done in the present case.

Treatment for laryngeal abscesses has varied but always includes systemic antibiotics and endoscopy. Early diagnosis will lead to better outcome. Appropriate airway management is critical in all cases, and patients may require tracheostomy in advanced airway compromise.[9] In the most extreme case, a laryngectomy was performed due to persistent laryngeal dysfunction and persistently infected cartilaginous sequestra postlaryngeal abscess. In other cases, drainage of the abscess was performed both endoscopically and transcutaneously.[10] Purely medical management with antibiotics was shown to be an effective treatment for our case due to timely clinical suspicion and intervention.

The pathologic mechanism leading to abscess formation has not been clearly explained, but it does appear that mechanical trauma and an immunocompromised state are important risk factors.[10] Identification of risk factors as well as rigorous evaluation and management of the airway is critical in patients with laryngeal abscesses due to the potential for fatal airway obstruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol 2003;24:374-83.  Back to cited text no. 1
    
2.
Howard RE. Laryngeal abscess. Laryngoscope 1931;41:344-47.  Back to cited text no. 2
    
3.
Souliere CR Jr., Kirchner JA. Laryngeal perichondritis and abscess. Arch Otolaryngol 1985;111:481-4.  Back to cited text no. 3
    
4.
Zapanta PE, Bielamowicz SA. Laryngeal abscess after injection laryngoplasty with micronized alloDerm. Laryngoscope 2004;114:1522-4.  Back to cited text no. 4
    
5.
Reed J, Shah RK, Jantausch B, Choi SS. Aryepiglottic abscess manifesting as epiglottitis. Arch Otolaryngol Head Neck Surg 2009;135:953-5.  Back to cited text no. 5
    
6.
Kernan J, Schugt H. Primary submucous laryngeal abscesses. Arch Otolaryngol 1933;17:22-9.  Back to cited text no. 6
    
7.
Nakagawa H, Shiotani A, Araki K, Kusuyama T, Fukuda H, Ogawa K, et al. Laryngeal carcinoma presenting as a large anterior neck abscess. Auris Nasus Larynx 2007;34:249-51.  Back to cited text no. 7
    
8.
Tannebaum RD. Adult retropharyngeal abscess: A case report and review of the literature. J Emerg Med 1996;14:147-58.  Back to cited text no. 8
    
9.
Sethi DS, Stanley RE. Parapharyngeal abscesses. J Laryngol Otol 1991;105:1025-30.  Back to cited text no. 9
    
10.
Bick E, Bailes I, Patel A, Brain AI. Fewer sore throats and a better seal: Why routine manometry for laryngeal mask airways must become the standard of care. Anaesthesia 2014;69:1304-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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