Epiglottitis.

I have been seeing a lot of patients with the seemingly straightforward chief complaint of "sore throat" the last several weeks at the clinic.  Some patients are diagnosed with streptococcal pharyngitis with a rapid strep test, some are diagnosed as viral, while others' sore throats seem to be more seasonal allergy related.  Spring is finally here and I have already started my daily claritin!  While sick visits can be a good challenge and are enjoyable for me, the "sore throat patient" can seem a bit methodical.  So, I reminded myself to keep an eye out for rare "zebras."  You know, a diagnosis that seems simple but turns into something crazier than usual.  That's when I remembered learning about epiglottitis.  Since I have never diagnosed an epiglottitis in my practice, I decided to look it up again and why not write about it on my blog to further seal it in my memory?

Epiglottitis is inflammation of the epiglottis, the flap at the base of the tongue that keeps food from going down the trachea and into the airway with swallowing.   It is most often caused by Haemophilus influenzae type b but may also be caused by other types of bacterial infection.  You may have heard of Hib, because it is the name of a great childhood vaccine.  Non-infectious etiologies of epiglottitis are rare but include thermal causes, crack cocaine or marijuana smoking, foreign body ingestion and head and neck chemotherapy.  Providers must be capable of diagnosing epiglottitis quickly.  While initial signs of epiglottitis can be mild, the condition progresses quickly and is life-threatening.

Case Presentation: A 19 year-old female presents to your clinic complaining or sore throat and a muffled voice.  She states that she has difficulty swallowing.  Her symptoms began upon waking a few hours earlier.  The patient is generally in good health with no significant medical history.  She has a fever with a temperature of 100.8 and is tachycardic with a pulse of 112.
On exam, you notice the patient is unable to swallow secretions and is spitting.  She is in no respiratory distress but states it is difficult for her to breathe.  Her pharynx appears normal but you note cervical lymphadenopathy on examining her neck.  Her lung sounds are clear.  Based on the patient's symptoms, you order an X-Ray of the soft tissues of her neck which shows a "thumb sign" indicating epiglottitis.

So, the diagnosis of epiglottitis is based on clinical presentation and coorelated with imaging.  While X-Ray has traditionally been used to diagnose epiglottitis, laryngoscopy is now the preferred method. And that is when I call the patient who is sitting in the xray lab and direct them to the ER immediately. The enlarged, inflamed epiglottis can cause airway obstruction making airway management of utmost importance in treatment.  Patients need to be closely monitored in the ICU and may need to be intubated if they become unstable.

Third generation cephalosporins such as Rocephin are first-line treatment for epiglottitis.  Corticosteroid use in epiglottitis is controversial and has not been shown to be effective.  Antipyretics such as acetaminophen should be used to treat fever as necessary. 

Ok, now I really need to start studying for my ACLS recertification class that is scheduled for next week!

The Disease of Busyness

As a Nurse Practitioner, I am around people all day long five days a week.  Every ten to thirty minutes, I see a different face, hear a different story, create a different plan.  Recently a theme throughout many of my visits is busyness.  People are busy.  Too busy to follow a healthy diet.  Too busy to exercise for 30 minutes.  Too busy to take their medications.  Too busy to see a marriage counselor.  The list goes on and on...  And you know what?  I believe them.  Many of my patients feel busy because they are busy - They work jobs, take care of their sick parents, have a spouse, coach their child's sports team, try to put food on the table, pay their bills.  At the end of the day, there is not much time to allocate toward their own health.  I am not only speaking of physical health, but this busyness also affects emotional and spiritual health.

There are times when I see this same busyness in my own life.   My personal busyness comes from several commitments, like the demands at my workplace or being highly involved with church or other organizations in the community.  I have also found that much of my busyness comes from my tendency toward order.  I like my house to be tidy.  I like my car to be clean.  I like my yard to look, well, not like a jungle.  While this task-focused aspect of my personality is not a bad thing, if left unmonitored it can be destructive.  I end up doing meaningless tasks much of the time.  I tell myself that after my checklist has been completed I can sit, pray, go for a run, or spend time with people.  The reality is that the checklist never ends and I end up being too tired to do anything else.

My patients are weary.  I also feel overwhelmed at times.  No one is immune to the disease of busyness that is so prevalent in our culture.  I know, I know, busyness does not have an ICD9 code but you get the point.  Busyness prevents us from having intentional and meaningful relationship with our spouses and our families because we are already spent.  It balks at genuine friendship and community.  It eventually inhibits our ability to enjoy life and we forget to "smell the roses."  Even more importantly, busyness can keep us from communing with God.  When we neglect prayer and reading God's Word, we are more prone to fall to the temptations of our sinful nature.  At first following our sinful nature may be pleasurable, but ultimately our lives will be a wreck.  So much stress and sadness could be avoided if we started to say "no" to busyness and instead started to follow God's Word.

So, I am going to echo Socrates and say, "Beware of the barrenness of a busy life."  Let a few dirty dishes in the sink because sometimes it is worth loosening your grip on the checklist.  Don't let the disease of busyness steal what matters most.