Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACER or SAEM. The editor reserves the right to edit and publish letters as space permits. Letters not meeting submission criteria will not be considered for publication.

CORR.ESPONDENCE Radiographs in the Diagnosis of Epiglottitis

To the Editor: I was disappointed to read another

paper ("Radiologic Diagnosis of Epi- glottitis: Objective Criteria for All Ages" [September 1990;19:978-982]) advocating the use of radiographs in the evaluation of the patient with epiglottitis. In my opinion, there is no role for radiographs in the diag- nostic approach to this disease,

Rober t d Rothstein, MD, FACEP - -

Sect ion Edi tor

Be thesda , MaryLand

Patients with epiglottitis can be di- vided into tWO categories: those in whose case the diagnosis is obvious, and those in whom the diagnoms is uncertain. The patient with obvious epiglottitis comes in with the "clas- s ic" presenta t ion , drooling, chin thrust forward, dyspnea, fever, etc. Such a pa t i en t should be t aken straight to the operating room for di- rect laryngoscopy and endotracheal inrubation, with the emergency phy- sician at the operating table, prepared to perform a cricothyrotomy if intu- bation is not possible. Radiographs obviously have no role in such cases.

The patient in whose case the diag- nosis is not obvious may be safely examined by either indirect laryngos- copy or flexible laryngoscopy; occa- sionally with children, the epiglottis can be seen if the base of the tongue is depressed. There is no danger posed by direct or indirect examina- non of the supraglottic structures in such cases.

There are several problems with radiographs. A normal film does not rule out epiglottitis. Patients with epiglottitis may have a normal radio- graph, particularly in the early stages. If the radiograph shows an enlarged epiglottis, in most if not all cases, laryngoscopy will be carried out to better define the pathology and allow for airway splinting.

Radiographs contr ibute little or

nothing to the diagnosis of epiglot- titis , may delay appropriate diagnos- tic procedures or treatments, and add to the expense. Heaven help your pa- tient if he obstructs in the radiology department!

Michael J Flannery, MD, FACEP North Memorial Medical Center Robbinsdale, Minnesota

In ~eply: We read the comments by Dr Flan-

nery concerning the use of radiogra- phy in the diagnosis of epiglottitis with interest and appreciate the op- portunity to respond to several im- portant issues. Our study was an at- tempt to apply objective criteria to the interpretation of radiographs and not a promotion of plain film radiog- raphy in all patients with suspected epiglottitis. We purposely avoided a discussion of when and where lateral neck radiography might be used in patients with suspected epiglottitis because we initially did not believe that these factors directly related to our study. Instead. we concentrated on the technical aspect of how to bet- ter interpret films using objective measurements.

We agree that appropriate manage- ment of patients with suspected epi- glotti t is does not involve sending them to the radiology department for plain soft tissue lateral neck films. Our study made no mention of the location of patients who underwent radiography and did not suggest that patients with suspected epiglottitis be sent to the radiology department. In our emergency department, all sta- ble patients with a low or moderate suspicion of epiglottitis undergo por- table radiography with a physician trained in airway management con- stantly at the bedside or they are ac- companied by this physician iwith airway equipment) to the radiology suite, which is within our depart- ment.

The statement that plain film radi- ography has absolutely no role in the diagnosis of epiglottitis is nor sup- ported by the medical literature, A quick review of every major emer- gency medicine and pediatric emer-

gency textbook in our library re- vealed that radiographs are uniformly promoted in the diagnosis of epiglot- titis.ls However, the exact role radi- ography plays is a matter of much de- bate and opinion. Radiography has several limitations as mentioned in our article (mainly the possibility of false-negatives). Indirect laryngos- copy and other direct visualization procedures by emergency specialists are als0 beginning to play a larger role in the evaluation of stable pa- tients with suspected epiglottitis.

We do not support any attempts at radiography on unstable pat ients with "classic" epiglottitis (stridor, drooling, dyspnea, and fever) as sug- gested by Dr Flannery. Treatment of these patients involves immediate airway management in the operating room by a team consisting of physi- cians with expertise in airway man- agement and surgical airway pro- cedures (ie, emergency tracheostomy because cricothyrotomy is often con- traindicated in the most common age groups with epiglottitis).

The majority of adults and a large number of children, however, do not have classic presentations and their m a n a g e m e n t is less s t ra ight for- ward.6, 7 In adults, there have been no reported complications from indirect laryngoscopy, and this procedure is probably safe in the initial assess- ment of these patients. 6 However. ra- diography may still be useful in dif- ferentiating other upper airway pa- t h o l o g y leg, f o r e ign bodies or abscessesl from epiglottitis. In chil- dren, manipulating the upper airway by indirect laryngoscopy or tongue blade is more hazardous and can po- tentially cause laryngospasm.8 Al- though this complicat ion may be overstated, no published studies have described a large series of children with non "class ic" epiglotti t is in whom upper airway manipulation by indirect laryngoscopy, flexible laryn- goscopy, or tongue blade have been performed wi thout complications. IMauro and colleagues do report that no complications occurred from epi- glottic visualization in 155 children with stridor; however, only six pa- tients in this series had epiglottitis). 9

We do not believe that the anecdo-

20:4 April 1991 Annals of Emergency Medicine 438/157