Asphyxia Death Caused by Epiglottic Abscess Rupture in an Adult: a Case Report

Asphyxia death caused by epiglottic abscess rupture in an adult: A case report

Yong Cao 1,2, Youjia Yu1, Xiaohong Gao3, Hong Jin4, Meigui Lu1, Daoyin Gong5, Feijun Huang1,*

______Abstract: We report a case of Asphyxia death caused by epiglottic abscess rupture. Patient was initially managed as acute epiglottis with parenteral antibiotics, about two hours later, the patient died with bleeding from his nose and mouth. In this case, the patient exhibited a hemorrhage at the top of the epiglottic abscess by the abscess surface mucosa rupture (0.5cm×0.1cm). We reviewed this case with respect to the autopsy findings, pathological changes and circumstantial correlations of the investigation. Key Words: epiglottic abscess, asphyxia death, autopsy, forensic pathology.

different category of blast injuries is the one epiglottis mucosa and throat (Fig. C, D), together with A related with exploding tyres. Injuries caused edema of throat mucosa, epiglottis and surrounding by exploding tyres can be seen as direct injuries caused tissue. An epiglottic abscess nodule (1.6 × 1.3 × 0.6cm) by rim fragments and barotraumas as a result of high (Fig. E) was detected at the right side of the surface of pressures [1]. epiglottis. A 47-year-old male was found dead at home with The wall thickness of epiglottis was 1.0 cm (Fig. a lot of blood flowing from his nose and mouth 2 hours G). Extensive epiglottis interstitial hemorrhage and after leaving the hospital. From beginning to end, the severe congestion of epiglottis were observed (Fig. C). patient did not complain of expiratory dyspnea or show Large quantity of pink foamy liquid was retained in the sign of obstruction. The individual was pronounced dead trachea and bronchi (Fig. B) and overflowed from the after emergency treatment in the hospital. lung section. External examination revealed large amount of Microscopic investigation demonstrated diffused blood in oval and nasal cavity (Fig. A). The fingernails hemorrhage in the epiglottis interstitial (Fig. H, I), large and toenails showed severe cyanosis and the external number of neutrophils in the epiglottis abscess nodules, auditory canal were normal. No lesion was observed on granulation tissue around the abscess and congestion the surface of body. of multiple tissues and organs. Severe lung congestion, Autopsy revealed bloodstain on the surface of edema, focal hemorrhage and partial bronchospasm were

1) Department of Forensic Pathology, West China School of Basic Science and Forensic Medicine, Sichuan University, 3-17 Renmin South Road, Chengdu, Sichuan 610041, PR China * Corresponding author: Tel.: +86-130-9632-6175, Email: [email protected] 2) Department of Pathology, Mudanjiang Medical University, Aimin District, Mudanjiang 157011, PR China 3) Biotechnology Laboratory, Mudanjiang Medical University, Aimin District, Mudanjiang 157011, PR China 4) Department of Clinical Laboratory, Hongqi Hospital, Mudanjiang Medical University, Aimin District, Mudanjiang 157011, PR China 5) Institute of Basic Medicine, Chengdu University of Traditional Chinese Medicine, No. 1166 Liutai Avenue, Wenjiang District, Chengdu, Sichuan 610000, PR China

233 Cao Y. et al Asphyxia death caused by epiglottic abscess rupture in an adult: A case report

Figure. Autopsy revealed edema of epiglottis mucosa and surrounding tissue, hemorrhage of the epiglottic abscess surface and a lot of pink foamy liquid in the bronchi. A. A large amount of blood in oval and nasal cavity; B. Pink foamy liquid in the bronchi (white arrow); C and D. Severe laryngeal congestion and edema, epiglottis stenosis (white arrow); E. Epiglottic abscess nodule measuring 1.6 cm × 1.3cm× 0.6cm (white arrow) at the right side of the surface of epiglottis; F. Epiglottic abscess rupture measuring 0.5cm×0.1cm (white arrow).

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Figure. G. The wall thickness of the epiglottis measuring 1.0cm (white arrow);H and I. The epiglottis interstitial diffuse hemorrhage and inflammatory cell infiltration. observed. Small amounts of hemorrhage were found in the No other lethal pathological changes and myocardial interstitial. Parts of the myocardial fibers were mechanical traumas were found during autopsy. wavy changed, small amount of fat cells and inflammatory The risk factors for epiglottic abscess include cells were observed in myocardial interstitial. There was age of onset, diabetes and the presence of foreign body evidence of cerebral edema. The cause of death was [2]. Berger et al. reported that 10 of the 116 epiglottitis deemed suffocation due to airway obstruction caused patients were diabetic, 16 of them had background disease by epiglottic abscess rupture (0.5cm×0.1cm) (Fig. F), [3]. The clinical features of epiglottic abscess include bleeding and severe laryngeal edema. fever, odynophagia and hoarseness. Interestingly, airway obstructions rarely become the presenting symptom as Discussion compared to odynophagia and fever [4]. Therefore, CT examination is recommended for patients with a stable Acute laryngemphraxis refers to the upper airway and swollen epiglottis, even if the swelling is not respiratory obstruction caused by various diseases very obvious [5]. which induce laryngostenosis or obstructive breathing Although some patients did not have any difficulties. This symptom is more common in infants symptoms of airway obstruction, the laryngoscopy and young children, and also occurs in adults. It is a very findings which showed severely narrowed supralaryngeal critical condition that severe breathing difficulties would airway warrant us to perform tracheostomy in order to take place in a short time. Without timely treatment, establish airway as well as provide route for administration some patients may die from suffocation. Many causes of anesthesia and drainage of the abscess. However, recent may contribute to laryngeal obstruction, including report suggested other methods of treatment to avoid inflammation of the throat, allergic and certain systemic tracheotomy. Kim SG et al. reported that 11 epiglottic diseases, inhalation injury (inhalation hydrothermal hot abscesses were successfully treated with spinal needle toxic or irritating gases) etc [1]. aspiration that avoided the need for a tracheostomy [6]. About our case, five characteristics was At the same time, an iv antibiotics plus corticosteroids discovered by autopsy as follows: should be administrated the moment a suspicion of The deceased had an epiglottic abscess nodule epiglottitis is present [7]. (1.6 cm × 1.3 cm × 0.6cm) bleeding and laryngeal edema, This case shows that in the course of clinical in which large number of neutrophils were found. diagnosis and treatment of patients with sore throat, The deceased had focal pulmonary congestion, painful swallowing, the main symptoms of oropharyngeal edema, pulmonary hemorrhage, bronchospasm, etc, mucosa if no obvious lesions, especially, when some which were consistent with acute myocardial ischemic patients do not complain of breathing difficulty or show changes. sign of obstruction, all of them should be routine for Multifocal hemorrhage in myocardial interstitial, indirect laryngoscopy to rule out the existence of acute wave-like changes of multifocal myocardial fiber and epiglottitis, epiglottis abscesses and other emergencies congestion of multiple tissues and organs were found. All adopted after diagnosis and effective treatment to avoid of them were consistent with signs of acute respiratory serious complications. and circulatory system failure.

235 Cao Y. et al Asphyxia death caused by epiglottic abscess rupture in an adult: A case report

References 1. Zhao ZQ. Forensic Pathology. Fourth Edition, People's Health Publishing House 2009.7.4:439-440. 2. Stack BC Jr, Ridley MB. Epiglottic abscess. Head Neck 1995; 17(3): 263-265. 3. Berger G et al., The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol, 2003. 24(6): p. 374-383. 4. Heeneman H, Ward KM. Epiglottic abscess: Its occurance and management. J Otolaryngol 1977; 6(1): 31-36. 5. Ito, K., H. Chitose, and M. Koganemaru, Four cases of acute epiglottitis with a peritonsillar abscess. Auris Nasus Larynx, 2011. 38(2): p. 284-248. 6. Kim SG, Lee JH, Park DJ et al. Efficacy of spinal needle aspiration for epiglottic abscess in 90 patients with acute epiglottitis. Acta Otolaryngol 2009; 129(7): 760-767. 7. Hindy J et al., Epiglottic abscess as a complication of acute epiglottitis. Am J Otolaryngol, 2013. 34(4): p. 362-365.

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