September 2022 Medical Image of the Month: Epiglottic Calcification

Figure 1. Lateral (A) and frontal (B) topogram from a neck CT demonstrates linear calcifications in the expected location of the epiglottis (black arrows).  Sagittal multiplanar reconstructions demonstrate prominent calcification of the epiglottis (white arrow).

In consideration of dysphagia, most cases predominate in the oropharyngeal region with the remainder caused primary by esophageal causes. Lesser known and studied is the development of dysphagia and globus sensation from epiglottic pathology, namely epiglottic calcification. With less than a dozen published cases in literature, very little data exists on identification, diagnosis, and treatment of this known cause of morbidity. Here we present a case of oropharyngeal dysphagia arising from a rare cause, epiglottic calcification.

An 81-year-old man with a history of aortic stenosis and carotid artery stenosis presented with worsening dysphagia over the course of one month. The patient reported significant dysphagia, initially to solids and subsequently to liquids causing a weight loss of over 50 pounds. Physical exam of the oropharynx and neck were unremarkable. A bedside swallow evaluation suggested mildly decreased hyolaryngeal movement, but no other significant abnormalities.  A barium swallow study revealed incomplete epiglottic excursion during the pharyngeal phase of swallowing. The patient then underwent evaluation with a contrast-enhanced esophagogram, which showed severe esophageal dysmotility and gastroesophageal reflux. A CT of the neck demonstrated calcification of the epiglottis without epiglottal enlargement. ENT was consulted, the patient underwent flexible fiberoptic laryngoscopy and also EGD with biopsy.  No other esophageal or gastric pathology were identified other than the epiglottic calcification. As no effective treatment is known at this time, the patient was changed to a modified diet with ongoing speech and swallow therapy as an outpatient.

Epiglottic calcification is a rare cause of dysphagia that is poorly understood in its etiology, clinical course and outcome (1). This case demonstrates that despite consultant team recommendations, no clear evaluation pathway or treatment currently exists. Currently, diagnosis can be accomplished with radiologic evaluation along with exclusion of other causes; however, no definitive treatments are available for this rare condition. Although the condition itself is rare, epiglottic calcification should be considered when other more common causes of significant dysphagia are ruled out.  

Shil Punatar DO¹, Dayoung Song MD¹, Azkaa Zaman DO¹, Benjamin Jiao DO², and Tilemahos Spyratos DO^1,3

¹Department of Internal Medicine, Franciscan Health, Olympia Fields, IL

²Department of Radiology, Franciscan Health, Olympia Fields, IL

³Department of Gastroenterology, Franciscan Health, Olympia Fields, IL

Reference

1. Günbey HP, Günbey E, Sayit AT. A rare cause of abnormal epiglottic mobility and dyspagia: calcification of the epiglottis. J Craniofac Surg. 2014 Nov;25(6):e519-21. [CrossRef[[PubMed]

Cite as: Punatar S, Song D, Zaman A, Jiao B, Spyratos T. September 2022 Medical Image of the Month: Epiglottic Calcification. Southwest J Pulm Crit Care Sleep. 2022;25(3):41-42. doi: https//doi.org/10.13175/swjpccs031-22 PDF

Medical Image of the Week: Acute Epiglottitis

Figure 1. Lateral (Panel A) and AP (Panel B) views of the neck demonstrate a patent airway, but epiglottis and its associated folds are quite thickened suggesting the patient has developing epiglottitis. The lateral view demonstrates a ‘thumbprint’ sign with an enlarged epiglottis (T).

A 24 year old man without a significant past medical history presented with a 3 day history of sore throat, fever and less than 24 hour history of pain with breathing and swallowing secretions. He was intubated using fiberoptic nasopharyngoscopy in the emergency department due to stridor with a 6.0 mm endotracheal tube until successfully extubated five days later. Initially he was treated with broad spectrum antibiotics and methylprednisolone 40 mg intravenously every 12 hours. A CT scan of the neck did not show an epiglottic abscess.

Acute epiglottitis in adults appears to have a rising incidence with an associated mortality of 7% that is related to Haemophilus influenzae type b, as well as other miscellaneous pathogens, mechanical injury or smoke inhalation. Risk factors associated with obstruction are drooling, rapid onset of symptoms, evidence of abscess formation and a history of diabetes mellitus. Epiglottic abscess is infrequent sequelae of acute epiglottis. Use of steroids in severe cases is common, but there is no evidence of benefit.

Chirag Desai MD, Mohammad Dalabih MD, Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

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(6);374-83. [CrossRef] [PubMed] 

Reference as: Desai C, Dlabih M, Campion J. Medical image of the week: acute epiglottitis. Southwest J Pulm Crit Care. 2013;7(3):161. doi: http://dx.doi.org/10.13175/swjpcc119-13 PDF