|Year : 2013 | Volume
| Issue : 1 | Page : 26-28
Acute laryngeal abscess following acute sinusitis: A rare presentation in the modern era
Shraddha Jain1, Sagar Gaurkar1, Prasad Deshmukh1, Sunil Kumar2
1 Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, DMIMS (DU), Sawangi, Wardha, Maharashtra, India
2 Department of Medicine, Jawahar Lal Nehru Medical College, DMIMS (DU), Sawangi, Wardha, Maharashtra, India
|Date of Web Publication||24-Sep-2013|
Department of Otorhinolaryngology and Head and Neck Surgery, Jawahar Lal Nehru Medical College, DMIMS (DU), Sawangi, Wardha - 442 005, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Acute laryngeal abscess is a rare but potentially lethal condition. There are historic descriptions of its association with systemic illnesses like typhoid fever or as a result of spread of infection following upper respiratory tract catarrh. The etiology of laryngeal abscess in recent times has changed to those with underlying malignancy, trauma due to airway instrumentation, nasogastric intubation, and external beam radiotherapy. Here we report a case of acute laryngeal abscess following catarrh, identical to the historic descriptions, probably the first such report in the modern era, highlighting the importance of its early diagnosis and high index of suspicion, which led to a very good recovery in our patient.
Keywords: Abscess, acute, laryngeal, sinusitis
|How to cite this article:|
Jain S, Gaurkar S, Deshmukh P, Kumar S. Acute laryngeal abscess following acute sinusitis: A rare presentation in the modern era. J Laryngol Voice 2013;3:26-8
| Introduction|| |
Acute laryngeal abscess is a suppurative inflammation of the submucous connective tissue of the larynx. Historically, it has been classified into primary and secondary. The former may begin in the perichondrium, from trauma, overexertion of laryngeal muscles, or catarrhal inflammation leading to pus formation and latter develop as a result of extension of infection from tonsillar or nasopharyngeal infections. Also, they have been found to be associated with typhoid, measles, scarlet fever, erysipelas, pyemia, or general sepsis. , Other cases are those associated with tuberculosis or syphilis of larynx. 
The etiology of laryngeal abscess in recent times has changed to those with underlying malignancy, trauma due to airway instrumentation, nasogastric intubation, external beam radiotherapy, preexisting laryngocele, , injection laryngoplasty,  and skin tattooing. 
The present case is interesting to report as after exhaustive literature search in PubMed, Indmed, Medlar, and other search engines, this is probably the first reported case of acute laryngeal abscess following catarrh in the modern era, identical to the historic descriptions. , The patient had no other inciting factor for the condition except acute on chronic rhinosinusitis. In spite of difficult diagnosis and complicated course of the disease, the excellent outcome in our patient made us to report this case.
| Case Report|| |
A 45-year-old male patient came to the otolaryngology emergency of our hospital with complaints of difficulty in breathing, change in voice, dysphagia even for liquids, odynophagia, pain in neck, and high grade fever of 6 days duration following upper respiratory infection. Initially, he had purulent nasal discharge with postnasal drip followed by change in voice and difficulty in swallowing over the next few days. Later, he developed noisy breathing.
On examination, patient had inspiratory stridor with mild suprasternal recession. Local examination of neck revealed mild laryngeal fullness on right side with laryngeal tenderness and no significant lymphadenopathy. There was no torticollis or trismus. Oral and oropharyngeal examination was normal. Indirect laryngoscopy revealed a normal epiglottis with edematous right arytenoid and aryepiglottic fold and right lateral pharyngeal wall was pushing the laryngeal inlet towards left. There was pooling of secretions in the hypopharynx.
Soft tissue X-rays of neck - anteroposterior and lateral view - revealed severe narrowing of the airway, which was seen to be pushed to left [Figure 1] with retropharyngeal widening. Ultrasonography of neck revealed hypoechoic lesion in the right paratracheal region pushing the right lobe of thyroid. Diffuse wall thickening with fluid was noted in the larynx. Computed tomography (CT) scan of the neck [Figure 2] at the level of thyroid cartilage showed multiloculated peripherally enhancing collection around bilateral cricoarytenoid joint with involvement of retropharyngeal space and extending outside larynx on the right side causing severe airway compromise. Laboratory analysis revealed leukocytosis (white blood cell count of 15,000 with 85% neutrophil predominance, hemoglobin level of 13.5 g/dl, ESR of 105 mm). Basic metabolic panel and liver function tests were unremarkable. His human immunodeficiency virus (HIV) test was negative. The patient was admitted to the intensive care unit (ICU) and empirically started on intravenous amoxicillin-clavulinate, gentamicin, clindamycin, and metronidazole along with injection dexamethasone for the first day considering it to be a deep-neck space infection. Emergency tracheostomy was done. Over the next few days, his fever subsided and blood counts came back to normal. On the third day, the patient developed sudden cardiac arrest and he was resuscitated. Repeat X-ray soft tissue neck showed improvement in the air column, which came to midline.
|Figure 1: Soft tissue X-ray of neck - anteroposterior view showing severe narrowing of the airway, which is seen to be pushed to the left|
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|Figure 2: Axial contrast-enhanced computed tomography at the level of thyroid cartilage showing multiloculated peripherally enhancing hypodense collection around bilateral cricoarytenoid joint (yellow arrow) with involvement of retropharyngeal space and extending outside larynx on the right side (pink arrow) causing severe airway compromise|
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Endoscopic examination of larynx revealed edematous right aryepiglottic fold with whitish slough over arytenoids, the biopsy of which was taken to rule out any underlying malignancy [Figure 3]. This caused release of some pus, the culture of which grew normal respiratory flora. His dysphagia improved after this.
The histopathology revealed neutrophilic infiltrate in background of chronic inflammatory cells in fibrocollagenous stroma [Figure 4]. The diagnosis of acute laryngeal abscess was made.
|Figure 3: Endoscopic examination of larynx showing edematous right aryepiglottic fold with whitish slough over arytenoids|
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|Figure 4: Neutrophilic infiltrate in background of chronic inflammatory cells in fibrocollagenous stroma, showing unremarkable squamous epithelia (H and E, ×40)|
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After some days, his breathing difficulty increased. X-ray chest showed minimal pleural effusion, which were managed conservatively. Repeat endoscopy was normal with mild slough over arytenoids and CT scan showed complete resolution with good airway. The patient was decannulated for tracheostomy and discharged in a stable condition.
| Discussion|| |
Acute laryngeal abscesses are rare as a complication of other infections in the present antibiotic era. They could be intralaryngeal or extralaryngeal.  The intralaryngeal origin is usually in thyroid cartilage, cricoid cartilage, or epiglottis, whereas, extralaryngeal origin is on anterior surface of epiglottis, aryepiglottic folds or pyriform fossae. The extralaryngeal origin could be due to spread of abscess in the visceral space of neck. The anterior visceral space extends beneath the strap muscles encircles the thyroid gland, trachea, esophagus, and is in complete communication with the retropharyngeal space bordered posteriorly by the visceral fascia.  Infection of the visceral space usually results from trauma to the upper aerodigestive tract or rarely secondary to infected laryngocele, suppuration in prelaryngeal lymph nodes, or retropharyngeal space infection. , In our patient, there was involvement of retropharyngeal space along with extralaryngeal spread on right side medial to thyroid gland along the visceral space of the neck from aryepiglottic folds. The infection had probably occurred as a result of secondary laryngeal inflammation due to the infected secretions from sinuses.
It is a serious condition where airway compromise occurs rapidly and requires urgent airway management and institution of broad spectrum antibiotics directed against Staphylococcus and Streptococcus along with CT-imaging for confirmation and extent of disease. Diagnostic endoscopy with biopsy must be done to rule out underlying malignancy or granulomatous infections. The pus needs to be drained endoscopically as in our case or may require external drainage.
The condition must be differentiated from laryngeal perichondritis with abscess formation between the inner and outer perichondria leading to cartilage necrosis, an important cause of acquired subglottic stenosis (SGS). 
It must also be differentiated from cervicofascial necrotizing fasciitis, which usually has skin involvement in the form of discoloration or necrosis and laryngeal involvement may comprise of necrosis or blackening of laryngeal mucosa or cartilage.  The condition can be confirmed by CT scan and biopsy and requires debridement of the necrotic material.
| Conclusion|| |
Acute laryngeal abscess following upper respiratory catarrh is a possibility even in the modern antibiotic era. Prompt institution of antibiotic therapy along with airway management, CT imaging, and endoscopic or external drainage of pus are the mainstay of treatment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]