急性喉頭蓋炎における気管切開拒否例への対応について

抄録

Acute epiglottitis is a life-threatening disease. Patients with this condition need tracheotomy for safe management of the airway. This is a critical aspect because doctors are liable to face legal action in case they make a mistake in responding to acute epiglottitis. We report a case of severe swelling of the epiglottis, where the patient was on the verge of being choked because he did not allow us to perform a tracheostomy. The patient, a 55-year-old opera singer, had a sore throat and visited the emergency department of our hospital. He had swellings in the lower right tonsil and lingual face of the epiglottis. Based on laryngeal fiberscopy and CT imaging, we diagnosed his condition as acute epiglottitis accompanied by a right peritonsillar abscess. He was hospitalized and received an antibacterial medicine and a steroid through an intravenous drip. But after 10 hours, the patient’s condition deteriorated to respiratory distress and he developed a hot potato voice. Laryngeal fiberscopy showed a further inflammation of the epiglottis. We highly recommended an urgent tracheotomy to the patient, but he sternly denied the tracheotomy because he was worried about the impact of the procedure on his voice as an opera singer. After he signed a written informed consent that he would be responsible for all disadvantages incurred by not receiving a tracheotomy, we moved him to the ICU and completed the necessary preparations for an urgent tracheotomy if needed. Two head and neck doctors kept the patient under observation all night at the bedside. Fortunately, the swelling improved by the morning and he was discharged from the hospital seven days later.

In this case, the patient avoided choking without a tracheotomy despite severe swelling of the epiglottis. In this report, we refer to documents and consider the indications of tracheotomy, the characteristics of cases where conservative treatment was effective, and the measures to counter people who refuse a tracheotomy.