Supraglottic Myxedema: Two Cases And A Review Of The Literature

ABSTRACT Objective: We report 2 patients who presented with clinical symptoms of acute upper airway obstruction from presumed supraglottic myxedema and compare their clinical presentation, diagnosis, and management with previously reported cases. Methods: Clinical data, laboratory results, imaging, and procedure reports were reviewed for both cases. A literature search was performed in MEDLINE using the terms “supraglottic myxedema,” “myxedema,” and “laryngeal edema.” Relevant references were selected and reviewed. Results: A 63-year-old man presented with confusion and facial and neck edema. The patient was subsequently intubated for airway protection. During intubation the epiglottis could not be visualized due to airway edema. Thyroid function testing revealed elevated thyroid-stimulating hormone (TSH) and low free thyroxine (FT4). Computed tomography (CT) scan of the neck without contrast noted nonspecific mild, diffuse edema within the subcutaneous soft tissues. A 70-year-old man with a history of papillary thyroid cancer treated with total thyroidectomy and radioactive iodine presented with sore throat, stridor, lower eyelid edema, and proptosis. Fiberoptic intranasal scope noted supraglottic edema. CT scan of the neck without contrast showed prominent pharyngeal mucosal thickening associated with retropharyngeal edema with resultant airway narrowing. TSH was elevated and FT4 was undetectable. Both patients required prolonged intubation that led to tracheostomy. Symptomatic improvement and resolution of airway edema was noted after treatment with levothyroxine and glucocorticoid therapy. Conclusion: These cases and the review of literature suggest that supraglottic myxedema is a rare complication of severe hypothyroidism. Medical management of hypothyroidism and airway support are preferred treatments. Glucocorticoids have unproven additional therapeutic benefit. Abbreviations: CT = computed tomography; FT4 = free thyroxine