What is the best course of action for a patient with intermittent throat swelling for 2.5 weeks, now experiencing airway compromise, severe dyspnea (difficulty breathing), and syncope (fainting) due to coughing?

Immediate Emergency Department Evaluation and Management Required

This patient requires immediate emergency department evaluation with ENT and anesthesia consultation, as the combination of intermittent throat swelling, progressive airway compromise, syncope from coughing-induced airway obstruction, and inability to speak without constant hydration represents a life-threatening airway emergency that demands urgent diagnostic workup and definitive airway management.

Immediate Actions Upon Presentation

Oxygenation and Positioning

• Administer high-flow humidified oxygen immediately upon arrival 1, 2
• Position the patient upright (head-up or semi-recumbent) to provide mechanical advantage to respiration 2
• Never ignore a patient complaining of difficulty breathing, even if objective signs are absent, as this may indicate serious airway compromise 1, 3

Early Recognition and Help

• Call for senior anesthesia and ENT consultation immediately—getting expert help early is a priority when airway compromise is suspected 4
• Pulse oximetry is a poor indicator of airway compromise; decreasing oxygen saturation is a late sign of impending hypoxemia 4
• Stridor may be a late sign and warrants immediate management without delay 1, 5

Critical Assessment Parameters

Warning Signs Present in This Patient

• Syncope from airway obstruction: This represents near-complete airway compromise and is a medical emergency 1
• Inability to speak without constant hydration: Suggests severe laryngeal or supraglottic pathology 6
• Progressive symptoms over 2.5 weeks: Rules out simple viral illness and suggests structural or inflammatory pathology requiring intervention 7

Immediate Monitoring

• Monitor respiratory rate, heart rate, blood pressure, oxygen saturation, temperature, and level of consciousness 1, 2
• End-tidal carbon dioxide monitoring is desirable to detect early airway obstruction 3, 2
• Close observation is necessary, as pulse oximetry alone is insufficient 2

Diagnostic Workup

Flexible Nasopharyngolaryngoscopy

• Perform flexible endoscopic laryngeal assessment by an experienced operator to visualize the airway and identify the cause 1
• This is essential to differentiate between epiglottic abscess, uvular edema, laryngeal edema, angioedema, or other structural pathology 6, 7

Differential Diagnosis to Consider

• Epiglottic abscess: Patients show severe symptoms and are at increased risk of sudden airway obstruction 7
• Uvular edema (Quincke's disease): Can cause upper airway obstruction with throat discomfort, altered voice, and tachypnea 6
• Laryngeal edema: May require steroids and close monitoring 1, 2
• Angioedema: Progressive swelling requiring immediate intervention

Immediate Pharmacological Management

Anti-inflammatory Therapy

• Administer intravenous dexamethasone immediately to reduce upper airway obstruction and edema 1
• For inflammatory airway edema, give steroids equivalent to 100 mg hydrocortisone every 6 hours, starting immediately and continuing for at least 12 hours 2

Bronchodilator/Sympathomimetic Therapy

• If upper respiratory obstruction or stridor develops, administer nebulized epinephrine 1 mg to reduce airway edema 2
• Sympathomimetic drugs by injection and inhalation have shown complete resolution of uvular swelling within 30 minutes in acute cases 6

Tranexamic Acid

• Consider intravenous tranexamic acid if bleeding or vascular causes are suspected, though effects are not immediate 1

Airway Management Strategy

Equipment Preparation

• A difficult airway trolley must be immediately available at bedside 1, 2
• Have emergency front-of-neck airway equipment ready, including cricothyroidotomy kit 1, 8
• Ensure availability of portable lighting 1

Decision Points for Definitive Airway

Given this patient's syncope from airway obstruction, consider:

• If airway compromise worsens despite medical management: Proceed to controlled intubation in the operating room with most experienced anesthesiologist available 1
• If patient becomes unconscious or confused: Call intensive care anesthetist immediately; do not attempt intubation until the most expert available doctor is present 1
• Cricothyroidotomy readiness: In a "can't intubate, can't ventilate" scenario, this provides oxygenation below the glottis and may be life-saving 8

Elective Tracheostomy Consideration

• If airway patency may be compromised for a considerable period due to the extent of swelling or underlying pathology, elective surgical tracheostomy should be considered 1
• This decision is informed by: extent of current airway compromise, likelihood of deterioration, ability to rescue the airway, and expected duration of compromise 1

Location of Care

Admission Requirements

• This patient requires hospital admission with continuous monitoring in a high-dependency or intensive care unit 1
• Transfer to operating theatre, post-anesthesia care unit, or ICU for close observation is indicated given the severity 1
• Never leave this patient unmonitored on a general ward 1

Observation Frequency

• Hourly observations for at least the first 6-24 hours given the risk of sudden deterioration 5
• Trained staff must monitor the patient continuously until physiologically stable 1

Common Pitfalls to Avoid

• Do not discharge this patient from the emergency department: The history of syncope from airway obstruction is an absolute contraindication to outpatient management 1, 4
• Do not delay calling for expert help: Hypoxia is the commonest cause of airway-related deaths, and most complications occur when care is suboptimal 9
• Do not rely solely on pulse oximetry: It is a late indicator of airway compromise 4
• Do not assume improvement means resolution: Life-threatening complications are not restricted to the immediate presentation period 1

Specific Interventions Based on Diagnosis

If Epiglottic Abscess Identified

• Spinal needle aspiration is both safe and effective, with all patients cured without severe complications in published series 7
• No patient in one series of 90 cases required tracheostomy or intubation when treated promptly with antibiotics, steroids, and aspiration when indicated 7

If Simple Edema Without Abscess

• Continue high-dose steroids and close monitoring 2
• Nebulized epinephrine as needed for symptomatic relief 2
• Reassess frequently for progression 1