Rorschach Test Revealed

Last week we set the challenge was to correctly identify:

  • the imaging modality,
  • the structures shown, and
  • the underlying diagnosis
This was the first correct answer:

CT face Coronal section through lips tongue and nose, resembling a hamburger with a cocktail umbrella stuck in it. The lips and tongue look oedematous, dare I say it angioedema boys, and that’s a nasal ETT diagnosis — angioedema requiring nasal intubation???

Oh, and the other side has an NGT?

As an aside, you may be wondering: why CT a patient with angioedema?

Following awake fiberoptic nasal intubation in ED she was admitted to ICU. Oral intubation with a laryngoscope would have been impossible as her tongue was so swollen nothing could be passed orally. She remained intubated for 3 weeks until the swelling settled. During this time she started spiking temperatures and concerns were raised that there could be an infective component, however no collections were seen on CT. The cause of her angioedema was the good ole ACE inhibitor she had been taking for some time for hypertension. Her fevers were actually due to a ventilator associated pneumonia (she also had trouble handling her secretions and may have aspirated prior, or during, intubation).

The significant findings on CT were:

  • extensive opacification of the paranasal sinuses and the ethmoids.
  • Endotracheal tube and a nasogastric tube in situ.
  • Complete loss of the airway from the post-nasal nasal space caudally to the level of the thyroid. Diffuse oedema in the soft tissues which envelop the two tubes.

Here are some more images demonstrating the findings — note the complete lack of air around the ETT above the thyroid:

And finally if you’re not sure what a patient with severe angioedema looks like, here’s a pic from GMEP:

angioedema-tongue

References and Links

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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