Rorschach Test Revealed

aka 020.2

Remember this from last week:

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?

First across the finish line was our mate in Tasmania, Domhnall Brannigan, who if he wasn’t already a Fellow of the Utopian College of Emergency for Medicine, is now. He was nearly disqualified for wanton use of question marks, but the UCEM adjudicators decided to be lenient as they hadn’t explicitly stated these criteria for disqualification prior to the challenge being issued… However, the promised ‘legend’ status was retracted because, in retrospect, UCEM felt that this one was way too easy.

There were some other great, imaginative answers provided too, that could have been correct in an alternate universe… Thanks to all for the contributions.

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:

Click image to enlarge

Click to enlarge

Click image to enlarge

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

Angioedema of the tongue — photo from GMEP (click image for source)

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