DESCRIPTION

• Rapidly progressive inflammation of the epiglottis and surrounding tissues leading to airway compromise
• May be more indolent in adults than pediatrics; rapid progression to total airway occlusion still seen in adults
• Although the incidence of pediatric epiglottitis has been decreasing, the incidence in adults is increasing
• Inflammation of supraglottic structures:
  • Epiglottis:
    • Edema is the primary airway concern
    • May be primary or secondary from adjacent structures
  • Vallecula
  • Arytenoids
• Incidence is 1–4:100,000 adults per year and rising
• More common in men: 3:1
• Adult mortality rate is 7% (< 1% in children)
• Most common in 5th decade of life
• Immunocompromised patients may be particularly fulminant, with minimally associated symptoms and unusual pathogens, such as Candida and Pseudomonas aeruginosa
• Complications:
  • Total airway obstruction
  • Retropharyngeal abscess
  • Acute respiratory distress syndrome
  • Pneumonia
  • Empyema

ETIOLOGY

• Infectious causes:
  • Haemophilus influenzae B, also type A and nontypeable strains
  • Haemophilus parainfluenzae
  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Group A Streptococcus
  • Neisseria meningitis
  • Herpes simplex
  • Cytomegalovirus
  • P. aeruginosa
  • Numerous other uncommon agents
• Physical agents:
  • Chemical and thermal burns
  • Toxic or illicit drug inhalation
• Trauma, instrumentation

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• General:
  • Fever
• Upper respiratory tract infection symptoms
• Prodrome absent in significant number of cases
• Head, eyes, ears, nose, throat:
  • Dysphagia
  • Muffled voice
  • Voice change:
    • "Hot potato" voice
    • Hoarseness
  • Foreign body sensation in throat
  • Drooling
  • Associated tonsillar, peritonsillar, uvular findings
• Respiratory:
  • Subjective sense of obstructed airway
  • Short of breath

Physical Exam

• General:
  • Fever
  • Toxic appearing
  • Sitting up in "tripod" stance
• Head, eyes, ears, nose, throat:
  • "Cherry red" epiglottis is classic, may be pale and edematous in up to 50%
  • Hyoid/thyroid cartilage tender to gentle palpation
  • Tracheal rock: Pain with movement of the larynx from side to side
  • Lymphadenopathy
• Respiratory:
  • Stridor
  • Sudden loss of airway
  • Respiratory distress with accessory muscle use

ALERT

ESSENTIAL WORKUP

If significant respiratory distress:

• Avoid invasive diagnostic procedures
• Manage empirically with antibiotics and control of airway prior to further diagnostic evaluation

DIAGNOSIS TESTS & INTERPRETATION

Lab

• CBC with differential
• Blood cultures
• Cultures of pharynx:
  • Only if no signs of respiratory distress

Imaging

• In patients with moderate to severe respiratory distress, the airway should be managed prior to imaging
• Portable lateral soft tissue x-ray:
  • Epiglottic "thumb" sign:
    • Thickening of the epiglottis
  • "Vallecula" sign:
    • The vallecula is normally well-delineated, deep, and roughly parallel to the pharyngotracheal air column
    • Absence of a deep and well-defined vallecula, approaching the level of the hyoid bone
  • Swelling of the arytenoids and aryepiglottic folds
  • Prevertebral soft tissue swelling
  • Significant false-negative with imaging
  • If suspected with negative film results, rule out with indirect visualization
• CT:
  • Indicated when a laryngoscopic evaluation cannot be performed or if coexistent soft tissue complications are suspected

Diagnostic Procedures/Surgery

• Avoid prior to airway management if any signs of respiratory distress are present, including stridor
• Nasopharyngoscopy (mini-fiberoptic scope)
• Indirect laryngoscopy

DIFFERENTIAL DIAGNOSIS

• Croup
• Airway foreign body
• Anaphylaxis
• Paradoxic vocal cord dysfunction
• Angioedema
• Laryngitis
• Pharyngitis
• Oropharyngeal abscess (peritonsillar or retropharyngeal)
• Bacterial tracheitis
• Congenital anomaly
• Meningitis

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Transport patients in position of comfort
• Supplemental oxygen as tolerated; avoid increasing anxiety
• Intubation indicated only if patient is in severe respiratory distress:
  • Likely difficult airway and significant chance of exacerbating compromise with laryngoscopy attempts
• Inhaled agents, racemic epinephrine, and β-agonists have no demonstrated value.

INITIAL STABILIZATION/THERAPY

• ABCs
• Be prepared with all equipment on hand for definitive airway management, including a surgical airway, from presentation until diagnosis is ruled out or transport to intensive care setting
• Exam of the airway can trigger airway obstruction
• Orotracheal intubation in patients with signs of obstruction or significant respiratory distress:
  • Respiratory distress/airway failure may develop precipitously
  • Consider ear-nose-throat/surgical consult if patient's condition permits for possible difficult/surgical airway
• Needle jet insufflation may be a life-saving temporizing measure if a surgical airway is not immediately attainable with failed intubation

ED TREATMENT/PROCEDURES

• Humidified oxygen support
• IV access, hydration as indicated
• Begin antibiotic coverage empirically
• Corticosteroids are controversial

MEDICATION

First Line

• Cefotaxime: 2 g IV q8h
• Ceftriaxone: 2 g IV q24h

Second Line

• Ampicillin/sulbactam: 3 g IV initially, then 200–300 mg/kg/d in 4 div. doses + vancomycin 1 g IV q12h
• Trimethoprim–sulfamethoxazole: 320 mg IV initially, then 4–5 mg/kg IV q12h
• Consider adding increased coverage against S. aureus:
  • Nafcillin: 150–200 mg/kg IV per day in 4 div. doses
  • Clindamycin: 600–900 mg IV q8h
• Rifampin prophylaxis:
  • Adults: 600 mg/d PO for 4 days
  • > 1 mo of age: 20 mg/kg/d PO for 4 days
  • < 1 mo of age: 10 mg/kg/d PO for 4 days

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Any patient with a suspected or confirmed diagnosis of epiglottitis should be admitted to an ICU setting for IV antibiotics and airway management

Discharge Criteria

• Patients should not be discharged unless the diagnosis has been ruled out by visualization of the supraglottic structures by a physician familiar with physical appearance of the disease
• Close contacts should receive prophylactic treatment with rifampin

Issues for Referral

ENT consultation should be obtained

• Failure to manage the airway in a timely manner
• Avoid any unnecessary intervention until airway is secured
• Mortality is 7% in adults with epiglottitis

ICD9

• 464.3 Acute epiglottitis
• 464.30 Acute epiglottitis without mention of obstruction
• 464.31 Acute epiglottitis with obstruction

ICD10

• J05.1 Acute epiglottitis
• J05.10 Acute epiglottitis without obstruction
• J05.11 Acute epiglottitis with obstruction

[Outline]

• ICD9
• ICD10

• Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: Epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122:818–823.
• Marx JA, Hockberger RS, Walls RM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
• Nentwich L, Ulrich AS. High-risk chief complaints II: Disorders of the head and neck. Emerg Med Clin North Am. 2009;27:713–746.
• Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am. 2008;41:551–566.
• Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health. 2011;47:77–82.
• Woods CR. Epiglottitis. In: Rose BD, ed. UpToDate. Wellesley, MA: UpToDate; 2012.

Jonathan Fisher

Colby Redfield