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Basics

[Section Outline]

Author:

JonathanFisher

Aubri S.Carman


Description!!navigator!!

Etiology!!navigator!!

Diagnosis

[Section Outline]

Signs and Symptoms!!navigator!!

History

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

Physical Exam

  • General:
    • Fever
    • Tachycardia
    • Sitting up in “tripod” stance
  • Head, eyes, ears, nose, throat:
    • “Cherry red” epiglottis is classic, may be pale and edematous in up to 50%
    • Pooling secretions in oropharynx
    • Hyoid/thyroid cartilage tender to gentle palpation
    • Tracheal rock: Pain with movement of the larynx from side to side
    • Lymphadenopathy
  • Respiratory:
    • Inspiratory stridor
    • Sudden loss of airway
    • Respiratory distress with accessory muscle use
ALERT
  • Patients with respiratory distress are at high risk for rapid progression to complete airway obstruction
  • Surgical airway management may be required

Essential Workup!!navigator!!

If significant respiratory distress:

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • CBC with differential
  • Blood cultures
  • Cultures of pharynx:
    • Only if no signs of respiratory distress or airway already definitively managed

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, seen in 77-88% of patients
    • “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 using fiberoptic scope
  • CT:
    • Indicated when a laryngoscopic evaluation cannot be performed or if coexistent soft tissue complications are suspected
    • Also indicated in recurrent episodes of the disease to rule out underlying tissue malformations or other findings

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!!navigator!!

Treatment

[Section Outline]

Prehospital!!navigator!!

Initial Stabilization/Therapy!!navigator!!

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

First Line

  • Cefotaxime: 2 g IV q8h + vancomycin: 15 mg/kg IV q12h
  • Ceftriaxone: 2 g IV q24h + additional staphylococcal coverage as below
  • 7-10 d of treatment on average

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 trimethoprim and 1,600 mg sulfamethoxazole IV initially, then 4-5 mg/kg as trimethoprim IV q12h
  • Respiratory fluoroquinolones
  • If MRSA, moderate to severe sepsis, and /or meningitis are not a concern, consider using the following in place of vancomycin:
    • Nafcillin: 2 g IV q4h
    • Clindamycin: 600-900 mg IV q8h
  • Rifampin prophylaxis:
    • Adults: 600 mg/d PO for 4 d
    • >1 mo of age: 20 mg/kg/d PO for 4 d
    • <1 mo of age: 10 mg/kg/d PO for 4 d

Follow-Up

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 and , if possible, definitive airway should be established in the OR

Pearls and Pitfalls

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

Additional Reading

Codes

ICD9

ICD10

SNOMED