Author:
JonathanFisher
Aubri S.Carman
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 is 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
- The source of infection is often the posterior nasopharynx
- Incidence is 1-4:100,000 adults per yr and rising
- More common in men: 3:1
- Adult mortality rate is 7% (<1% in children)
- Often more severe in these patients:
- Diabetes
- BMI >25 kg/m2
- Concurrent pneumonia
- Epiglottic cysts
- Tobacco use and substance abuse are common comorbidities
- Immunocompromised patients may be particularly fulminant, with minimal associated symptoms and unusual pathogens, such as Cand ida and Pseudomonas aeruginosa
- Complications:
- Total airway obstruction
- Retropharyngeal abscess
- Acute respiratory distress syndrome
- Pneumonia
Etiology
- Infectious causes:
- Haemophilus influenzae B, also type A and nontypeable strains
- Haemophilus parainfluenzae
- Streptococcus pneumoniae
- Staphylococcus aureus
- β-hemolytic streptococcus: Groups A, B, C, F, G
- Neisseria meningitis
- Herpes simplex
- P. aeruginosa
- Numerous other uncommon agents
- Most frequently, no causal organism is isolated
- Physical agents:
- Chemical and thermal burns
- Toxic or illicit drug inhalation
- Trauma, instrumentation
Signs and Symptoms
History
- General:
- 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
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Essential Workup
If significant respiratory distress:
- Avoid invasive diagnostic procedures
- Manage empirically with antibiotics and control of airway prior to further diagnostic evaluation
Diagnostic Tests & Interpretation
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
- Croup
- Airway foreign body
- Anaphylaxis
- Angioedema
- Pharyngitis/tonsillitis
- Oropharyngeal abscess (peritonsillar or retropharyngeal)
- Bacterial tracheitis
- Congenital anomaly
- Uvulitis
- Diphtheria
- Upper airway trauma
Prehospital
- 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
- Heliox given through a high-flow circuit with tight-fitting mask can act as a temporizing measure by increasing laminar flow of oxygen
- 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 and /or heliox
- Pulse oximetry and cardiopulmonary monitoring
- IV access, hydration as indicated
- Begin antibiotic coverage empirically
- Corticosteroids are controversial but now recommended
Medication
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
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