Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM
Review Date: 9/17/2012
Definition
Epiglottitis is an acute condition in which a cellulitis of the epiglottis and adjacent structure occurs. This condition poses a significant risk of rapid progression to airway obstruction.
Description
- Epiglottitis is a life-threatening disease in which the epiglottis and surrounding structures (arytenoepiglottic folds/arytenoids, and vallecula) are infected, inflamed, and edematous
- Common signs and symptoms include:
- Difficulty breathing
- Difficulty controlling secretions
- Fever (often high)
- Irritability in children
- Sore throat
- Tripoding to maintain an airway
- Diagnosis is usually based on clinical findings, and diagnostic tests or other interventions, but should not preclude or delay airway management in suspected cases
Epidemiology
Incidence/Prevalence
- Uncommon disease in the United States with an incidence in adults of about 1 case per 100,000 per year
- There has been a significant decrease in incidence due to after vaccination for Haemophilus influenzae type b (HIB) became routine in the mid 1980s
- More prevalent in countries without universal immunization against H. influenzae type b
Age- A 2010 retrospective study in the US observed that the mean patient age for epiglottitis is 44.9 years
Gender
- In adults, epiglottitis is most often affects men; male to female ratio is roughly 3:1
Race
- Caucasian people are more often affected
Risk factors
- Immunocompromised state
- Non-vaccination with Hib vaccine
- Middle age
Etiology
- Swelling and inflammation of the epiglottis, with the classical cause being Haemophilus influenza. However, due to immunization for HIB, causative organisms are more commonly Staphylococcus aureus (MSSA and MRSA), and Streptococcus pneumoniae, than in the past
- Rare bacterial pathogens like Pasteurella multocida have also been reported
- Viral pathogens such as parainfluenza are less commonly implicated as an etiologic agent
- Fungal infection is also a rare etiology of epiglottitis; candidal epiglottitis has been reported
- Trauma, such as blow to the throat has also been reported to cause epiglottis
History
- Rapid and progressive onset of severe symptoms over hours, with inability to clear secretions, tripoding and loss of airway unless airway management is urgently undertaken
- Fever, followed by stridor and labored breathing
- In adults , sore throat and odynophagia are the predominant symptoms (presentation is more indolent)
- Muffled voice
- Dysphagia with resultant drooling and refusal to eat is common in children
- It is not uncommon to have symptoms preceding epiglottis that are similar to an upper respiratory tract infection (URTI)
Physical findings on examination
- Cervical adenopathy
- Drooling
- Fever
- Hypoxia
- Irritability
- Mild cough
- Muffled voice
- Respiratory distress
- Severe pain on gentle palpation over the hyoid bone or larynx
- Shock/toxic appearance (occasionally, due to associated septicemia)
- Stridor, in advanced airway obstruction
- Tachycardia
- Tripoding (leaning forward in a sitting position, with head forward)
Blood test findings
- Blood culture
- If the patient is systemically unwell, blood cultures may be taken (positive for infection in ~25 % of adult cases)
- Epiglottic cultures may be performed if the airway is secure
Radiographic findings
- Lateral neck x-ray
- In stable patients who are not in extremis, lateral neck soft-tissue radiographs are useful screening tools. In unstable patients, unless the x-ray is occurring in the resuscitation bay (portably), the patient should not leave an emergency or critical area without a secured airway
- The classic lateral neck radiographic findings are a swollen epiglottis (thumb print sign), obliteration of the vallecula (vallecula sign) and thickened aryepiglottic folds
- CT Neck
- In stable patients who are able to lie flat, side or face down without airway obstruction, CT with IV contrast can evaluate the airway, including epiglottis
- Chest x-ray
- Obtain a chest x-ray to evaluate for endotracheal tube placement and evaluate for pneumonia
Other diagnostic test findings
- Fiberoptic laryngoscopy
- Direct fiberoptic laryngoscopy may be performed in a controlled setting, where life support measures are available, for direct visualization and culture of epiglottis and placement of endotracheal tube. Indirect laryngoscopy in the examination room is not recommended, especially in children, because of the risk of laryngospasm
General treatment items
- Pre-hospital
- Intubation is indicated only if the patient is in severe respiratory distress, probably difficult airway and significant chance of exacerbating compromise with laryngoscopy attempts
- Initial stabilization therapy
- Maintenance of an adequate airway should be the main concern
- 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
- Early endotracheal intubation is advised for children
- Close monitoring of adult patients in ICU is needed because respiratory distress/airway failure may develop precipitously
- Notify ear, nose and throat (ENT) specialist or pediatric surgeon to standby in case tracheostomy becomes necessary
- Before extubation, laryngoscopy is recommended
- Do not agitate the patient
- Orotracheal intubation may be needed in patients with signs of obstruction or significant respiratory distress
- Racemic epinephrine and corticosteroids for treating epiglottitis is not well established
- Administer supplemental oxygen, as needed, or as pre-oxygenation pending intubation
- Begin empiric antibiotics promptly after blood and epiglottic cultures are obtained. Thereafter modify antibiotics, guided by culture results. The following antibiotics are generally accepted as empiric therapy; however cultures may alter the antibiotic of choice:
- Ampicillin/Sulbactam (Unasyn)
- Cefotaxime
- Cefuroxime
- Ceftriaxone
- Quinolones (2nd-4th generation)
- Treatment of symptoms such as lethargy, malaise, and fever includes analgesic-antipyretic agents such as aspirin, acetaminophen, or ibuprofen
- Following are the clinical pitfalls
- Most common mistake is underestimating the potential for sudden deterioration
- Unnoticed deterioration due to inadequate monitoring
- Intubation carried out by inexperienced anesthesiologist or health personnel
- Close contacts with patients in whom H. influenzae type b is isolated should receive rifampin prophylaxis. H. influenzae vaccine is not 100% effective
- In adults, recurrent episodes are unusual and warrant immune system investigation. Treatment of patients with recurrent acute epiglottitis may require immunization or antibody replacement
- If patient does not respond to empiric antibiotics, infectious disease subspecialist should be consulted
- Surgical management
- Emergency tracheostomy may be necessary
Medications indicated with specific doses
- Ceftriaxone [IM/IV]
- Ampicillin/sulbactam [IM/IV]
- Cefuroxime [IM/IV]
- Cefotaxime [IM/IV]
- Clindamycin [IM/IV]
- Vancomycin [IV]
- Rifampin
- Aspirin
- Acetaminophen [Oral]
- Ibuprofen [Oral]
Dietary or Activity restrictions
- Initially IV fluids and then nasogastric feedings while the patient is intubated
Disposition
Admission criteria
- Any patient with a confirmed or suspected diagnosis of epiglottitis should be admitted to an ICU for airway management and intravenous antibiotics
Discharge criteria- Patients should not be discharged unless the diagnosis has been ruled out by visualization of the supraglottic anatomical structures by a physician familiar with physical appearance of the disease
