Epiglottitis is an infection with severe symptoms. It is usually septic and may progress rapidly to a life-threatening infection. A serious condition should be suspected e.g. if the patient is dyspnoeic on presentation.
Epiglottitis in children has historically almost exclusively been caused by Haemophilus influenzae type b bacteria. Since the widespread use of the Hib vaccine, Haemophilus epiglottitis is now rare in children.
In unvaccinated adult population Haemophilus epiglottitis is possible, even though pneumococcus, other streptococci and staphylococci are the usual causative organisms. In them, the disease usually extends to the supraglottic structures: the condition is nowadays referred to as supraglottitis.
If you suspect epiglottitis or supraglottitis, refer the patient immediately to an ENT specialist as an emergency case. During the transfer the patient should assume the sitting up posture, leaning forward. The disease may progress rapidly and hence a patient with dyspnoea should be transported for further care accompanied by a doctor.
Signs and symptoms
Epiglottitis is characterized by the swelling of the epiglottis (pictures 12), and often, particularly in adults, also including the swelling of the other structures above the glottis (supraglottitis). The disease usually progresses less rapidly in adults compared with children.
Sore throat and dysphagia; pain in the throat may be severe enough to prevent swallowing. In the worst case the patient is drooling as he/she is unable to swallow saliva.
Often rapidly rising high fever
No dyspnoea in the initial phase
When symptoms are severe, the patient will instinctively assume the sitting up posture and lean forward to prevent the swollen epiglottis from pressing down and blocking the airway.
A severe course of the disease is predicted by dyspnoea, stridor, increased breathing frequency, hypoxia, rapid disease progression, drooling, slurred speech, H. influenzae bacteraemia, leucocytosis, the patient attempting to assume the typical posture and underlying illnesses, such as diabetes or an immunosuppressive condition.
Transfer to hospital
Epiglottitis and supraglottitis are serious infections that are diagnosed clinically. Typical patient history raising suspicion of epiglottitis or supraglottitis warrants referring the patient for further investigations.
Establish venous access and send the patient to hospital by ambulance in a sitting up position, leaning forward. A doctor must accompany a patient suffering from dyspnoea. Be prepared to provide ventilatory assistance and, in an emergency, to perform coniotomy. A pulse oximeter should be used during the transfer for the monitoring of oxygen saturation.
Any irritation of the mouth, pharynx and larynx should be avoided before the patient reaches hospital. Often it is advisable to leave the examination of the larynx to an ENT specialist at the receiving hospital.
Diagnosis
Laryngeal oedema is established with a nasofiberoscope.
In hospital, samples will be taken at least for basic blood count with platelets, CRP and blood cultures (two samples), which should always be taken, even though in adults the culture result is often negative.
In differential diagnostics, other conditions obstructing the larynx should be taken into account, e.g. oedema sometimes associated with deep infections in the area of the pharynx or the neck, laryngeal angio-oedema, injuries, toxic inhalations and, especially in children, foreign bodies and severe acute laryngitis.
Treatment
Antimicrobial therapy consists of intravenous cefuroxime at a dose of 1.5 g administered 3-4 times daily, provided that the patient has normal renal function.
Intravenous glucocorticoids may be given, even though the scientific evidence on their efficacy is inconsistent.
Racemic adrenaline should be used with caution because after the favourable effect there is a risk of worsening (rebound phenomenon).
In addition to the general monitoring of the patient's condition, the hospital staff will pay particular attention to the development of dyspnoea by observing the patient's clinical picture (obvious distress when breathing, stridor, assessment of the larynx) and the pulse oximeter.
The majority of patients with epiglottitis recover with the aid of medication. Only a small proportion of patients will require special procedures to safeguard the airway.