Epiglottitis

last authored: Aug 2010, Heather Osborn
last reviewed:

Introduction

Epiglottitis is inflammation of the epiglottis and adjacent supraglottic tissue. It causes supraglottic airway obstruction, which can be life-threatening. Infectious epiglottitis may be caused by a number of bacterial, viral and fungal causes, depending on patient age and immune status.

Acute epiglottitis has decreased significantly in children since the introduction of the Haemophilus influenzae type B (Hib) vaccine. Nonetheless, Hib epiglottitis has been known to occur in children who have been immunized against Hib. Other pathogens commonly detected in children include H. Influenza types A and F and non-typeable, Streptococci, and Staphylococcus aureus.

In adults, epiglottitis is associated with a broad range of bacteria, viruses and fungi, and in most cases, cultures are negative. However, among culture-positive cases, Hib is the most commonly isolated organism. The annual incidence of Hib has been increasing in adults. Non-infectious epiglottitis occurs in children and adults following thermal injury, caustic ingestion, or trauma by a foreign body.

The Case of Sammy Jenkins

A 5-year old boy presents to the Emergency department with a sudden onset of high fever, dysphagia, drooling and dyspnea. His mother frantically explained that she first noticed symptoms about 4 hours ago, and they have been progressively worsening. She did not observe any precipitating cause. You observe the child sitting in a “tripod position” with his neck flexed and head extended. He refuses to talk but when he gives brief cries his voice sounds normal.

You are concerned about his rapidly progressing respiratory depression. You quickly page anaesthesia and ensure that all the necessary equipment for intubation and for an emergent tracheotomy are close at hand. As you are doing so, a differential diagnosis is running through your head…..

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Causes and Risk Factors

Risk factors in children include a lack of immunization or incomplete immunization against Hib, immune deficiency, and airway trauma (physical, chemical, thermal).

Risk factors in adults include hypertension, diabetes mellitus, substance abuse, immune deficiency, and airway trauma.

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Pathophysiology

Infectious epiglottitis results from bacteremia or from direct spread to the epithelial layer of the epiglottis. The posterior nasopharynx is the most common source of infection. Cellulitis of the epiglottis and adjacent structures develops. Swelling is rapidly progressive, causing airway obstruction that can result in cardiopulmonary arrest.

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Signs and Symptoms

history
physical exam

History

Symptoms are abrupt in onset and progress within hours. Many patients will have minor upper respiratory tract symptoms before the onset of acute illness. There is a wide spectrum of severity. The progression of symptoms is slower in adults than children.

The classic presentation involves “the three D’s”: dysphagia, drooling and distress. Other symptoms:

severe throat pain which limits speech
odynophagia
muffled voice
anxiety
irritability in children
respiratory distress

Physical Exam

Signs include:

toxic appearance
fever
tripod positioning
limited speech due to pain
muffled “hot potato” voice
tender anterior neck
cough
drooling

Stridor/stertor, intercostal/suprasternal retraction, tachypnea and cyanosis are late signs!

In moderate or significant respiratory distress, where epiglottitis is considered likely, intraoral exam should not be attempted. Instead, the patient has been taken to the OR and a secure airway obtained before direct assessment with laryngoscopy and bronchoscopy. Endoscopy in the OR should be arranged as expeditiously as possible in this situation, and the patient should be attended at all times by someone capable of intubating or obtaining a surgical airway as needed. With endoscopy, a swollen, erythematous epiglottis will be seen, as well as inflammation of the surrounding tissues.

In patients with mild symptoms in whom other diagnoses are considered more likely, careful intraoral exam can be conducted. However, this should only be undertaken in a setting where the airway could be secured immediately if needed.

The oral cavity and oropharynx will usually appear normal, although excess secretions may be noted.

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Investigations

lab investigations
diagnostic imaging

Lab Investigations

Avoid aggravating the patient with unnecessary blood draws, as this can worsen respiratory distress. No immediate lab investigations are required as diagnosis is made with clinical presentation and plain neck films. Once airway is secure, serum HIB capsule antigen and blood cultures may be drawn to assist in directing antibiotic treatment, as well as a CBC and differential.

Diagnostic Imaging

Diagnostic imaging is often not necessary.

Plain lateral neck films may be used to confirm the diagnosis.

Features suggestive of epiglottitis:

enlarged epiglottis protruding from the hypopharynx (the “thumbprint sign”)
loss of the vallecular air space
thickened aryepiglottic folds
loss of normal cervical lordosis
distension of the hypopharynx

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Differential Diagnosis

The differential includes:

laryngomalacia
tumor
intubation trauma
sarcoidosis
foreign body aspiration

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Treatments

If symptoms are moderate or severe, establish an emergent airway: intubation should be done in the operating room, with preparation for a tracheotomy if required.

Parenteral antibiotics and corticosteroids for 7 – 10 days. Ceftriaxone or cefuroxime are common first choices, as is Ampicillin with chloramphenicol. Antibiotics can be optimized pending culture and sensitivity results.

Careful monitoring

Consider extubation after 2 – 3 days

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