Introduction

Epiglottitis is an inflammatory condition of the epiglottis and nearby structures like the arytenoids, aryepiglottic folds, and vallecula. Epiglottitis is a life-threatening infection that causes profound swelling of the upper airways which can lead to asphyxia and respiratory arrest.[1]

Etiology

The cause of epiglottitis is more commonly infectious rather than noninfectious. It can be bacterial, viral, or fungal in origin. In children, Haemophilus influenzae type B (HIB) is the most common cause. However, this has decreased since the widespread use of immunization. Other agents such as Streptococcus pyrogenes, S. pneumoniae, and S. aureus have been implicated. In immunocompromised hosts, Pseudomonas aeruginosa and Candida have been named. Noninfectious causes can be traumatic such as thermal, caustic, or foreign body ingestion.[2][3][4]

Epidemiology

Since the addition of the HIB vaccine to the infant immunization schedule, the annual incidence of epiglottitis in children has decreased overall. However, the incidence in adults has remained stable. Additionally, the age of children who have had epiglottitis has increased from 3 years old to about 6 to 12 years old.[5]

Pathophysiology

The airways in the pediatric population are markedly different compared to those of adults. In a young child, the epiglottis is located more superiorly and anteriorly than in an adult. There is also a more oblique angle with the trachea. Further, the infant epiglottis is floppy compared to an adult's, whose epiglottis is more rigid. These anatomical differences are why airway compromise is more common in infants than adults.

Toxicokinetics

Other complications of epiglottitis include:

• Cervical adenitis
• Empyema
• Epiglottic abscess
• Meningitis
• Pneumonia
• Pneumothorax
• Septic arthritis
• Septic shock
• Vocal cord granuloma

History and Physical

The history will reveal that this was a sudden onset. It will usually have occurred within the last 24 hours, or sometimes the last 12 hours. The patient will appear toxic. They will likely be sitting upright with their mouth open in tripod position and possibly have a muffled voice. Drooling, dysphagia, and distress, or anxiety in children, are present. These are often referred to as the 3 Ds. Swelling of the upper airway results in turbulent airflow during inspiration or stridor. Signs of severe upper airway obstruction such as intercostal or suprasternal retractions, tachypnea, and cyanosis are concerning for impending respiratory failure and should signal the provider to act quickly. Avoid an exam of the throat with a tongue blade as it may result in loss of the airway.

Evaluation

An oropharyngeal exam is performed to evaluate a suspected case of epiglottitis. This diagnosis is primarily one of clinical suspicion. A lateral neck radiograph will show swelling of the epiglottis, also referred to as the “thumb sign.” It is not necessary to make the diagnosis but can be used to narrow down the provider’s differential diagnosis. A flexible fiberoptic laryngoscopy can be performed, but only in a very controlled setting such as the operating room due to the risk of inducing laryngospasm. Ultrasonography has been mentioned as another way to evaluate these patients, revealing an “alphabet P sign” in a longitudinal view. A complete blood count with differential, a blood culture, and an epiglottal culture should only be obtained in patients with a secured endotracheal tube.[6]

Treatment / Management

The mainstay of treatment is to secure the airway. Experienced providers should intubate these patients since their airways are regarded as difficult. An individual capable of performing a tracheotomy should be available if needed. The patient should be admitted to the intensive care unit after the airway is secured. The use of corticosteroids to reduce edema has been cited, with an overall shorter intensive care unit stay for these patients. Empiric antimicrobials should be initiated. Once culture and sensitivity results are available, the regimen should be adjusted.[7][8]

Differential Diagnosis

Because of the availability of the HIB vaccine, acute epiglottitis due to H. influenzae is not common. Thus, most health care providers may have less insight into the disorder. This lack often leads to delays in starting antibiotics. It can also delay sending the patient to a regular medical floor in an unmonitored room or even the radiology department. Acute epiglottitis can result in sudden airway obstruction. It is never wise to send the patient anywhere without proper monitoring and resuscitative equipment.

Other conditions that can mimic the presentation include an airway obstruction from a foreign object, acute angioedema, caustic ingestion causing airway compromise, diphtheria, or peritonsillar and retropharyngeal abscesses.

Prognosis

For most patients with epiglottitis, the prognosis is good when the diagnosis and treatment are prompt. Even those who require intubation are usually extubated in a few days without any residual sequelae. However, when the diagnosis is delayed in children, airway compromise can occur, and death is not uncommon.

The cause of death is usually due to sudden upper airway obstruction and difficulty intubating the patient, with extensive swelling of the laryngeal structures. Thus, every patient admitted with a diagnosis of acute epiglottitis must be seen by an ear, nose, and throat surgeon or anesthesiologist, and a tracheostomy tray must be made available at the bedside. Globally, a mortality rate of 3% to 7% has been reported in patients with unstable airways.

Complications

Complications of epiglottitis include the following:

• Cellulitis
• Cervical adenitis
• Death
• Empyema
• Epiglottic abscess
• Meningitis
• Pneumonia
• Pulmonary edema
• Respiratory failure
• Septic shock

Postoperative and Rehabilitation Care

Once the patient is admitted, the following care is necessary:

• Do not agitate the patient
• Administer humidified oxygen
• Allow the patient to choose the position which is most comfortable
• Avoid the use of inhalers and sedatives
• Be prepared for a sudden worsening of the clinical condition
• Always have a tracheostomy cut down set at the bedside

Consultations

Once a patient has been diagnosed with acute epiglottitis, the following professionals should be consulted:

• Anesthesiologist, in case an airway is required
• Ear, nose, and throat specialist or surgeon, in case a tracheostomy is needed
• Intensivist
• Infectious disease specialist
• Pulmonologist

Deterrence and Patient Education

Close contacts of patients with H. influenzae should be prescribed rifampin prophylaxis. One may opt to administer the HIB vaccine, but it is not 100% effective.

Patients who have recurrent episodes of acute epiglottitis warrant investigation of the immune system.

Pearls and Other Issues

 Clinical Negligence Leading to Malpractice

• Underestimating the potential for sudden airway compromise and respiratory arrest
• Failure to send the patient to a monitored room or inadequate monitoring
• Failure to have a tracheostomy set at the bedside
• Rushing to intubate the patient without having a support team that includes an ear, nose, and throat surgeon or anesthesiologist
• Performing an oral exam that results in irritation of the upper airways and sudden airway compromise, leading to death

Enhancing Healthcare Team Outcomes

Epiglottitis is a relatively common presentation to the emergency department. Because of its high morbidity and mortality, it is highly recommended that the disorder is managed by a multidisciplinary team that includes an intensivist, pulmonologist, infectious disease consult, anesthesiologist and an ENT surgeon. Since most patients present to the emergency room, it is important that the triage nurse and emergency room physician know the signs and symptoms of the disorder. The condition can rapidly lead to respiratory distress and death. Today, most patients with acute epiglottitis have a good outcome. Some patients may require mechanical ventilation for a few days. However, all patients with acute symptoms must be admitted, and a tracheostomy tray must be available at the bedside. The oral cavity should not be probed, and the patient must not be stressed. The moment the patient is admitted an anesthesiologist and.or ENT surgeon must be notified in case there is a need for an airway.[9]

Questions

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References

1.

Baird SM, Marsh PA, Padiglione A, Trubiano J, Lyons B, Hays A, Campbell MC, Phillips D. Review of epiglottitis in the post Haemophilus influenzae type-b vaccine era. ANZ J Surg. 2018 Nov;88(11):1135-1140. [PubMed: 30207030]

2.

Schröder AS, Edler C, Sperhake JP. Sudden death from acute epiglottitis in a toddler. Forensic Sci Med Pathol. 2018 Jun 20; [PubMed: 29926438]

3.

Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS ONE. 2018;13(6):e0199036. [PMC free article: PMC5995441] [PubMed: 29889887]

4.

Chen C, Natarajan M, Bianchi D, Aue G, Powers JH. Acute Epiglottitis in the Immunocompromised Host: Case Report and Review of the Literature. Open Forum Infect Dis. 2018 Mar;5(3):ofy038. [PMC free article: PMC5846294] [PubMed: 29564363]

5.

Butler DF, Myers AL. Changing Epidemiology of Haemophilus influenzae in Children. Infect. Dis. Clin. North Am. 2018 Mar;32(1):119-128. [PubMed: 29233576]

6.

Shapira Galitz Y, Shoffel-Havakuk H, Cohen O, Halperin D, Lahav Y. Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention. Laryngoscope. 2017 Sep;127(9):2106-2112. [PubMed: 28493349]

7.

Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med. 2018 May;54(5):619-629. [PubMed: 29523424]

8.

Lindquist B, Zachariah S, Kulkarni A. Adult Epiglottitis: A Case Series. Perm J. 2017;21 [PMC free article: PMC5283781] [PubMed: 28241903]

9.

Damm M, Eckel HE, Jungehülsing M, Roth B. Airway endoscopy in the interdisciplinary management of acute epiglottitis. Int. J. Pediatr. Otorhinolaryngol. 1996 Dec 05;38(1):41-51. [PubMed: 9119592]