Epiglottitis is an inflammation of the epiglottis — the flap at the base of the tongue that keeps food from going into the trachea (windpipe). Due to its place in the airway, swelling of this structure can interfere with breathing, and constitutes a medical emergency. Infection can cause the epiglottis to obstruct or completely close off the windpipe. Synonyms for this infection are supraglottitis, oedema glottis, and supraglottic croup.
Epiglottitis involves bacterial infection of the epiglottis, most often caused by Haemophilus influenzae type B, although some cases are attributable to Streptococcus pneumoniae, Streptococcus agalactiae, Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae, and Moraxella catarrhalis. With the advent of the Hib vaccine, the incidence of epiglottitis has decreased, but the condition has not been eliminated.
The disease used to be most common between the ages of 2 and 7. After the vaccine it is becoming more of an adult disease. An underlying malignancy must always be considered.
Signs and symptoms
Epiglottitis commonly affects children, and it is associated with fever, difficulty in swallowing, drooling, hoarseness of voice, and typically stridor. Stridor is a sign of upper airways obstruction and is a surgical emergency. The child often appears acutely ill, anxious, and has very quiet shallow breathing with the head held forward, insisting on sitting up in bed. The early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.
Notably, there is absence of a cough.
Epiglottitis is an airway emergency and intubation is required initially. Since the introduction of the Hemophilus influenzae (Hib) vaccination (the congugate vaccine is best) in many Western countries, childhood incidence has decreased while adult incidence has remained the same; the disease is thus becoming relatively more common in adults than children. Modern cases in adults are most typically seen among abusers of crack cocaine, and have a subacute presentation.
Diagnosis is confirmed by direct inspection using laryngoscopy, although this may provoke airway spasm. If epiglottitis is suspected, attempts to visualise the epiglottis using a tongue depressor are strongly discouraged for this reason; therefore, diagnosis is made on basis of direct fibreoptic laryngoscopy carried out in controlled environment like an operating room. Imaging is rarely useful, and treatment should not be delayed for this test to be carried out.
The epiglottis and arytenoids are cherry-red and swollen. The most likely differential diagnostic candidates are croup, peritonsillar abscess, and retropharyngeal abscess.
On lateral C-spine X-ray, the thumbprint sign (or “thumb sign”) describes a swollen, enlarged epiglottis; usually with dilated hypopharynx and normal subglottic structures.
On CT imaging, the “halloween sign” describe a normal thickness epiglottis. It can safely excluded the acute epiglottitis. Furthermore, CT imaging can help to diagnose other conditions such as peritonsillar abscess or retropharyngeal abscess which had similar clinical features.
CT imaging show “halloween sign”
Neck X-ray shows thumbprint sign.
Left column: Normal epiglottis. Right column: Epiglottitis.
Swollen epiglottis in laryngoscopy
Epiglottitis may require urgent tracheal intubation to protect the airway, though this is not always the case. In some cases, epiglottitis requires the use of antibiotics while the patient benefits from a breathing tube. In more serious cases, tracheal intubation is necessary. In such cases, immediate intubation is not advised, because the inflamed epiglottis is very sensitive and the care provider may irritate the epiglottis with the laryngoscope, causing the epiglottis to close off completely and forcing the use of a surgical airway opening (cricothyrotomy). Most children can be managed by keeping lights low and the child calm and in a position of comfort. Intubation may still become necessary if the child begins to rapidly decompensate and show signs of impending respiratory arrest (decreased work of breathing with abnormal skin signs). If the patient’s stridor becomes quieter, obstruction is likely to follow, and thus intubation should be expedited even further.
In addition, patients should be given antibiotics, such as second- or third-generation cephalosporins, either alone or in combination with penicillin or ampicillin for streptococcal coverage. If allergy to penicillins is present, Co-trimoxazole or clindamycin is an alternative. In household contacts of any unvaccinated child infected with H. influenzae, rifampicin is used as prophylaxis.
Some patients may develop pneumonia, lymphadenopathy, or septic arthritis.
George Washington is one historical figure thought to have died of epiglottitis.
EPIGLOTTIC ABSCESS (PRIMARILY S.A.) IS RARE —SO REALLY BE SUSPICIOUS ABOUT AN UNDERLYING PROBLEM
NOT ALWAYS DUE TO H. INF TYPE B (STREP PNEUMO AND S.A. ARE MOST COMMON IN ADULTS)
DECREASED 85% SINCE THE CONJUGATED VACCINE
BEST IS T-CELL DEP RESPONSE TO THE CONJUGATE VACCINE
CHERRY RED EPIGLOTIS
FAST ONSET(HOURS) — SPEED OF ONSET TENDS TO REFLECT Px–WITHIN 24 HOURS–SUBMUCOSAL INFXN
DROOLING –INABILITY TO HANDLE OWN SALIVA
LEANING FORWARD—EPIGLOTTIS TENDS TO SWELL ON ITS LINGUAL ASPECT AND PUSH POST—-MUCOSA IS TIGHTLY ADHERED TO LARYNGEAL SURFACE AND LOOSELY TO LINGUAL SURFACE
CAN OBSTRUCT AT ANY MOMENT
CAVEATE—NEVER COMFORTABLE IN A SUPINE POSITION AND RARELY A COUGH
LARYNGEAL SARCOID MAY APPEAR THE SAME WITHOUT THE TOXICITY
Rx: OROTRACHEAL INTUBATION IN THE OR—-BE PREPARED TO DO A TRACH—CAN CHANGE OVER TO A NASOTRACHEAL TUBE IN THE OR—USUALLY NEED TO BE INTUBATED ABOUT 72 HOURS
ADULTS YOU CAN INTUBATE AND LEAVE SEDATED IN THE UNIT FOR A COUPLE OF DAYS—IF YOU HAVE A GOOD UNIT—OTHERWISE TRACH
IV ABX—ROCEPHIN/CEFUROXIME/CEFOTAXIME (30% AMP RESISTANT)
BLOOD CULTURES AND TARGETED ABX IF POSSIBLE
IV STEROIDS (DECADRON 1 MG/KG UP TO 15)—-MIGHT HOLD THIS UNTIL YOU KNOW YOU ARE COVERED