Epiglottitis

Last updated: January 9, 2022

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Epiglottitis is the rapid progressive inflammation of the epiglottis and surrounding supraglottis that classically was primarily caused by Haemophilus influenzae type b (Hib). Acute epiglottitis has become rare following the implementation of the Hib vaccine and most cases now involve other bacteria. Although acute epiglottitis can occur at any age, especially when unimmunized, young children are most commonly affected. Children suffering from epiglottitis typically appear toxic and position themselves in a tripod stance (sitting and leaning forward) in an attempt to improve their airway diameter. The disease is characterized by the acute onset of fever, drooling, sore throat, dysphagia, and, in severe cases, respiratory distress accompanied by inspiratory retractions and cyanosis. Impending airway obstruction is also accompanied by a muffled voice and restlessness. Epiglottitis is diagnosed based on the clinical presentation. If the diagnosis is unclear and the patient is stable, a lateral cervical x-ray may be considered on which a thumbprint sign may be seen. If the patient is unstable, their airway should first be secured, after which direct laryngeal examination may be performed. Patients should be closely monitored in a hospital and receive IV antibiotics. Most patients make a full recovery after prompt and adequate treatment.

Peak incidence: 6–12 years (but can occur at any age, including adults, especially when unimmunized) [1]

Epidemiological data refers to the US, unless otherwise specified.

References:[2]

Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and vallecula) → supraglottic inflammation and edema narrowing of the airway airway obstruction (partial or complete) [2]

The hallmarks of epiglottitis are the three Ds: Dysphagia, Drooling, and Distress.

References:[2][4]

In young children, airway management is a higher priority than diagnostic evaluation . Advanced airway placement is rarely required in adults. [3]

Approach [3][5][6]

Acute epiglottitis is an airway emergency. Urgently consult a physician experienced in difficult airway management (e.g., an emergency physician, anesthesiologist, or otolaryngologist).

Endotracheal intubation [4][6][8]

Intubation should be performed under direct visualization; avoid blind nasotracheal intubation as it risks airway obstruction. [3]

Emergency surgical airway [8][9]

Indicated if intubation is unsuccessful

Approach [5][10][11][12][13]

Secure the airway before initiating diagnostic studies or procedures in patients with impending airway compromise, especially in children.

Visualization of the epiglottis [5][10][11][12][13]

Imaging [5][10][11][12][13]

Soft-tissue lateral neck x-ray [14]

  • Indication: mainly performed in children if the clinical presentation in early cases is inconclusive
  • Procedure: should be carried out under the supervision of an experienced physician
  • Characteristic findings
    • Thumbprint sign: enlarged epiglottis and supraglottic narrowing
    • Narrowing or complete loss of the normal pre-epiglottic air shadow (vallecula sign)
    • Thick aryepiglottic folds

CT of the neck with IV contrast [15]

Additional diagnostic studies [10]

Empiric IV antibiotics [6][10]

There are no guidelines on specific empiric antibiotic recommendations. All patients should receive IV antibiotics that are active against Hib, S. aureus, S. pyogenes, and S. pneumonia. Following cultures, antibiotics can be narrowed according to identified organisms.

Adjunctive therapy [10][13][19][20]

The differential diagnoses listed here are not exhaustive.

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