Basics
Description
- Rapidly progressive inflammation of the epiglottis and surrounding tissues leading to airway compromise
- May be more indolent in adults than pediatrics; rapid progression to total airway occlusion still seen in adults
- Although the incidence of pediatric epiglottitis has been decreasing, the incidence in adults is increasing
- Inflammation of supraglottic structures:
- Epiglottis:
- Edema is the primary airway concern
- May be primary or secondary from adjacent structures
- Vallecula
- Arytenoids
- Incidence is 1-4:100,000 adults per year and rising
- More common in men: 3:1
- Adult mortality rate is 7% (<1% in children)
- Most common in 5th decade of life
- Immunocompromised patients may be particularly fulminant, with minimally associated symptoms and unusual pathogens, such as Candida and Pseudomonas aeruginosa
- Complications:
- Total airway obstruction
- Retropharyngeal abscess
- Acute respiratory distress syndrome
- Pneumonia
- Empyema
Etiology
- Infectious causes:
- Haemophilus influenzae B, also type A and nontypeable strains
- Haemophilus parainfluenzae
- Streptococcus pneumoniae
- Staphylococcus aureus
- Group A Streptococcus
- Neisseria meningitis
- Herpes simplex
- Cytomegalovirus
- P. aeruginosa
- Numerous other uncommon agents
- Physical agents:
- Chemical and thermal burns
- Toxic or illicit drug inhalation
- Trauma, instrumentation
Diagnosis
Signs and Symptoms
History
- General:
- Upper respiratory tract infection symptoms
- Prodrome absent in significant number of cases
- Head, eyes, ears, nose, throat:
- Dysphagia
- Muffled voice
- Voice change:
- "Hot potato"Ł voice
- Hoarseness
- Foreign body sensation in throat
- Drooling
- Associated tonsillar, peritonsillar, uvular findings
- Respiratory:
- Subjective sense of obstructed airway
- Short of breath
Physical Exam
- General:
- Fever
- Toxic appearing
- Sitting up in "tripod"Ł stance
- Head, eyes, ears, nose, throat:
- "Cherry red"Ł epiglottis is classic, may be pale and edematous in up to 50%
- Hyoid/thyroid cartilage tender to gentle palpation
- Tracheal rock: Pain with movement of the larynx from side to side
- Lymphadenopathy
- Respiratory:
- Stridor
- Sudden loss of airway
- Respiratory distress with accessory muscle use
Patients with respiratory distress are at high risk for rapid progression to complete airway obstruction. Surgical airway management may be required. á
Essential Workup
If significant respiratory distress: á
- Avoid invasive diagnostic procedures
- Manage empirically with antibiotics and control of airway prior to further diagnostic evaluation
Diagnosis Tests & Interpretation
Lab
- CBC with differential
- Blood cultures
- Cultures of pharynx:
- Only if no signs of respiratory distress
Imaging
- In patients with moderate to severe respiratory distress, the airway should be managed prior to imaging
- Portable lateral soft tissue x-ray:
- Epiglottic "thumb"Ł sign:
- Thickening of the epiglottis
- "Vallecula"Ł sign:
- The vallecula is normally well-delineated, deep, and roughly parallel to the pharyngotracheal air column
- Absence of a deep and well-defined vallecula, approaching the level of the hyoid bone
- Swelling of the arytenoids and aryepiglottic folds
- Prevertebral soft tissue swelling
- Significant false-negative with imaging
- If suspected with negative film results, rule out with indirect visualization
- CT:
- Indicated when a laryngoscopic evaluation cannot be performed or if coexistent soft tissue complications are suspected
Diagnostic Procedures/Surgery
- Avoid prior to airway management if any signs of respiratory distress are present, including stridor
- Nasopharyngoscopy (mini-fiberoptic scope)
- Indirect laryngoscopy
Differential Diagnosis
- Croup
- Airway foreign body
- Anaphylaxis
- Paradoxic vocal cord dysfunction
- Angioedema
- Laryngitis
- Pharyngitis
- Oropharyngeal abscess (peritonsillar or retropharyngeal)
- Bacterial tracheitis
- Congenital anomaly
- Meningitis
Treatment
Pre-Hospital
- Transport patients in position of comfort
- Supplemental oxygen as tolerated; avoid increasing anxiety
- Intubation indicated only if patient is in severe respiratory distress:
- Likely difficult airway and significant chance of exacerbating compromise with laryngoscopy attempts
- Inhaled agents, racemic epinephrine, and β-agonists have no demonstrated value.
Initial Stabilization/Therapy
- ABCs
- Be prepared with all equipment on hand for definitive airway management, including a surgical airway, from presentation until diagnosis is ruled out or transport to intensive care setting
- Exam of the airway can trigger airway obstruction
- Orotracheal intubation in patients with signs of obstruction or significant respiratory distress:
- Respiratory distress/airway failure may develop precipitously
- Consider ear-nose-throat/surgical consult if patients condition permits for possible difficult/surgical airway
- Needle jet insufflation may be a life-saving temporizing measure if a surgical airway is not immediately attainable with failed intubation
Ed Treatment/Procedures
- Humidified oxygen support
- IV access, hydration as indicated
- Begin antibiotic coverage empirically
- Corticosteroids are controversial
Medication
First Line
- Cefotaxime: 2 g IV q8h
- Ceftriaxone: 2 g IV q24h
Second Line
- Ampicillin/sulbactam: 3 g IV initially, then 200-300 mg/kg/d in 4 div. doses + vancomycin 1 g IV q12h
- Trimethoprim-sulfamethoxazole: 320 mg IV initially, then 4-5 mg/kg IV q12h
- Consider adding increased coverage against S. aureus:
- Nafcillin: 150-200 mg/kg IV per day in 4 div. doses
- Clindamycin: 600-900 mg IV q8h
- Rifampin prophylaxis:
- Adults: 600 mg/d PO for 4 days
- >1 mo of age: 20 mg/kg/d PO for 4 days
- <1 mo of age: 10 mg/kg/d PO for 4 days
Follow-Up
Disposition
Admission Criteria
Any patient with a suspected or confirmed diagnosis of epiglottitis should be admitted to an ICU setting for IV antibiotics and airway management á
Discharge Criteria
- Patients should not be discharged unless the diagnosis has been ruled out by visualization of the supraglottic structures by a physician familiar with physical appearance of the disease
- Close contacts should receive prophylactic treatment with rifampin
Issues for Referral
ENT consultation should be obtained á
Pearls and Pitfalls
- Failure to manage the airway in a timely manner
- Avoid any unnecessary intervention until airway is secured
- Mortality is 7% in adults with epiglottitis
Additional Reading
- Guldfred áLA, Lyhne áD, Becker áBC. Acute epiglottitis: Epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122:818-823.
- Marx áJA, Hockberger áRS, Walls áRM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
- Nentwich áL, Ulrich áAS. High-risk chief complaints II: Disorders of the head and neck. Emerg Med Clin North Am. 2009;27:713-746.
- Sobol áSE, Zapata áS. Epiglottitis and croup. Otolaryngol Clin North Am. 2008;41:551-566.
- Tibballs áJ, Watson áT. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health. 2011;47:77-82.
- Woods áCR. Epiglottitis. In: Rose áBD, ed. UpToDate. Wellesley, MA: UpToDate; 2012.
Codes
ICD9
- 464.3 Acute epiglottitis
- 464.30 Acute epiglottitis without mention of obstruction
- 464.31 Acute epiglottitis with obstruction
ICD10
- J05.1 Acute epiglottitis
- J05.10 Acute epiglottitis without obstruction
- J05.11 Acute epiglottitis with obstruction
SNOMED
- 232433008 Adult acute epiglottitis and supraglottitis (disorder)
- 222008 Acute epiglottitis with obstruction (disorder)
- 80384002 Epiglottitis (disorder)
- 58576005 Haemophilus influenzae epiglottitis
- 29608009 Acute epiglottitis (disorder)