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Epiglottitis, Adult, Emergency Medicine

Basics

Description

- 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

- Physical agents: - Chemical and thermal burns - Toxic or illicit drug inhalation

- 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

- 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

- "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

  • 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 concernMay be primary or secondary from adjacent structuresValleculaArytenoids
  • 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 obstructionRetropharyngeal abscessAcute respiratory distress syndromePneumoniaEmpyema

Etiology

  • Infectious causes:Haemophilus influenzae B, also type A and nontypeable strainsHaemophilus parainfluenzaeStreptococcus pneumoniaeStaphylococcus aureusGroup A StreptococcusNeisseria meningitisHerpes simplexCytomegalovirusP. aeruginosaNumerous other uncommon agents
  • Physical agents:Chemical and thermal burnsToxic 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:DysphagiaMuffled voiceVoice change:"Hot potato"Ł voiceHoarsenessForeign body sensation in throatDroolingAssociated tonsillar, peritonsillar, uvular findings
  • Respiratory:Subjective sense of obstructed airwayShort of breath

Physical Exam

  • General:FeverToxic appearingSitting 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 palpationTracheal rock: Pain with movement of the larynx from side to sideLymphadenopathy
  • Respiratory:StridorSudden loss of airwayRespiratory 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 columnAbsence of a deep and well-defined vallecula, approaching the level of the hyoid boneSwelling of the arytenoids and aryepiglottic foldsPrevertebral soft tissue swellingSignificant false-negative with imagingIf 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 precipitouslyConsider 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. dosesClindamycin: 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)