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Epiglottitis, Adult, Emergency Medicine


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:
    • Fever
  • 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)
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