Epiglottitis

Background

• Otolaryngologic emergency
  • Can lead to rapid onset of life-threatening airway obstruction
• Most cases are seen in adults (since advent of H. flu vaccine)
• Etiology
  • Strep, staph, H. flu (unvaccinated)
  • Caustic burns

Clinical Features

• Three D's:
  • Drooling
  • Dysphagia
  • Distress
• Pain with gentle palpation of larynx and upper trachea
• Stridor
• Respiratory distress
• Often no cough seen or noted

Differential Diagnosis

Acute Sore Throat

Bacterial infections

• Streptococcal pharyngitis (Strep Throat)
• Neisseria gonorrhoeae
• Diphtheria (C. diptheriae)
• Bacterial Tracheitis

Viral infections

• Infectious mononucleosis (EBV)
  • Patients with peritonsillar abscess have a 20% incidence of mononucleosis
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackie virus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal space infection
• Peritonsillar Abscess (PTA)
• Epiglottitis
• Kawasaki disease
• Penetrating injury
• Caustic ingestion
• Lemierre's syndrome
• Peritonsillar cellulitis
• Lymphoma
• Internal carotid artery aneurysm
• Oral Thrush
• Parotitis
• Post-tonsillectomy hemorrhage
• Vincent's angina
• Acute necrotizing ulcerative gingivitis

Diagnosis

• Bedside nasopharyngoscopy for direct visualization
• Imaging only required if diagnosis uncertain
• Lateral neck x-ray
  • Obliteration of vallecula
  • Edema of prevertebral and retropharyngeal soft tissues
  • "Thumb sign" (enlarged epiglottis)

Management

• Emergent ENT consult
• O2 (humidified)
• IVF (hydration minimizes crusting in the airway)
• Nebulized Epinephrine to reduce edema

Antibiotics

Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae

Immunocompetent

• Ceftriaxone 2gm IV once daily (first line) OR
• Cefotaxime 2gm (50mg/kg) IV three times daily OR
• Ampicillin/Sulbactam 3g (50mg/kg) IV q 6 hours OR
• Levofloxacin 750mg IV once daily
• Consider Vancomycin 15-20mg/kg IV to any of the above if risk of MRSA

Immunocompromised

Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans

• Cefepime 2g (50/kg) IV q8 hours AND Vancomycin 15mg/kg IV q6 hours

Steroids

Methylprednisolone 125mg IV

Airway Managment

• First line therapy is awake fiberoptic Intubation with patient sitting up.
• Preparation should be made for simultaneous cricothyrotomy incase intubation fails

Disposition

• Admit