Epiglottitis

Background

Cross section of a trachea and esophagus anatomy.

Tracheal anatomy.

• Inflammation (typically infection) of epiglottis
• 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

Pediatric stridor

<6 Months Old

• Laryngotracheomalacia
  • Accounts for 60%
  • Usually exacerbated by viral URI
  • Diagnosed with flexible fiberoptic laryngoscopy
• Vocal cord paralysis
  • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
  • May have cyanosis or apnea if bilateral (less common)
• Subglottic stenosis
  • Congenital vs secondary to prolonged intubation in premies
• Airway hemangioma
  • Usually regresses by age 5
  • Associated with skin hemangiomas in beard distribution
• Vascular ring/sling

>6 Months Old

• Croup
  • viral laryngotracheobronchitis
  • 6 mo - 3 yr, peaks at 2 yrs
  • Most severe on 3rd-4th day of illness
  • Steeple sign not reliable- diagnose clinically
• Epiglottitis
  • H flu type B
    • Have higher suspicion in unvaccinated children
  • Rapid onset sore throat, fever, drooling
  • Difficult airway- call anesthesia/ ENT early
• Bacterial tracheitis
  • Rare but causes life-threatening obstruction
  • Symptoms of croup + toxic-appearing = bacterial tracheitis
• Foreign body (sudden onset)
  • Marked variation in quality or pattern of stridor
• Retropharyngeal abscess
  • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Evaluation

Plain neck XR film showing normal epiglottis (left column) and enlarged epiglottitis, also known as the "thumbprint sign" consistent with epiglottitis (right column).

Swollen epiglottis seen on laryngoscopy.

• 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)
  • Avoid attempting IV access in a young child if likely to cause significant agitation and precipitate airway compromise
• 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 vs dexamethasone 0.6mg/kg PO or IM
  • Controversial
    • Benefit: anti-inflammatory effect, decreases edema
    • Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids.

Airway Management

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

Disposition

• Admit to ICU