Epiglottitis

Background

  • 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

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

Viral infections

Noninfectious

Other

Pediatric stridor

<6mo

>6mo

Evaluation

  • 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

Immunocompromised

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

Steroids

  • Methylprednisolone 125mg IV
    • 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. [3]

Airway Managment[4]

  • 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

References

  1. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.
  3. http://bja.oxfordjournals.org/content/92/3/454.1.full
  4. Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72