Epiglottitis

Epiglottitis (or "supraglottitis") is a condition that requires prompt attention by the physician. Epiglottitis results from bacterial (and rarely viral) infection of the supraglottic structures, that is, the epiglottis and arytenoid cartilages. A high level of suspicion is necessary to make a diagnosis and avoid significant morbidity. Rapid decompensation and complete loss of the airway are the sequelae of most concern. The physician should always be suspicious when a patient presents with fever, sore throat, and difficulty swallowing, and when the severity of oropharyngeal physical findings is not in proportion to the symptoms. Croup, tonsillitis, periton-sillar abscess, and other neck infection may be incorrectly diagnosed in these patients. Epiglottitis occurs mainly in children age 2 to 7 years, although infants, older children, and adults can be affected. Mortality rates of 6% to 7% have been reported in adults.

Signs and symptoms of epiglottitis include rapidly developing sore throat, high fever, restlessness, and lethargy. A "supraglottic," muffled voice is common. Many patients have difficulty with their saliva and drool. Classically, these patients are in a sitting position leaning forward, because this position tends to alleviate obstructive symptoms from the supraglottic swelling. They may show signs of "air hunger" or may have stridor.

Differential diagnosis includes tonsillitis, peritonsillar abscess, retropharyngeal abscess, airway foreign body, and

Table 19-1 Distinguishing Features of Epiglottitis and Croup

Feature

Epiglottitis

Croup

Cause

Bacterial

Viral

Age

1 year to adult

1 to 5 years

Location of obstruction

Supraglottic

Subglottic

Onset

Sudden (hours)

Gradual (days)

Fever

High

Low grade

Dysphagia

Marked

None

Drooling

Present

Minimal

Posture

Sitting

Recumbent

Toxemia

Mild to severe

Mild

Cough

Usually none

Barking, brassy, spontaneous

Voice

Clear to muffled

Hoarse

Respiratory rate

Normal to rapid

Rapid

Larynx palpation

Tender

Not tender

Clinical course

Shorter

Longer

From Berry FA, Yemen TA. Pediatric airway in health and disease. Pediatr Clin North Am 1994;41:153.

croup. Physical examination with laryngoscopy is extremely useful in differentiating these diagnoses. Endoscopy should not be performed if there is concern of impending airway obstruction. Endoscopy will typically show erythema and edema of the epiglottis and arytenoid cartilages. Other findings include laryngeal tenderness on neck palpation, although palpation should be avoided when the diagnosis is being considered.

Any time the diagnosis of epiglottitis is in question, otorhinolaryngologic (ear-nose-throat, ENT) and infectious disease consultations are warranted. Placement of a tongue depressor has been known to precipitate acute airway obstruction and should be avoided entirely if epiglottitis is strongly suspected. Differentiation from croup can be difficult because there is considerable overlap of symptoms (Table 19-1) (Berry and Yemen, 1994). A lateral extended neck radiograph can help in the diagnosis. X-ray evidence includes the classic "thumbprint" sign. If epiglottitis is suspected or lateral neck radiography is confirmatory, the patient should be taken to the operating room (OR) for orotracheal intubation in the presence of an anesthesiologist and an otorhinolaryngologist. In any case of airway obstruction, cricothyrotomy or tracheotomy can be lifesaving, because orotracheal intubation can be difficult and sometimes impossible. Some patients, usually adults, may be treated expectantly with intravenous (IV) medications and intensive care unit (ICU) observation as long as personnel are available for control of the airway if necessary. If airway stability is questionable, observation is not recommended.

After control of the airway is achieved, cultures of the epiglottis should be obtained and directed antibiotics instituted. Haemophilus influenzae type b (Hib) is common and can be beta-

Figure 19-1 Large left peritonsillar abscess (arrow) that required surgical drainage.

lactamase producing. Other, less common organisms include beta-hemolytic streptococci, Streptococcus pneumoniae, and Staphylococcus aureus. Antibiotics should be administered par-enterally; effective antibiotics include cefotaxime, ceftriaxone, ampicillin plus sulbactam, or ampicillin plus chloramphenicol. Steroids can be useful for edema and inflammation, but their effectiveness has not been proved in controlled studies..

The incidence of epiglottitis in children is decreasing since the introduction of the Hib vaccine in the late 1980s. However, the incidence has remained stable or slightly increased in adults.

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