Epiglottitis


Article Author:
Amanda Guerra


Article Editor:
Muhammad Waseem


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
11/15/2018 11:43:44 PM

Introduction

Epiglottitis is an inflammatory condition of the epiglottis and nearby structures like the arytenoids, aryepiglottic folds, and vallecula. Epiglottitis is a life-threatening infection that causes profound swelling of the upper airways which can lead to asphyxia and respiratory arrest.[1]

Etiology

The cause of epiglottitis is more commonly infectious rather than noninfectious. It can be bacterial, viral, or fungal in origin. In children, Haemophilus influenzae type B (HIB) is the most common cause. However, this has decreased since the widespread use of immunization. Other agents such as Streptococcus pyrogenes, S. pneumoniae, and S. aureus have been implicated. In immunocompromised hosts, Pseudomonas aeruginosa and Candida have been named. Noninfectious causes can be traumatic such as thermal, caustic, or foreign body ingestion.[2][3][4]

Epidemiology

Since the addition of the HIB vaccine to the infant immunization schedule, the annual incidence of epiglottitis in children has decreased overall. However, the incidence in adults has remained stable. Additionally, the age of children who have had epiglottitis has increased from 3 years old to about 6 to 12 years old.[5]

Pathophysiology

The airways in the pediatric population are markedly different compared to those of adults. In a young child, the epiglottis is located more superiorly and anteriorly than in an adult. There is also a more oblique angle with the trachea. Further, the infant epiglottis is floppy compared to an adult's, whose epiglottis is more rigid. These anatomical differences are why airway compromise is more common in infants than adults.

Toxicokinetics

Other complications of epiglottitis include:

  • Cervical adenitis
  • Empyema
  • Epiglottic abscess
  • Meningitis
  • Pneumonia
  • Pneumothorax
  • Septic arthritis
  • Septic shock
  • Vocal cord granuloma

History and Physical

The history will reveal that this was a sudden onset. It will usually have occurred within the last 24 hours, or sometimes the last 12 hours. The patient will appear toxic. They will likely be sitting upright with their mouth open in tripod position and possibly have a muffled voice. Drooling, dysphagia, and distress, or anxiety in children, are present. These are often referred to as the 3 Ds. Swelling of the upper airway results in turbulent airflow during inspiration or stridor. Signs of severe upper airway obstruction such as intercostal or suprasternal retractions, tachypnea, and cyanosis are concerning for impending respiratory failure and should signal the provider to act quickly. Avoid an exam of the throat with a tongue blade as it may result in loss of the airway.

Evaluation

An oropharyngeal exam is performed to evaluate a suspected case of epiglottitis. This diagnosis is primarily one of clinical suspicion. A lateral neck radiograph will show swelling of the epiglottis, also referred to as the “thumb sign.” It is not necessary to make the diagnosis but can be used to narrow down the provider’s differential diagnosis. A flexible fiberoptic laryngoscopy can be performed, but only in a very controlled setting such as the operating room due to the risk of inducing laryngospasm. Ultrasonography has been mentioned as another way to evaluate these patients, revealing an “alphabet P sign” in a longitudinal view. A complete blood count with differential, a blood culture, and an epiglottal culture should only be obtained in patients with a secured endotracheal tube.[6]

Treatment / Management

The mainstay of treatment is to secure the airway. Experienced providers should intubate these patients since their airways are regarded as difficult. An individual capable of performing a tracheotomy should be available if needed. The patient should be admitted to the intensive care unit after the airway is secured. The use of corticosteroids to reduce edema has been cited, with an overall shorter intensive care unit stay for these patients. Empiric antimicrobials should be initiated. Once culture and sensitivity results are available, the regimen should be adjusted.[7][8]

Differential Diagnosis

Because of the availability of the HIB vaccine, acute epiglottitis due to H. influenzae is not common. Thus, most health care providers may have less insight into the disorder. This lack often leads to delays in starting antibiotics. It can also delay sending the patient to a regular medical floor in an unmonitored room or even the radiology department. Acute epiglottitis can result in sudden airway obstruction. It is never wise to send the patient anywhere without proper monitoring and resuscitative equipment.

Other conditions that can mimic the presentation include an airway obstruction from a foreign object, acute angioedema, caustic ingestion causing airway compromise, diphtheria, or peritonsillar and retropharyngeal abscesses.

Prognosis

For most patients with epiglottitis, the prognosis is good when the diagnosis and treatment are prompt. Even those who require intubation are usually extubated in a few days without any residual sequelae. However, when the diagnosis is delayed in children, airway compromise can occur, and death is not uncommon.

The cause of death is usually due to sudden upper airway obstruction and difficulty intubating the patient, with extensive swelling of the laryngeal structures. Thus, every patient admitted with a diagnosis of acute epiglottitis must be seen by an ear, nose, and throat surgeon or anesthesiologist, and a tracheostomy tray must be made available at the bedside. Globally, a mortality rate of 3% to 7% has been reported in patients with unstable airways.

Complications

Complications of epiglottitis include the following:

  • Cellulitis
  • Cervical adenitis
  • Death
  • Empyema
  • Epiglottic abscess
  • Meningitis
  • Pneumonia
  • Pulmonary edema
  • Respiratory failure
  • Septic shock

Postoperative and Rehabilitation Care

Once the patient is admitted, the following care is necessary:

  • Do not agitate the patient
  • Administer humidified oxygen
  • Allow the patient to choose the position which is most comfortable
  • Avoid the use of inhalers and sedatives
  • Be prepared for a sudden worsening of the clinical condition
  • Always have a tracheostomy cut down set at the bedside

Consultations

Once a patient has been diagnosed with acute epiglottitis, the following professionals should be consulted:

  • Anesthesiologist, in case an airway is required
  • Ear, nose, and throat specialist or surgeon, in case a tracheostomy is needed
  • Intensivist
  • Infectious disease specialist
  • Pulmonologist

Deterrence and Patient Education

Close contacts of patients with H. influenzae should be prescribed rifampin prophylaxis. One may opt to administer the HIB vaccine, but it is not 100% effective.

Patients who have recurrent episodes of acute epiglottitis warrant investigation of the immune system.

Pearls and Other Issues

 Clinical Negligence Leading to Malpractice

  • Underestimating the potential for sudden airway compromise and respiratory arrest
  • Failure to send the patient to a monitored room or inadequate monitoring
  • Failure to have a tracheostomy set at the bedside
  • Rushing to intubate the patient without having a support team that includes an ear, nose, and throat surgeon or anesthesiologist
  • Performing an oral exam that results in irritation of the upper airways and sudden airway compromise, leading to death

 

Enhancing Healthcare Team Outcomes

Epiglottitis is a relatively common presentation to the emergency department. Because of its high morbidity and mortality, it is highly recommended that the disorder is managed by a multidisciplinary team that includes an intensivist, pulmonologist, infectious disease consult, anesthesiologist and an ENT surgeon. Since most patients present to the emergency room, it is important that the triage nurse and emergency room physician know the signs and symptoms of the disorder. The condition can rapidly lead to respiratory distress and death. Today, most patients with acute epiglottitis have a good outcome. Some patients may require mechanical ventilation for a few days. However, all patients with acute symptoms must be admitted, and a tracheostomy tray must be available at the bedside. The oral cavity should not be probed, and the patient must not be stressed. The moment the patient is admitted an anesthesiologist and.or ENT surgeon must be notified in case there is a need for an airway.[9]


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Epiglottitis - Questions

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Which is true of acute epiglottitis?



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A 3-year-old child is brought to the emergency department with drooling, fever, and stridor. The child appears toxic and has her head tilted backward and neck extended. What is the most appropriate first step in her management?



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A toxic-appearing 3-year-old child is brought to the emergency department and appears to have epiglottitis. Which of the following is not necessary for determining diagnosis and treatment?



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Which of the following radiographic techniques/findings is not correctly paired with a diagnosis?



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What is the most common causative organism of epiglottitis?



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A 5-year-old presents with difficulty breathing and swallowing. On physical examination, the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe. Which of the following is the most appropriate management of this patient?



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After a patient with suspected acute epiglottitis is seen in triage, what is the next best step?



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What organism is most commonly associated with acute epiglottitis?



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Which is NOT a clinical feature of acute epiglottitis?



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A 3-year-old is brought to the emergency department with breathing problems. The child is noted to have stridor. Which of the following would be most concerning?



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Which of the following is the most appropriate management of a patient with suspected acute epiglottitis?



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What is the most likely diagnosis in a 7-year-old child with dysphagia, drooling, and a respiratory rate of 40 per minute?



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A 6-year-old presents with signs and symptoms consistent with acute epiglottitis. What is the most important step in managing this patient?



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Which of the following characteristics best describe voice quality in a child with acute epiglottitis?



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At what age is epiglottitis most common?



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A 5-year-old female is brought to the emergency department with a 6-hour history of inspiratory stridor and high fever. The child is anxious, leaning forward, and drooling. Which of the following is the best next step in management?



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A 4-year-old immunized male is brought to the emergency room with a sore throat and high fever. The child appears toxic and anxious. He is drooling and has inspiratory stridor. He is sitting in the sniffing position, and the lateral neck shows a "thumb sign." After establishing an airway, what is the antibiotic of choice?



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What is the most likely presentation of epiglottitis?



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A 4-year-old immunized child presents to the emergency room with a history of sore throat and high-grade fever. The child appears toxic and anxious. He is drooling and has inspiratory stridor. He is sitting in the sniffing position. The lateral neck x-ray shows a "thumb sign." Which of the following is the next best step in management?



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A 4 year old has been sick for 8 hours with drooling and fever to 39.7°C. She appears toxic. She is visiting from Ecuador and has had no immunizations. The heart rate is 130, respiratory rate is 28, and oxygen saturation is 93%. There is inspiratory stridor and she is leaning forward and will not lie down for examination. Lungs are clear. What is the next step in management?



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A 4-year-old has been sick for 8 hours with drooling and fever to 39.7 degrees Celsius. She appears toxic. She is visiting from Ecuador and has had no immunizations. The heart rate is 130, respiratory rate is 28, and oxygen saturation is 93 percent. There is inspiratory stridor, and she is leaning forward and will not lie down for examination. Lungs are clear. What is the most likely infectious organism?



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A 3-year-old patient has epiglottis diagnosed in the operating room by an otolaryngologist. What is the next step in management?



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A 4-year-old has been sick for 8 hours with drooling and fever to 39.7 degrees Celsius. She appears toxic. She is visiting from Ecuador and has had no immunizations. The heart rate is 130, respiratory rate is 28, and oxygen saturation is 93 percent. There is inspiratory stridor and she is leaning forward and will not lie down for examination. Lungs are clear. Which of the following is not in the differential diagnosis?



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Which of the following is true about the differences between epiglottitis and viral croup?



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A child arrives in the emergency room with acute onset of fever, sore throat, difficulty swallowing, drooling, and inspiratory stridor. What is the most appropriate initial management?



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An 8-year-old male is seen with a 12-hour history of a sore throat, dry cough, shortness of breath, fever, and difficulty swallowing. The mother claims that the child is not hungry and is drooling all the time. The child is unable to provide the history because of the sore throat. The mother tried to give him an acetaminophen, but he was not able to swallow it. The past medical history is unremarkable. He has no allergies and taking no medication. A physical exam reveals a distressed child sitting upright with the face forward. Which of the following is contraindicated?



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You are doing your rotation in the radiology department. A lateral neck x-ray of a 9-year-old child in the emergency room with a sore throat is presented. The radiologist indicates that there is a 'thumb' sign on the lateral neck x-ray. This is indicative of which of the following?



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An 11-year old presents with hoarseness, dysphagia, drooling and a high fever. It is suspected that he may have acute epiglottitis. Thickening of which structure on the lateral neck x-ray is indicative of this pathology?



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What is the ideal imaging modality to make a diagnosis of acute epiglottitis?



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A triage nurse has a 4-year-old child present to the emergency department with tachypnea, tachycardia, sore throat, retractions, and stridor. The child assumes a tripod or sniffing position immediately when placed on the stretcher. The child appears ill and quite anxious. The capillary refill is greater than 2 seconds, respiratory rate 52, pulse oximetry 90% on room air, and heart rate 162 beats/min by the pulse oximeter with a good waveform. The mother reports the child developed a sudden, high fever today, an inability to swallow liquids without spitting them out, and got "so sick, so fast." The child has missed several vaccinations, including the Haemophilus influenzae type B (Hib) vaccine. Based on this information, how does the nurse proceed? Select all that apply.



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A 9-year-old has been admitted to the pediatric intensive care unit (PICU) with a diagnosis of acute epiglottitis. What nursing interventions are appropriate in the care of this client? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 6158 Not availableImage 6158 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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A child has been admitted with a diagnosis of epiglottitis. Which of the following nursing interventions are necessary for such a patient? Select all that apply.



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Epiglottitis - References

References

Baird SM,Marsh PA,Padiglione A,Trubiano J,Lyons B,Hays A,Campbell MC,Phillips D, Review of epiglottitis in the post Haemophilus influenzae type-b vaccine era. ANZ journal of surgery. 2018 Nov     [PubMed]
Schröder AS,Edler C,Sperhake JP, Sudden death from acute epiglottitis in a toddler. Forensic science, medicine, and pathology. 2018 Jun 20     [PubMed]
Tsai YT,Huang EI,Chang GH,Tsai MS,Hsu CM,Yang YH,Lin MH,Liu CY,Li HY, Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PloS one. 2018     [PubMed]
Chen C,Natarajan M,Bianchi D,Aue G,Powers JH, Acute Epiglottitis in the Immunocompromised Host: Case Report and Review of the Literature. Open forum infectious diseases. 2018 Mar     [PubMed]
Butler DF,Myers AL, Changing Epidemiology of Haemophilus influenzae in Children. Infectious disease clinics of North America. 2018 Mar     [PubMed]
Shapira Galitz Y,Shoffel-Havakuk H,Cohen O,Halperin D,Lahav Y, Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention. The Laryngoscope. 2017 Sep     [PubMed]
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