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

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Pediatric stridor
  • A minimal amount of edema or inflammation in the pediatric airway can result in significant obstruction
    • Can lead to rapid decompensation

<6mo
  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Dx w/ flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated w/ feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs 2/2 prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated w/ skin hemangiomas in beard distribution
  • Vascular ring/sling

>6mo
  • 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
    • Sx 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
  • 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 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. [3]

Airway Management[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
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