Epiglottitis is an inflammation of the epiglottis — the flap at the base of the tongue that
keeps food from going into the trachea.
Due to its place in the airway, swelling of this structure can interfere with breathing,
and constitutes a medical emergency.
Infection can cause the epiglottis to obstruct or completely close off the windpipe.
With the advent of the Hib vaccine, the incidence of epiglottitis has decreased, but the condition
has not been eliminated.
Cause Epiglottitis involves bacterial infection
of the epiglottis, most often caused by Haemophilus influenzae type B, although some cases are
attributable to Streptococcus pneumoniae, Streptococcus agalactiae, Staphylococcus aureus,
Streptococcus pyogenes, Haemophilus influenzae, and Moraxella catarrhalis.
Signs and symptoms Epiglottitis commonly affects children, and
it is associated with fever, difficulty in swallowing, drooling, hoarseness of voice,
and typically stridor.
Stridor is a sign of upper airways obstruction and is a surgical emergency.
The child often appears acutely ill, anxious, and has very quiet shallow breathing with
the head held forward, insisting on sitting up in bed.
The early symptoms are insidious but rapidly progressive, and swelling of the throat may
lead to cyanosis and asphyxiation.
Epiglottitis is an airway emergency and intubation is required initially.
Since the introduction of the Hemophilus influenzae vaccination in many Western countries, childhood
incidence has decreased while adult incidence has remained the same; the disease is thus
becoming relatively more common in adults than children.
Modern cases in adults are most typically seen among abusers of crack cocaine, and have
a subacute presentation.
Diagnosis Diagnosis is confirmed by direct inspection
using laryngoscopy, although this may provoke airway spasm.
If epiglottitis is suspected, attempts to visualise the epiglottis using a tongue depressor
are strongly discouraged for this reason; therefore, diagnosis is made on basis of direct
fibreoptic laryngoscopy carried out in controlled environment like an operating room.
Imaging is rarely useful, and treatment should not be delayed for this test to be carried
out.
The epiglottis and arytenoids are cherry-red and swollen.
The most likely differential diagnostic candidates are croup, peritonsillar abscess, and retropharyngeal
abscess.
On lateral C-spine X-ray, the thumbprint sign describes a swollen, enlarged epiglottis;
usually with dilated hypopharynx and normal subglottic structures.
On CT imaging, the "halloween sign" describe a normal thickness epiglottis.
It can safely excluded the acute epiglottitis.
Furthermore, CT imaging can help to diagnose other conditions such as peritonsillar abscess
or retropharyngeal abscess which had similar clinical features.
Management Epiglottitis may require urgent tracheal intubation
to protect the airway, though this is not always the case.
In some cases, epiglottitis requires the use of antibiotics while the patient benefits
from a breathing tube.
In more serious cases, tracheal intubation is necessary.
In such cases, immediate intubation is not advised, because the inflamed epiglottis is
very sensitive and the care provider may irritate the epiglottis with the laryngoscope, causing
the epiglottis to close off completely and forcing the use of a surgical airway opening.
Most children can be managed by keeping lights low and the child calm and in a position of
comfort.
Intubation may still become necessary if the child begins to rapidly decompensate and show
signs of impending respiratory arrest.
If the patient's stridor becomes quieter, obstruction is likely to follow, and thus
intubation should be expedited even further.
In addition, patients should be given antibiotics, such as second- or third-generation cephalosporins,
either alone or in combination with penicillin or ampicillin for streptococcal coverage.
If allergy to penicillins is present, Co-trimoxazole or clindamycin is an alternative.
In household contacts of any unvaccinated child infected with H. influenzae, rifampicin
is used as prophylaxis.
Complications Some patients may develop pneumonia, lymphadenopathy,
or septic arthritis.
Notable deaths George Washington is one historical figure
thought to have died of epiglottitis.
References
External links Jordana Marinoff, "Bacteria Grab a Windpipe
and Hold it Hostage," Boston Globe, January 10, 2006
Medscape information [1]