Acute Epiglottitis

Background

• Acute epiglottitis is a life-threatening condition characterized by upper airway inflammation and obstruction that may occur at any age.
• In children, acute epiglottitis is most commonly due to rapidly progressive bacterial infection, but it may also have a viral or noninfectious (such as trauma) cause.
• The most common causative organisms are beta-hemolytic streptococci (most frequently group A), Staphylococcus aureus and Haemophilus influenzae type b (Hib) (in elderly and immunocompromised patients).

Evaluation

• The most common presentation of acute epiglottitis includes high fever, severe sore throat, and odynophagia accompanied by drooling.
  • Additional manifestations more commonly seen in children include cough, inspiratory stridor, difficulty breathing and dyspnea, muffled phonation/dysphonia, and a toxic appearance.
  • Additional manifestations more commonly seen in adults include change in voice and neck tenderness.
• In children, croup can be distinguished from epiglottitis by its more gradual onset and its characteristic barking cough and absence of drooling and dysphagia. Croup is more frequent in winter months while acute epiglottitis has no seasonal predilection.
• If airway obstruction is suspected, avoid using a tongue depressor.
• In the presence of respiratory distress, diagnostic procedures should be delayed and priority should be given to securing the airway.
• In less acute situations, consider a lateral neck x-ray to confirm suspected acute epiglottitis but do not perform if signs of airways compromise. The classic radiologic feature is the "thumb" sign, defined as swelling or severe inflammation of the epiglottis which may lead to irrevocable loss of airway.

Management

• Patients with signs of respiratory distress or upper airway obstruction should be treated as an immediate medical- and airway-management emergency (Strong recommendation).
  • Consider endotracheal/nasotracheal intubation or tracheostomy, and consider prophylactic intubation (not waiting for impending airway obstruction) in children.
  • Consider careful observation in an intensive care unit for older patients with uncomplicated acute epiglottitis, as long as trained personnel and equipment for intubation are readily available.
• Use broad-spectrum IV third-generation cephalosporins (in combination with an antistaphylococcal agent only if Staphylococcus aureus is a concern).
• Consider using IV or aerosol corticosteroid to limit pharyngeal edema and airway obstruction, but there is no high quality evidence that it affects the outcome.
• Racemic epinephrine should be used cautiously but may be used as a supportive measure while awaiting intubation.