Summary High risk and low prevalence diseases: Adult epiglottitis . Rachel E Bridwell, Alex Koyfman, Brit Long. PMID: 35489220 DOI: 10.1016/j.ajem.2022.04.018 Epiglottitis is a life -threatening emergency that occurs most frequently in adults in the current medical era with vaccines . Children most often present with acute respiratory distress and fever, while adults most often present with severe dysphagia subacutely. Other symptoms may include drooling, muffled voice, and breathlessness. Streptococcus and Staphylococcus bacteria are the most common etiologies, but others include viral, fungal, caustic, thermal, and autoimmune lesions. Lateral x-rays of the neck aid in diagnosis, but may be falsely negative. Visualization of the epiglottis is the key to diagnosis. Airway assessment and management are of utmost importance, which has moved from direct laryngoscopy to flexible intubation endoscopy and video laryngoscopy with anesthesia and/or otolaryngology assistance, if available. Antibiotics should be administered along with airway evaluation. Corticosteroids and nebulized epinephrine are controversial but should be considered. Patients should be admitted to the intensive care setting for close airway observation or ventilatory treatment if intubated. |
Epidemiology:
- Steadily increasing with an incidence of 1/100,000 to 4/100,000 in the US in adults.
- The pediatric incidence has decreased to 0.5/100,000.
- Previously more common in unvaccinated children, but now more common in adults.
- Life-threatening infection of the epiglottis.
- It occurs due to direct invasion of the epithelial layer by the organism or due to bacteremia.
- Bacteremia is most commonly associated with pediatric epiglottitis, although it does not correlate with the severity of the infection.
- Edema and accumulation of inflammatory cells in the potential space between the epiglottic cartilage and the epithelial layer, resulting in inflammation of the epiglottis and supraglottic structures.
Often, bacterial contamination can occur through viral or fungal infection, foreign body ingestion, thermal injury, lymphoproliferative disease or host graft disease, chronic granulomatous diseases, and ingestion of caustics.
Microbiology:
Often, polymicrobial and predominant bacteria include:
- Streptococcus pyogenes (group A streptococcus), Staphylococcus aureus (MSSA, MRSA).
- Pseudomonas aeruginosa should be considered in immunocompromised patients.
Assessment:
Adult and pediatric patients often differ in presentation.
Pediatric patients most commonly present with sudden decompensation, evidence of respiratory distress/tripod position
Adult patients present with:
- 90-100% with odynophagia
- 85% with dysphagia
- 74% with voice changes
- Tripod positioning is less common in adults due to larger airway caliber, which occurs in less than 50% of adult patients.
- Voice change
Rapid onset of symptoms within 12 to 24 hours is a harbinger of serious illness , although adults usually present subacutely.
Physical exam:
- 90% of patients with epiglottitis have a normal oropharyngeal examination .
- Fever in 26-90%.
- Dull voice (dysphonia) in 50-65%.
- Difficulty managing secretions 50-80%.
- Cervical lymphadenopathy.
- Intense pain on palpation of the external larynx or hyoid bone.
- Direct visualization of the epiglottis with nebulized lidocaine.
The doctor should look at the patient and place the Macintosh blade on the patient’s tongue. Ask the patient to speak in a high-pitched tone, elevating the supraglottic structures several centimeters for potential visualization.
Laboratory analysis:
Limited usefulness from clinical diagnosis:
Crops
- Blood: 0-17% performance
- Throat: 10-33% performance
- Epiglottis: 75% performance
There may be dehydration due to odynophagia, resulting in kidney injury, electrolyte abnormalities.
Imaging studies:
Lateral x-ray of the neck in standing position.
Fingerprint sign: epiglottic swelling with a sensitivity of 89.2% and a specificity of 92.2%.
Vallecula sign: The normal deep linear air space from the base of the tongue to the epiglottis is shallow or absent.
Epiglottic width greater than 6.3 mm demonstrates a sensitivity of 75.8% and a specificity of 97.8%.
False negative rate of 31.9%, so a negative x-ray does not rule out the diagnosis.
Contrast-enhanced computed tomography (CT) scan of the neck
Requires the patient to lie supine.
May aggravate impending airway occlusion.
Sensitivity of 88-100% and specificity of 97-96%.
Can show:
- Effusion
- Obliteration of surrounding fatty planes
- Thickening of false vocal cords
- Retropharyngeal enhancement and edema
- Epiglottic abscess: Associated with a high probability of requiring an airway
Point-of-care ultrasound
Allows evaluation in a comfortable position.
- Increased anteroposterior diameter of the midpoint and lateral epiglottis associated with epiglottitis.
- The alphabet sign P also suggests epiglottitis.
- Hypoechogenicity in a longitudinal view at the level of the thyrohyoid membrane.
Direct visualization of the epiglottis confirms the diagnosis, preparing for therapeutic intervention simultaneously.
Clinical management:
Optimal patient comfort position is key
Airway management
- Intubation with flexible endoscopy is the method of choice.
- Intubation occurs in patients with epiglottitis in 13.2% of cases.
- Video laryngoscopy is used less frequently, but is also an option.
- Do not use supraglottic devices; it may not seat properly and may cause airway occlusion.
Factors associated with a higher probability of intubation:
Historical factors : diabetes mellitus, subjective dyspnea, rapid progression of symptoms in 12-24 hours, laryngeal stridor.
Objective measurements : 20 breaths per minute with subjective complaint of dyspnea required visualization of the airway, while a respiratory rate greater than 30 breaths per minute, hypercarbia (PCO 2 greater than 45 mm Hg)
Antibiotics:
Ceftriaxone 2 g intravenously (IV) or ampicillin-sulbactam 3 g IV with vancomycin 20 mg/kg IV for coverage of methicillin-resistant Staphylococcus aureus (MRSA)
Severe allergy to penicillin: levofloxacin 750 mg IV
Immunocompromised: cefepime 2g IV is recommended for coverage of P. aeruginosa
Corticosteroids are controversial , although 20% to 83% will receive corticosteroids.
They have not shown any improvement in ICU length of stay, length of hospital stay, or length of intubation.
Nebulized epinephrine can help temporize the airways by helping with bronchodilation .
Do not use in children : causes additional agitation, laryngospasm and rapid deterioration without benefit in the literature.
Things to remember:
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References:
Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Adult epiglottitis. Am J Emerg Med. 2022 Jul; 57:14-20.
