Acute Epiglottitis

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Introduction

  • Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures.
  • It can progress rapidly to life-threatening airway obstruction if not treated.
  • The condition is commonest in children.
  • Pathogens in children include H. influenza type B, types A, F, Streptococci and Staph. aureus
  • The commonest is H. influenza type B.
  • In adults a wide range of pathogens, including viruses, bacteria, fungi are involved but H. influenza type B appears to be the most common.
  • In immunocompromised hosts, epiglottitis may be caused by Pseudomonas aeruginosa and Candida.
  • Non-infectious causes include, thermal injury, corrosive ingestion, foreign body ingestion
  • Rarely may occur as a result of graft-versus-host disease in transplantation.

Clinical features

Common presentation in children

  • Difficulty with breathing
  • Stridor
  • Hoarse voice
  • Pharyngitis
  • Fever
  • Sore throat
  • Tenderness of anterior neck
  • Cough
  • Difficulty swallowing

Adult presentation usually less fulminant

  • Sore throat
  • Fever
  • Muffled voice
  • Drooling
  • Stridor
  • Hoarseness
  • Difficulty swallowing
  • Difficulty breathing

Differential Diagnosis

  • Laryngotracheitis or spasmodic croup
  • Uvilitis
  • Bacterial tracheitis
  • Peritonsillar or retropharyngeal abscesses
  • Foreign body lodged in the larynx
  • Angioedema
  • Upper airway congenital anomalies
  • Diphtheria

Complications

  • Airway obstruction
  • Epiglottic abscess
  • Secondary infection
  • Necrotizing epiglottitis (rare, in immunodeficiency)
  • Death
Investigations
  • Radiograph (lateral neck x-ray)
  • “Thumb sign” appearance of the enlarged epiglottitis
  • Ultrasound
  • Microbiology

Treatment goals

  • Safeguard airway
  • Control infection

Drug treatment

  • Amoxicillin/Clavulanic acid
    • Adult 625 mg - 1g 12 hourly for 7 - 10 days
    • Children 80-90 mg/kg 12 hourly (high dose) in view of epiglottitis being a serious infection)

Or:

  • Cefuroxime
    • Adult: 250 mg orally every 12 hours for 5 – 10 days
    • Child: 125 mg orally every 12 hours for 5 – 10 days 

Or:

  • Ceftriaxone
    • Adult: 500mg – 1 g 12 hourly IM/IV for 5 – 10 days
    • Child:
      • neonate, infuse over 60mins, 20 – 50 mg/kg daily
      • Child under 50 kg: 20 -50 mg/kg daily by deep IM injection or by IV injection over 2 – 4 minutes or by IV infusion; up to 80 mg/kg daily in severe infections

Supportive measures

  • Oxygen
  • Steam inhalation
  • Nasotracheal intubation may be necessary
  • Maintain adequate caloric intake and hydration

Notable adverse drug reactions , contraindications and caution

  • Cefuroxime : avoid in pregnancy and in patients with renal impairment.
  • Ceftriaxone : rashes, fever, GIT disturbances
  • Dose reduction in the elderly patients with renal impairment

Prevention

  • Haemophilus influenza vaccine
    • Child 2months – 18years : 0.5mls
    • Should be part of childhood immunization.