Acute Epiglottitis

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A severe rapidly progressive infection of the epiglottis and surrounding tissues that may be rapidly progressive and fatal because of sudden airway obstruction by the inflamed tissues.

Infection through the respiratory tract extends downwards to produce a supraglottic cellulitis with marked inflammation. The inflamed epiglottis mechanically obstructs the airway. The work of breathing increases; resulting CO2 retention and hypoxia may lead to fatal asphyxia within a few hours.

Causes

  • Haemophilus influenza type B is almost always the pathogen
  • Streptococci may very rarely be responsible

Signs and symptoms

  • Muffled voice (54%)
  • Cervical adenopathy
  • Fever
  • Severe pain on gentle palpation over the larynx or hyoid bone
  • Mild cough
  • Irritability
  • Tachycardia
  • Toxic appearance of patient

Signs and symptoms indicating urgent intubation include:

  • Respiratory distress
  • Airway compromise on examination
  • Stridor
  • Inability to swallow
  • Drooling
  • Sitting erect
  • Deterioration within 8-12 hours

Differential diagnosis

  • Caustic Ingestions
  • Acute laryngitis
  • Croup

Complications

  • Complete airway obstruction and asphyxiation leading to death

Investigations

  • X-ray showing enlarged epiglottis (thumb sign) which is associated with airway obstruction. Avoid radiography until the patient's airway is secure
  • Direct visualization of the epiglottis using nasopharyngoscopy/laryngoscopy is the preferred method
  • Blood cultures may be taken, particularly if the patient is systemically unwell

Caution

  • Avoid tongue depression examination as this may cause complete airway blockage and sudden death
  • Do not force patient to lie down as it may precipitate airway obstruction
  • Because of the rapidity with which airway obstruction can occur, repeat evaluations of airway patency are indicated

Clinical pitfalls include the following:

  • Underestimating the potential for sudden deterioration
  • Inadequate monitoring in which deterioration goes unnoticed
  • Rushing intubation without proper support (anaesthesiologist and person experienced in difficult intubation)
  • Performing unnecessary medical procedures that result in agitation and respiratory collapse

Treatment objectives

  • Airway management is the most urgent consideration
  • Control infection

Non-pharmacological treatment

  • Oxygen
  • Steam inhalation
  • Nasotracheal intubation may be required

Pharmacological treatment

Avoid

  • Sedatives
  • Inhalers
  • Racemic epinephrine

Use

  • Antibiotic therapy should begin after blood and epiglottic cultures have been obtained
  • Antipyretic agents may also be necessary

Prevention

  • Hib vaccine as part of the pentavalent DPT/HepB/Hib vaccine immunization