Epiglottitis is an
inflammation of the
epiglottis - the flap that sits at the base of the
tongue, which keeps food from going into the
trachea (windpipe). Due to its place in the
airway, swelling of this structure can interfere with
breathing and constitutes a
medical emergency. The infection can cause the epiglottis to either obstruct or completely close off the windpipe.
With the advent of the Hib vaccine, the incidence has been reduced, but the condition has not been eliminated.
Signs and symptoms
Epiglottitis typically affects children, and is associated with
fever,
difficulty in swallowing, drooling, hoarseness of voice, and
stridor. It is important to note however that since the introduction of the
Hemophilus influenzae vaccination in many Western countries (including the UK) has lowered childhood incidence while adult incidence has remained the same, the disease is becoming
relatively more common in adults than children. 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. Cases in adults are most typically seen amongst abusers of
crack cocaine and have a more subacute presentation.
George Washington is thought to have died of epiglottitis.
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, and
Streptococcus pyogenes.
Diagnosis
Diagnosis is confirmed by direct inspection using
laryngoscopy, although this may provoke airway
spasm. If it is suspected, attempts to visualise the epiglottis using a
tongue depressor are STRONGLY discouraged for this reason. A
paediatric,
anaesthesia or
ENT specialist should be alerted immediately. 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 (or just "thumb sign") describes a swollen enlarged epiglottis.
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 a patient is experiencing the benefits of a breathing tube. In more serious cases,
tracheal intubation is necessary. In such cases, it is not advised to immediately head in the direction of intubation because the inflammed epiglottis is very sensitive and if you irritate the epiglottis with the laryngoscope you can cause the epiglottis to close off completely forcing the use of a surgical airway (
cricothyrotomy). Most children can be managed by letting the child be in a position of comfort, keep the lights down low and keep the child calm. Intubation is a good thing to have in the back of your mind and it may become necessary if the child starts to rapidly
decompensate and show signs of impending
respiratory arrest (decreased work of breathing with abnormal skin signs) given in the initial stages to reduce symptoms, but this will not treat the underlying cause. It should also be noted that if
stridor becomes quieter, obstruction is likely to follow, and thus intubation should be expedited even further.
In addition, patients should be given antibiotic such as second- or third generation cephalosporins (either alone or in combination with penicillin or ampicillin for streptococcal coverage).
Complications
Some patients may develop
pneumonia,
lymphadenopathy or
septic arthritis.
References
External links
Jordana Marinoff, "Bacteria Grab a Windpipe and Hold it Hostage," Boston Globe, January 10, 2006
Category:Laryngology
Category:Medical emergencies
Category:Bacterial diseases
Category:Acute upper respiratory infections
