II. Epidemiology

  1. Adults
    1. Uncommon, but adults comprise most cases since the HaemophilusInfluenzae B (Hib Vaccine)
  2. Children
    1. Young children were historically the primary cohort for Epiglottitis prior to the HaemophilusInfluenzae B (Hib Vaccine)
    2. Commonly misdiagnosed as croup (20% in some studies)
    3. Average age 2 to 6 years
      1. Older than that seen in Croup

III. Definitions

  1. Epiglottitis
    1. Literally, inflammation of the epiglottis
    2. In practice, refers to the potentially fatal infection of supraglottic tissue, resulting in Supraglottitis
  2. Supraglottitis
    1. Inflammation from the aryepiglottic folds and epiglottis, up to the pharynx, uvula and Tongue base

IV. Causes

  1. Common Bacterial Causes
    1. Group A beta hemolytic Streptococcus (Streptococcus Pyogenes)
    2. Streptococcus Pneumoniae
    3. Staphylococcus aureus
    4. Moraxella catarrhalis
    5. HaemophilusInfluenzae type B
      1. Previously most common cause of Epiglottitis in children
      2. No longer a common cause in United States (due to Hib Vaccine)
      3. More common in adults than children now with waning VaccinationImmunity and failed Herd Immunity
  2. Other Bacterial Causes
    1. Viridans Streptococcus
    2. Streptococcus Agalactiae
    3. Neisseria Meningitidis
    4. Kingella kingae
    5. Bacteroides
  3. Non-Bacterial Causes
    1. Herpes Simplex Virus
    2. Candida albicans
      1. Immunocompromised patients
    3. Thermal airway Burn Injury

V. Findings: Symptoms and Signs (Acute onset with rapid progression)

  1. Mnemonic: Classic 4D presentation (Dysphagia, Dysphonia, Drooling, Dyspnea)
  2. Initial Symptoms
    1. Severe Pharyngitis (82%)
    2. High fever
  3. Mild or subtle Stridor (77%)
    1. "Look worse then they sound" (opposite of Croup)
    2. Child may be sitting in tripod position (see Pediatric Assessment Triangle)
  4. Shortness of Breath (100%)
    1. In severe cases, patients may assume tripod position, leaning forward with mouth open
  5. Irritability or restlessness (46%)
  6. Dysphagia (64%)
  7. Odynophagia
  8. Drooling (41%)
  9. Soft muffled voice ("hot potato" voice), Dysphonia or Hoarseness (31%)
  10. Malodorous breath

VI. Differential Diagnosis

  1. See Pediatric Airway Obstruction Causes
  2. See Croup Differential Diagnosis
  3. See Stridor
  4. Bacterial Tracheitis
    1. More common than Epiglottitis in post Hib Vaccine era

VII. Diagnosis (Differentiate from Croup)

  1. Absence of cough
  2. Dysphagia (Difficult Swallowing with Drooling)
  3. Toxic appearance
    1. Classically sitting forward with scared expression in tripod position

IX. Imaging

  1. Consider CT Neck for adults with suspected epigottitis
  2. Lateral Neck XRay
    1. Thumb shaped epiglottis (swollen supraglottis)
    2. Diminished vallecula

X. Management: General

  1. Emergent ENT or anesthesia Consultation to assist with definitive airway management (see below)
  2. Ready for emergent airway management (Endotracheal Intubation, Cricothyrotomy)
    1. Adult: Endotracheal Intubation is required in up to 20% of cases
  3. Avoid Tongue depressor or other oral instruments
    1. Epiglottis irritation may lead to complete obstruction
  4. Keep patient calm
  5. Parenteral Antibiotics to cover Bacteria listed above
    1. First-line combination therapy (dual agents)
      1. Vancomycin 15 mg/kg (up to 1 gram) IV every 12 hours AND
      2. Third Generation Cephalosporin (choose one)
        1. Ceftriaxone 50 mg/kg (up to 2 grams) IV every 24 hours OR
        2. Cefotaxime 50 mg/kg (up to 2 grams) IV every 8 hours
    2. Penicillin Allergy (severe IgE mediated, e.g. Anaphylaxis)
      1. Levofloxacin 100 mg/kg up to 750 mg IV every 24 hours AND
      2. Clindamycin 7.5 mg/kg (up to 600 to 900 mg) IV every 6 to 8 hours
      3. Precautions
        1. MRSA resistance is increasing to Clindamycin (>10% in some communities)
        2. Levofloxacin even in children is justified in severe Penicillin Allergy and Epiglottitis
    3. References
      1. Gilbert (2019) Sanford Guide
  6. Systemic Corticosteroids
    1. Dexamethasone is recommended at high dose (previously avoided)
    2. Swadron and Reverte in Herbert (2014) EM:Rap 14(10): 7-8
  7. Avoid potentially harmful therapies
    1. Avoid Racemic Epinephrine
      1. Kissoon (1985) Pediatr Emerg Care (3):143-4 +PMID: 3842885 [PubMed]

XI. Management: Airway

  1. Alert patient able to maintain airway
    1. Controlled intubation by Anesthesia or otolaryngology in the operating room
    2. Epiglottis inspection under Anesthesia (fiery red)
    3. Culture epiglottis if possible
  2. Patient not alert and not able to maintain airway
    1. Bag-valve mask ventilation
    2. Consider prone position
    3. Prepare for emergent Cricothyrotomy or Tracheostomy
    4. Attempt Endotracheal Intubation
    5. Consider Laryngeal Mask Airway as temporary rescue while securing airway (e.g. Cricothyrotomy)

XII. References

  1. Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
  2. Dahan, Campbell and Melville (2020) Crit Dec Emerg Med 34(11): 3-10
  3. Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, Burlington, p. 55-6
  4. Cressman (1994) Pediatr Clin North Am, 41(2):265-76 [PubMed]
  5. Pappas (1997) Consultant, April 1997:857-67

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