• Clinical science
  • Clinician

Epiglottitis (Supraglottitis)

Summary

Epiglottitis is the rapid progressive inflammation of the epiglottis and surrounding supraglottis that classically was primarily caused by Haemophilus influenzae type b (Hib). Acute epiglottitis has become rare following the implementation of the Hib vaccine and most cases now involve other bacteria. Although acute epiglottitis can occur at any age, especially when unimmunized, young children are most commonly affected. Children suffering from epiglottitis typically appear toxic and position themselves in a tripod stance (sitting and leaning forward) in an attempt to improve their airway diameter. The disease is characterized by the acute onset of fever, drooling, sore throat, dysphagia, and, in severe cases, respiratory distress accompanied by inspiratory retractions and cyanosis. Impending airway obstruction is also accompanied by a muffled voice and restlessness. Epiglottitis is diagnosed based on the clinical presentation. If the diagnosis is unclear and the patient is stable, a lateral cervical x-ray may be considered on which a thumbprint sign may be seen. If the patient is unstable, their airway should first be secured, after which direct laryngeal examination may be performed. Patients should be closely monitored in a hospital and receive IV antibiotics. Most patients make a full recovery after prompt and adequate treatment.

Epidemiology

  • Peak incidence: 6–12 years; (but can occur at any age, including adults, especially when unimmunized)

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Pathophysiology

Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and vallecula) → supraglottic inflammation and edema → narrowing of the airwayairway obstruction (partial or complete)
References:[1][2]

Clinical features

The hallmarks of epiglottitis are the three Ds: Dysphagia, Drooling, and Distress!

Think of SNORED to remember the clinical features of epiglottitis: Septic, No cough, Rapid onset, Expiratory snore, and Drool.
References:[3][1]

Airway management

Approach [4][5][6][7][8][9]

  • Apply supplemental oxygen as needed.
  • Evaluate for signs of severe airway obstruction (e.g., stridor, tachypnea, retractions, hypercapnia, altered mental state)
  • If there is suspicion for severe airway obstruction, secure the airway with emergency endotracheal intubation.
  • If there are no signs of severe airway obstruction, consider careful visualization of the epiglottis or imaging to confirm the diagnosis.

Acute epiglottitis is an airway emergency and requires airway management by an experienced physician (e.g., an emergency physician or otolaryngologist).

Endotracheal intubation [10]

  • Indications
    • Respiratory distress
    • Inability to swallow
    • Stridor
    • Drooling
  • Procedure
    • Perform in an OR, ICU, or emergency room.
    • Should be performed by an anesthesiologist or otolaryngologist, if available
    • Ensure difficult airway cart is at the bedside.
    • Prepare for difficult intubation.
    • Maintaining spontaneous ventilation under general anesthesia is preferable.
    • Consider rapid sequence induction if there is rapid clinical deterioration.

Surgical airway [10][11]

Diagnostics

Epiglottitis is primarily a clinical diagnosis. In patients without signs of impending airway obstruction, visualization of the epiglottitis can confirm the diagnosis. Imaging may not be necessary. [4][5][7][12][13]

Emergency airway management is indicated when airway obstruction is imminent and should not be delayed by diagnostic evaluation.

Visualization of the epiglottis [4][5][7][12][13]

  • Indication: There is suspicion for epiglottis but no signs of impending airway obstruction.
  • Procedure
    • Direct pharyngoscopy: oropharyngeal examination with a tongue blade
    • Direct laryngoscopy: can be performed during or after intubation
    • Indirect laryngoscopy (mirror examination) or flexible fiberoptic laryngoscopy
    • Perform in an OR, ICU, or emergency room.
  • Additional considerations
    • Avoid increasing anxiety (especially in children).
      • Keep the patient comfortable and in a calm setting.
      • Keep the patient in a sitting position at all times (do not force the patient to lie supine).
      • If the patient is a child, let the parent/guardian hold the mask, and use distractions and humor to help keep the child relaxed.
    • In children, this procedure should only be performed by a skilled otolaryngologist.
  • Characteristic findings

In epiglottitis and impending airway compromise, it is imperative to secure the airway before attempting diagnostic laryngoscopy, especially in children.

Imaging [4][5][7][12][13]

If pharyngoscopy findings are unclear in stable patients with no signs of impending airway obstruction and laryngoscopy cannot be performed, imaging can confirm the diagnosis and exclude other diagnoses.

Soft-tissue lateral neck x-ray [14]

  • Indication: mainly performed in children if the clinical presentation in early cases is inconclusive
  • Procedure: should be carried out under the supervision of an experienced physician
  • Characteristic findings
    • Thumbprint sign: enlarged epiglottis and supraglottic narrowing
    • Loss of vallecular air space (vallecula sign)
    • Thick aryepiglottic folds

CT of the neck with IV contrast [15]

Additional diagnostic studies [4]

  • Blood cultures (2 sets)
  • Swab of the epiglottis and epiglottic culture : to guide antibiotic therapy
  • Hib immunization status of the patient (and close contacts, if applicable)

Treatment

Empiric IV antibiotics [4][6]

There are no guidelines on specific empiric antibiotic recommendations. All patients should receive IV antibiotics that are active against Hib, S. aureus, S. pyogenes, and S. pneumonia. Following cultures, antibiotics can be narrowed according to identified organisms.

Adjunctive therapy [4][19][13][20]

Acute management checklist

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Prognosis

References:[21][22]

Prevention

  • Hib vaccine (see immunization schedule)
  • Postexposure prophylaxis with rifampin [23][4][24]
    • Indications
      • All index patients that are < 2 years of age and did not receive ceftriaxone or cefotaxime to treat Hib infections should receive postexposure prophylaxis.
      • All household contacts: if any member of the household is < 4 years of age and unimmunized and/or < 18 years of age and immunocompromised
      • All daycare attendees: if ≥ 2 cases of invasive Hib disease occurred within 60 days in this setting and unimmunized children attend the daycare facility
  • 1. Woods CR. Epiglottitis (Supraglottitis): Clinical Features and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis. Last updated June 23, 2015. Accessed February 17, 2017.
  • 2. Gompf SG. Epiglottitis. In: Epiglottitis. New York, NY: WebMD. http://emedicine.medscape.com/article/763612. Updated February 8, 2017. Accessed February 17, 2017.
  • 3. Fischer C. Master the Boards USMLE Step 2 CK. New York, NY: Kaplan Publishing; 2015.
  • 4. Alcaide ML, Bisno AL. Pharyngitis and Epiglottitis. Infect Dis Clin North Am. 2007; 21(2): pp. 449–469. doi: 10.1016/j.idc.2007.03.001.
  • 5. Lindquist B et al. Adult Epiglottitis: A Case Series. The Permanente Journal. 2016. doi: 10.7812/tpp/16-089.
  • 6. J. Lance Lichtor, Maricarmen Roche Rodriguez, Nicole L. Aaronson, Todd Spock, T. Rob Goodman, Eric D. Baum. Epiglottitis. Anesthesiology. 2016; 124(6): pp. 1404–1407. doi: 10.1097/aln.0000000000001125.
  • 7. Shapira Galitz Y, Shoffel-Havakuk H, Cohen O, Halperin D, Lahav Y. Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention. Laryngoscope. 2017; 127(9): pp. 2106–2112. doi: 10.1002/lary.26609.
  • 8. Madhotra D, Fenton J, Makura Z, Charters P, Roland N. Airway intervention in adult supraglottitis. Ir J Med Sci. 2004; 173(4): pp. 197–199. doi: 10.1007/bf02914550.
  • 9. Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi Journal of Anaesthesia. 2012; 6(3): p. 279. doi: 10.4103/1658-354x.101222.
  • 10. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013; 118(2): pp. 251–270. doi: 10.1097/aln.0b013e31827773b2.
  • 11. COTÉ CJ, HARTNICK CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?. Pediatric Anesthesia. 2009; 19: pp. 66–76. doi: 10.1111/j.1460-9592.2009.02996.x.
  • 12. Frantz TD. Acute Epiglottitis in Adults. JAMA. 1994; 272(17): p. 1358. doi: 10.1001/jama.1994.03520170068038.
  • 13. Guardiani E, Bliss M, Harley E. Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: Evolving principles in diagnosis and management. Laryngoscope. 2010; 120(11): pp. 2183–2188. doi: 10.1002/lary.21083.
  • 14. Darras KE, Roston AT, Yewchuk LK. Imaging Acute Airway Obstruction in Infants and Children. Radiographics. 2015; 35(7): pp. 2064–2079. doi: 10.1148/rg.2015150096.
  • 15. Smith MM, Mukherji SK, Thompson JE, Castillo M. CT in adult supraglottitis. AJNR Am J Neuroradiol. 1996; 17(7): pp. 1355–8. pmid: 8871724.
  • 16. Willert C. Management of Acute Epiglottitis. JAMA: The Journal of the American Medical Association. 1982; 247(1): p. 26. doi: 10.1001/jama.1982.03320260014009.
  • 17. Zoorob R, Sidani MA, Fremont RD, Kihlberg C. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012; 86(9): pp. 817–22. pmid: 23113461.
  • 18. Saag MS et al. The Sanford Guide to Antimicrobial Therapy 2016. Sperryville: Antimicrobial Therapy, Inc; 2016.
  • 19. Glynn F, Fenton JE. Diagnosis and management of supraglottitis (Epiglottitis). Curr Infect Dis Rep. 2008; 10(3): pp. 200–204. doi: 10.1007/s11908-008-0033-8.
  • 20. Kent S, Hennedige A, McDonald C, et al. Systematic review of the role of corticosteroids in cervicofacial infections. British Journal of Oral and Maxillofacial Surgery. 2019; 57(3): pp. 196–206. doi: 10.1016/j.bjoms.2019.01.010.
  • 21. Woods CR. Epiglottitis (Supraglottitis): Treatment and Prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/epiglottitis-supraglottitis-treatment-and-prevention. Last updated June 23, 2015. Accessed February 18, 2017.
  • 22. Udeani J. Pediatric Epiglottitis. In: Pediatric Epiglottitis. New York, NY: WebMD. http://emedicine.medscape.com/article/963773. Updated January 14, 2016. Accessed February 17, 2017.
  • 23. ACIP. Recommendations of the Immunization Practices Advisory Committee (ACIP) Update: Prevention of Haemophilus influenzae Type b Disease. Morbidity and Mortality Weekly Report. . url: https://www.cdc.gov/mmwr/preview/mmwrhtml/00022926.htm.
  • 24. Briere EC, Rubin L, Moro PL, et al. Prevention and control of haemophilus influenzae type b disease: recommendations of the advisory committee on immunization practices (ACIP). MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 2014; 63(RR-01): pp. 1–14. pmid: 24572654.
  • Owusu-Ansah S. Emergent Management of Pediatric Epiglottitis. In: Bechtel KA. Emergent Management of Pediatric Epiglottitis. New York, NY: WebMD. http://emedicine.medscape.com/article/801369. Updated November 22, 2014. Accessed February 17, 2017.
  • Yeh S. Prevention of Haemophilus Influenzae Type B Infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/prevention-of-haemophilus-influenzae-type-b-infection. Last updated February 10, 2017. Accessed February 18, 2017.
last updated 08/18/2020
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