AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Epiglottitis is an acute inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds.

George Washington probably died of epiglottitis in 1799.

Pathophysiology

Epiglottitis is an acute inflammation involving the epiglottis, vallecula, aryepiglottic folds, and arytenoids.

Frequency

United States

Epiglottitis is an uncommon disease. Incidence in adults is about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men, occurring during the fifth decade of life. The ratio of incidence in children to adults was 2.6:1 in 1980 and dropped to 0.4:1 in 1993. Occurrence has decreased since introduction of the Haemophilus influenzae B vaccine. However, vaccine failures are possible.

International

Epiglottitis is generally more common in nations that do not immunize against H influenzae type B. For example, in Sweden from 1987-1989, incidence was 14.7 per 100,000 people per year in children aged 0-4 years and 3.2 per 100,000 people per year overall. A large-scale Hib vaccination program in 1992-1993 resulted in a substantial decrease in Swedish cases of acute epiglottitis.

A retrospective review from the tropical country of Singapore over 8 years, ending in 1999, demonstrated 32 cases of acute epiglottitis, only 1 of which occurred in a child. During this time, Hib immunization was not routine, so Hib immunization cannot be used to explain the increased adult epiglottitis prevalence found in this study.

Mortality/Morbidity

• Risk of death is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures.
• The adult mortality rate is around 7%.
• Mortality rate in pediatric cases is less than 1%.

Sex

• The male-to-female ratio is approximately 3:1.

Age

• Average age among adults is approximately 45 years.
• The condition is now more common in adults than in children in the United States.
• In the pediatric population, epiglottitis is most common in those aged 3-7 years, although any age may be affected.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

The onset and progression of symptoms is rapid (George Washington woke up with a sore throat and died that night.). Although, in adolescents and adults, a less fulminant presentation is frequently demonstrated.

Historically, acute epiglottitis was most common in children aged 2-4 years. Since the introduction of the Hib vaccine and the accompanying dramatic reduction in H influenzae type B invasive disease incidence, epiglottitis has become rare in children. A comparison made between a large US children's hospital's chart review from 1995-2003 and a prior report from the same hospital done 27 years earlier, showed a 10-fold decline in acute epiglottitis admissions with streptococci becoming the major pathogens. Epiglottitis incidence in adults has remained constant.

In a 2005 retrospective review of patients with acute epiglottitis; symptoms of stridor, voice muffling, rapid clinical course, and a history of diabetes mellitus were significantly associated with the need for airway intervention.

• Sore throat (95%)
• Odynophagia/dysphagia (95%)
• Muffled voice (54%)
• Usually, no prodromal symptoms occur in children. Adults may have preceding upper respiratory infection (URI) symptoms.

Physical

• Fever
• Drooling/inability to handle secretions
• Cervical adenopathy
• Stridor - A late finding indicating advanced airway obstruction
• Muffled voice (54%)
• Tripod position - Sitting up on hands with the tongue out and the head forward
• Hypoxia
• Respiratory distress
• Severe pain on gentle palpation over larynx
• Mild cough
• Fever
• Irritability
• Tachycardia
• Toxic appearance of patient

Causes

• In adults with acute epiglottitis, blood cultures for H influenzae are positive in about 25% of cases. In remaining adult cases, Haemophilus parainfluenzae, Streptococcus pneumoniae, and group A streptococci are frequently isolated from pharyngeal cultures.
• Less common etiologies include other bacteria (eg, Staphylococcus aureus, mycobacteria, Bacteroides melaninogenicus, Enterobacter cloacae, Escherichia coli, Fusobacterium necrophorum, Klebsiella pneumoniae, Neisseria meningitidis, Pasteurella multocida), herpes simplex virus (HSV), other viruses, infectious mononucleosis, Candida (in immunocompromised patients), Aspergillus (in immunocompromised patients), thermal causes (including those associated with crack cocaine smoking and marijuana smoking), and caustic insults.
• Before widespread Hib vaccination, H influenzae caused almost all pediatric cases.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Airway obstruction
Aspirated foreign body
Bacterial tracheitis
Caustic ingestions
Laryngitis
Sepsis

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• For those in extremis, samples for laboratory tests should not be drawn and epiglottic swab culture should not be obtained until the airway has been secured. Most adults present in a less acute fashion, and immediate testing is appropriate.
• Epiglottic swab
• Blood culture - Positive in approximately 25% of adult cases

Imaging Studies

• Radiographic evaluation for suspected epiglottitis is being replaced by direct visualization of the epiglottis using nasopharyngoscopy as the preferred method of diagnosis.
• For presentations in extremis, avoid radiography until the airway is secure because of the danger of sudden obstruction.
• Most adults can safely undergo imaging. In evaluating stable patients with suspected epiglottitis, lateral neck soft tissue radiographs are useful screening tools. Perform radiography with portable equipment, if indicated; this may confirm the diagnosis.
• • The epiglottis is usually 3-5 mm in thickness; in one study of 30 patients with epiglottitis, using a criteria of 7-mm thickness provided 100% sensitivity and specificity.
  • Another useful tool in differentiating epiglottitis is to examine the vallecula. To locate the vallecula, use a soft tissue lateral neck radiograph taken while the patient's mouth is closed. The hyoid is the air pocket found at the level of the hyoid bone just anterior to the epiglottis. To locate the hyoid, trace from the tongue base to the level of the hyoid bone. The vallecula is normally well delineated, deep, and roughly parallel to the pharyngotracheal air column. Identification of an abnormal-appearing vallecula on neck radiograph allows the clinician to more accurately interpret the presence of epiglottitis.
• Chest radiography
• • Avoid until the patient's airway is secure.
  • Obtain chest radiograph (CXR) for endotracheal tube (ET) placement.
  • CXR may reveal pneumonia.
• Initial study regarding the applicability of using bedside ultrasonography in the evaluation of the normal epiglottis found it to be both easy to perform and accurate. Further analysis regarding usage of bedside ultrasonography in evaluating epiglottic disease and pathologic epiglottic enlargement may help to determine if there will be a future clinical role for ultrasonography in caring for acute epiglottitis.

Procedures

• Consider nasopharyngoscopy for patients who are not in extremis and when epiglottitis diagnosis is suspected.
• Orotracheal intubation may be required with little warning.
• Cricothyrotomy may be necessary for any patient with epiglottitis. Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present in the patient's bay. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) also may be considered to ventilate the patient temporarily. In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy. PTJV can produce high intratracheal pressures that appear to lift up and open the glottis with escape of the pressurized gasses causing the glottis edges to flutter, thereby allowing improved identification of the glottic aperture.

TREATMENT

Section 6 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Prehospital Care

• Do not attempt intubation in the field unless acute airway obstruction is present.
• In the event of respiratory failure or obstruction, if Emergency Medical Services (EMS) is unable to intubate, then cricothyroidotomy or needle-jet insufflation are the next lines of treatment.

Emergency Department Care

• Some authors have tried to grade degrees of epiglottitis severity to guide treatment. A patient in extremis requires immediate airway management. Signs and symptoms associated with a need for intubation include respiratory distress, stridor, inability to swallow, sitting erect, and deterioration within 8-12 hours. When in doubt, securing the airway is likely the safest approach.
• • Intubation or immediate formal tracheostomy or cricothyrotomy may be performed in the operating room if the case is less severe.
  • Patients without signs of airway compromise may be managed without immediate airway intervention by close monitoring in the ICU.
• Avoid agitating the patient with acute epiglottitis. Let the patient take a position in which he or she feels comfortable.
• Administer supplemental humidified oxygen if possible, but do not force the patient as the resultant agitation could worsen the condition.
• Equipment for intubation, cricothyroidotomy, or needle-jet ventilation should be available at the bedside.
• An anesthesiologist and an ear, nose, and throat (ENT) specialist or a general surgeon should be notified as soon as possible in case of emergency or if operative management is anticipated. Early anesthesiologist and otolaryngologist consultation facilitates initial safe airway management, which is then followed by appropriate antibiotic treatment.
• Avoid therapy such as sedation, inhalers, or racemic epinephrine.

Consultations

• Consult an anesthesiologist and ENT specialist or general surgeon.

MEDICATION

Section 7 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
• References

Antibiotic therapy should begin after blood and epiglottic cultures have been obtained. Antipyretics may be necessary. Racemic epinephrine, steroids, and beta-agonists have not been shown to be helpful.

Drug Category: Antibiotics

Empiric coverage for group A Streptococcus pneumoniae, Staphylococcus pyogenes, and H influenzae should be provided (a third-generation cephalosporin or amoxicillin/clavulanic acid).

Drug Category: Analgesic-antipyretics

These agents are helpful in relieving associated lethargy, malaise, and fever associated with the disease.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Watch for air leaks around the endotracheal tube.
• Laryngoscopy is recommended prior to extubation. An ENT specialist and an anesthesiologist should be immediately available.

Deterrence/Prevention

• Close contacts of patients in whom Haemophilus influenzae type B is isolated should receive rifampin prophylaxis (20 mg/kg; not to exceed 600 mg/d for 4 d).
• H influenzae vaccine is available but not 100% effective.
• Occurrence of recurrent episodes of acute epiglottitis in adults is unusual and, when present, warrants immune system investigation since a quantitative or specific antibiotic deficiency may be present. Treatment of patients with recurrent acute epiglottitis may involve immunization or antibody replacement.

Complications

• Pulmonary edema
• Epiglottic abscess
• Pneumonia
• Meningitis
• Cervical adenitis
• Septic arthritis
• Pericarditis
• Cellulitis
• Septic shock
• Vocal granuloma
• Pneumothorax
• Pneumomediastinum (rare)
• Subsequent necrotizing fasciitis of the head and neck (rare)
• Death (asphyxia)

Prognosis

• Most patients can be extubated within several days.
• Good prognosis with appropriate treatment

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Epiglottitis.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Underestimating the potential for sudden deterioration (most common error)
• Inadequate monitoring in which deterioration goes unnoticed (second most common error)
• Rushing intubation without proper support (ENT available)
• Performing unnecessary medical procedures that result in agitation and respiratory collapse
• Obtaining unnecessary radiographs when diagnosis can be made by history and physical examination alone or with nasopharyngoscopy

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Soft-tissue lateral neck radiograph reveals edema of epiglottis consistent with acute epiglottitis.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Berg S, Trollfors B, Nylen O, et al. Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden. Scand J Infect Dis. 1996;28(3):261-4. [Medline].
• Caballero M, Sabater F, Traserra J, et al. Epiglottitis and necrotizing fasciitis: a life-threatening complication of infectious mononucleosis. Acta Otolaryngol. Oct 2005;125(10):1130-3. [Medline].
• Carey MJ. Epiglottitis in adults. Am J Emerg Med. Jul 1996;14(4):421-4. [Medline].
• Chan KO, Pang YT, Tan KK. Acute epiglottitis in the tropics: is it an adult disease?. J Laryngol Otol. Sep 2001;115(9):715-8. [Medline].
• Chandradeva K, Palin C, Ghosh SM, Pinches SC. Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema. Br J Anaesth. May 2005;94(5):683-6. [Medline].
• Ducic Y, Hebert PC, MacLachlan L, et al. Description and evaluation of the vallecula sign: a new radiologic sign in the diagnosis of adult epiglottitis. Ann Emerg Med. Jul 1997;30(1):1-6. [Medline].
• Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. Jun 2006;22(6):443-4. [Medline].
• Gagnon R, Bedard PM, Cote L, et al. Recurrent acute epiglottitis in adults: defective antibody response. Ann Allergy Asthma Immunol. May 2002;88(5):513-7. [Medline].
• Gerber AC, Pfenninger J. Acute epiglottitis: management by short duration of intubation and hospitalisation. Intensive Care Med. 1986;12(6):407-11. [Medline].
• Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72. [Medline].
• Kornak JM, Freije JE, Campbell BH. Caustic and thermal epiglottitis in the adult. Otolaryngol Head Neck Surg. Feb 1996;114(2):310-2. [Medline].
• Werner SL, Jones RA, Emerman CL. Sonographic assessment of the epiglottis. Acad Emerg Med. Dec 2004;11(12):1358-60. [Medline].
• Wetmore RF, Handler SD. Epiglottitis: evolution in management during the last decade. Ann Otol Rhinol Laryngol. Nov-Dec 1979;88(Pt 1):822-6. [Medline].
• Wick F, Ballmer PE, Haller A. Acute epiglottis in adults. Swiss Med Wkly. Oct 12 2002;132(37-38):541-7. [Medline].
• Yong MG, Choo MJ, Yum CS, et al. Radiologic laryngeal parameters in acute supraglottitis in Korean adults. Yonsei Med J. Aug 2001;42(4):367-70. [Medline].

Article Last Updated: Dec 11, 2006