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Clinical Summary

Epiglottitis or supraglottitis is an infection of the epiglottis and adjacent tissues. Bacterial epiglottitis, a rare but potentially fatal infection, is caused primarily by H influenzae, but S pneumoniae, S aureus, and β-hemolytic Streptococcus have also been isolated. The advent of the H influenzae B vaccination for infants has changed what used to be a disease primarily of children, with a peak age range from 2 to 6 years, to one occurring predominantly in adults. Bacterial epiglottitis occurs most commonly in the winter and spring.

Patients, especially children, with acute epiglottitis appear quite ill. They present with sore throat, fever, drooling, severe dysphagia, dyspnea, muffled or hoarse voice, and occasionally inspiratory stridor. Patients with severe respiratory distress assume the “tripod” position: sitting upright with the neck extended, arms supporting the trunk, and the jaw thrust forward. This position maximizes airway patency and caliber. Adults typically have an indolent course with a prodromal viral illness, but many children have a sudden onset and rapid progression to respiratory distress.

Management and Disposition

Airway management is paramount. Even prior to diagnosis, children should be calmed, comforted by a parent, and allowed to assume whatever position they feel is most comfortable. Anesthesiology and ENT should be consulted immediately. Indications for intubation are clinical, but severe stridor and respiratory distress are clear reasons to intervene. Nasotracheal intubation over a flexible endoscope is preferred. Needle cricothyrotomy can provide temporary oxygenation until a surgical airway is provided.

Plain radiographs of the neck may reveal the classic “thumb” sign, a thickened epiglottis on the lateral soft-tissue neck radiograph. Visualization of the epiglottis is possible in the stable adult patient via direct and indirect laryngoscopy and fiberoptic nasopharyngoscopy. In children, the top of the swollen epiglottis may be visualized on careful oral examination, whereas pharyngoscopy is typically reserved for an experienced anesthesiologist or otolaryngologist in a controlled setting.

The mainstay of epiglottitis treatment is antibiotic therapy. Third-generation parenteral cephalosporins, ampicillin with sulbactam or trimethoprim-sulfamethoxazole, have proven efficacy in treating epiglottitis. Steroids or epinephrine, either nebulized or subcutaneous, may provide some improvement in edema.

In addition to airway compromise, complications of epiglottitis include epiglottic abscess, meningitis, pulmonary edema, pneumonia, and empyema (associated with H influenzae).

Pearls

  1. Transport of patients with suspected epiglottitis must be done by an experienced transport team. The airway must be secured before transport of all but the most stable patients.

  2. During intubation, pushing on the patient’s chest may cause a bubble to form at the airway orifice, guiding placement of the tube.

  3. In areas with a significant prevalence of infection with community-associated methicillin-resistant S aureus (MRSA), clindamycin should be considered as part of the empiric choice for gram-positive coverage.

  4. Failure to intervene prior to loss of the airway carries a sixfold increase in mortality.

FIGURE 5.58
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