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Clinical Summary

Epiglottitis (also known as supraglottitis) is a life-threatening condition characterized by sudden onset of fever, irritability, sore throat, moderate to severe respiratory distress with stridor, and variable degrees of drooling. It results from a cellulitis of the epiglottis, aryepiglottic folds, and adjacent tissues. The patient generally appears toxic and prefers a sitting position, leaning forward with the neck extended in a sniffing position with an open mouth. With the addition of the H influenzae type B vaccine to the routine immunization schedule, there has been a dramatic decrease in the incidence of epiglottitis as well as a shift in the bacterial etiology. Although H influenzae type B is still the most common cause, many cases are now caused by nontypeable H influenzae, streptococci, staphylococci (especially MRSA), and Candida albicans. Adults typically have a more indolent course characterized by severe sore throat and odynophagia. Direct thermal injury has been reported as a noninfectious cause. On soft-tissue lateral neck x-ray, the epiglottis is seen as rounded and blurred (thumbprint sign). Epiglottitis may progress to complete upper airway obstruction if not treated. Differential diagnosis includes acute infectious laryngitis, acute laryngotracheobronchitis (croup), acute spasmodic laryngitis, membranous (bacterial) tracheitis, anaphylactic reaction, foreign-body aspiration, retropharyngeal abscess, and extrinsic or intrinsic compression of the airway (tumors, trauma, cysts).

FIGURE 14.91

Epiglottitis. Lateral soft-tissue x-ray of the neck demonstrating thickening of aryepiglottic folds and thumbprint sign of epiglottis. (Photo contributor: Richard M. Ruddy, MD.)

Management and Disposition

Immediate intervention is required. If epiglottitis is suspected, the child should be allowed to remain in a position of comfort if they are maintaining an adequate airway. If impending respiratory failure is present, an airway must be established. If possible, this should be done in the operating room or designated area where advanced airway management with sedation is available. An experienced anesthesiologist and surgeon should be readily available in case a surgical airway is necessary. Once the airway has been controlled, the patient should be sedated to avoid unplanned extubation. Parenteral antibiotic therapy should be initiated with ceftriaxone or cefotaxime. Antistaphylococcal coverage against MRSA with clindamycin or vancomycin is also indicated, and therapy can be adjusted once culture results are available.

Pearls

  1. Definitive diagnosis of epiglottitis requires direct visualization of a red, swollen epiglottis, preferably in an operating room with advanced airway measures readily available.

  2. Allow the child to remain undisturbed in a position of comfort while preparing for airway management. An agitated child is at increased risk for sudden, complete upper airway obstruction.

  3. H influenzae type B can still cause epiglottis even in immunized children.

  4. The mean age of epiglottis is increasing since the introduction of the H influenzae type B vaccine.

FIGURE 14.92

Epiglottitis. The same patient immediately after extubation. Although erythema and some edema persist, the ...

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