Epiglottitis: Difference between revisions
(Major expansion: adult vs pediatric features, airway management, double setup, antibiotic regimens, references) |
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*Inflammation and edema of the epiglottis and supraglottic structures | *Inflammation and edema of the epiglottis and supraglottic structures | ||
*A '''life-threatening airway emergency''' — can progress to complete obstruction within hours | *A '''life-threatening airway emergency''' — can progress to complete obstruction within hours | ||
*Incidence in children has decreased dramatically since Hib vaccine; now more common in | *Incidence in children has decreased dramatically since Hib vaccine; now more common in adults<ref name="shah">Shah RK, et al. Epiglottitis in the Hemophilus influenzae type b vaccine era. ''Laryngoscope''. 2004;114(3):557-560. PMID 15091234.</ref> | ||
*Common pathogens: | *Common pathogens: | ||
**Children: | **Children: Haemophilus influenzae type b (unvaccinated) | ||
**Adults: Streptococcus, Staphylococcus, H. influenzae (non-typeable), polymicrobial | **Adults: Streptococcus, Staphylococcus, H. influenzae (non-typeable), polymicrobial | ||
*Non-infectious causes: thermal injury, caustic ingestion, foreign body, crack cocaine | *Non-infectious causes: thermal injury, caustic ingestion, foreign body, crack cocaine | ||
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===Adults=== | ===Adults=== | ||
*Severe sore throat (out of proportion to pharyngeal exam findings) | *Severe sore throat (out of proportion to pharyngeal exam findings) | ||
* | *Odynophagia (pain with swallowing), dysphagia, drooling | ||
*Muffled or "hot potato" voice | *Muffled or "hot potato" voice | ||
*Stridor (late finding — suggests impending obstruction) | *Stridor (late finding — suggests impending obstruction) | ||
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===Children (Classic Presentation)=== | ===Children (Classic Presentation)=== | ||
*Abrupt onset high fever, toxic appearance | *Abrupt onset high fever, toxic appearance | ||
* | *Tripod positioning (sitting forward, neck extended, chin protruding) | ||
*Drooling, stridor, refusal to swallow | *Drooling, stridor, refusal to swallow | ||
*Anxiety, air hunger | *Anxiety, air hunger | ||
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==Evaluation== | ==Evaluation== | ||
* | *Lateral soft tissue neck X-ray (if patient is stable): | ||
** | **Thumbprint sign (swollen epiglottis) — ~90% sensitive in adults | ||
**Thickened aryepiglottic folds | **Thickened aryepiglottic folds | ||
* | *Flexible nasopharyngolaryngoscopy (definitive diagnosis in adults; by ENT or ED) | ||
* | *CT neck with contrast if concern for deep space infection, abscess | ||
*Labs: CBC, blood cultures | *Labs: CBC, blood cultures | ||
*'''Do NOT examine the oropharynx in a child with suspected epiglottitis''' (risk of laryngospasm) | *'''Do NOT examine the oropharynx in a child with suspected epiglottitis''' (risk of laryngospasm) | ||
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==Management== | ==Management== | ||
===Airway=== | ===Airway=== | ||
* | *Airway management is the top priority | ||
*Keep patient in position of comfort | *Keep patient in position of comfort | ||
*Have surgical airway equipment immediately available ('''cricothyrotomy''' kit) | *Have surgical airway equipment immediately available ('''cricothyrotomy''' kit) | ||
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*Ideally double setup: direct/video laryngoscopy + surgical airway prepared | *Ideally double setup: direct/video laryngoscopy + surgical airway prepared | ||
*Heliox (70:30 helium:oxygen) may temporize in partial obstruction | *Heliox (70:30 helium:oxygen) may temporize in partial obstruction | ||
* | *Nebulized epinephrine (racemic 2.25% 0.5 mL or L-epinephrine 1:1000 5 mL) for stridor | ||
===Antibiotics=== | ===Antibiotics=== | ||
* | *Ceftriaxone 2 g IV (or Cefotaxime) PLUS | ||
* | *Vancomycin if MRSA concern or critically ill<ref name="syed">Syed MI, et al. Adult epiglottitis: trends in the current era. ''Eur Arch Otorhinolaryngol''. 2012;269(10):2269-2274. PMID 22218491.</ref> | ||
*Alternative: Ampicillin-sulbactam 3 g IV | *Alternative: Ampicillin-sulbactam 3 g IV | ||
===Adjuncts=== | ===Adjuncts=== | ||
* | *Dexamethasone 10 mg IV (or methylprednisolone) — may reduce edema (limited evidence) | ||
*IV fluids (patients often dehydrated due to inability to swallow) | *IV fluids (patients often dehydrated due to inability to swallow) | ||
*Humidified oxygen | *Humidified oxygen | ||
==Disposition== | ==Disposition== | ||
* | *Admit all patients with epiglottitis | ||
*ICU for airway monitoring, especially if stridor, drooling, or respiratory distress | *ICU for airway monitoring, especially if stridor, drooling, or respiratory distress | ||
*ENT consultation | *ENT consultation | ||
Latest revision as of 09:31, 22 March 2026
Background
- Inflammation and edema of the epiglottis and supraglottic structures
- A life-threatening airway emergency — can progress to complete obstruction within hours
- Incidence in children has decreased dramatically since Hib vaccine; now more common in adults[1]
- Common pathogens:
- Children: Haemophilus influenzae type b (unvaccinated)
- Adults: Streptococcus, Staphylococcus, H. influenzae (non-typeable), polymicrobial
- Non-infectious causes: thermal injury, caustic ingestion, foreign body, crack cocaine
Clinical Features
Adults
- Severe sore throat (out of proportion to pharyngeal exam findings)
- Odynophagia (pain with swallowing), dysphagia, drooling
- Muffled or "hot potato" voice
- Stridor (late finding — suggests impending obstruction)
- Fever
- Anterior neck tenderness ("thyroid cartilage tenderness")
Children (Classic Presentation)
- Abrupt onset high fever, toxic appearance
- Tripod positioning (sitting forward, neck extended, chin protruding)
- Drooling, stridor, refusal to swallow
- Anxiety, air hunger
- Do NOT agitate the child (crying/agitation may precipitate complete obstruction)
Differential Diagnosis
- Croup (lower-grade fever, barking cough, younger age)
- Peritonsillar abscess
- Retropharyngeal abscess
- Ludwig angina
- Angioedema
- Foreign body aspiration
- Bacterial tracheitis
Evaluation
- Lateral soft tissue neck X-ray (if patient is stable):
- Thumbprint sign (swollen epiglottis) — ~90% sensitive in adults
- Thickened aryepiglottic folds
- Flexible nasopharyngolaryngoscopy (definitive diagnosis in adults; by ENT or ED)
- CT neck with contrast if concern for deep space infection, abscess
- Labs: CBC, blood cultures
- Do NOT examine the oropharynx in a child with suspected epiglottitis (risk of laryngospasm)
- Do NOT delay airway management for imaging if patient is in distress
Management
Airway
- Airway management is the top priority
- Keep patient in position of comfort
- Have surgical airway equipment immediately available (cricothyrotomy kit)
- If intubation needed: most experienced provider, preferably in OR with ENT standby
- Ideally double setup: direct/video laryngoscopy + surgical airway prepared
- Heliox (70:30 helium:oxygen) may temporize in partial obstruction
- Nebulized epinephrine (racemic 2.25% 0.5 mL or L-epinephrine 1:1000 5 mL) for stridor
Antibiotics
- Ceftriaxone 2 g IV (or Cefotaxime) PLUS
- Vancomycin if MRSA concern or critically ill[2]
- Alternative: Ampicillin-sulbactam 3 g IV
Adjuncts
- Dexamethasone 10 mg IV (or methylprednisolone) — may reduce edema (limited evidence)
- IV fluids (patients often dehydrated due to inability to swallow)
- Humidified oxygen
Disposition
- Admit all patients with epiglottitis
- ICU for airway monitoring, especially if stridor, drooling, or respiratory distress
- ENT consultation
- Observation for 24-48 hours minimum; typically improves within 48-72 hours