Epiglottitis: Difference between revisions
Spenceemmett (talk | contribs) |
|||
| (5 intermediate revisions by 3 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Inflammation(typically infection) of epiglottis | [[File:Cross section of a trachea and esophagus.png|thumb|Cross section of a trachea and esophagus anatomy.]] | ||
[[File:Blausen 0865 TracheaAnatomy.png|thumb|Tracheal anatomy.]] | |||
*Inflammation (typically infection) of epiglottis | |||
*Otolaryngologic emergency | *Otolaryngologic emergency | ||
**Can lead to rapid onset of life-threatening airway obstruction | **Can lead to rapid onset of life-threatening airway obstruction | ||
| Line 12: | Line 14: | ||
*Three D's: | *Three D's: | ||
**Drooling | **Drooling | ||
**Dysphagia | **[[Dysphagia]] | ||
**Distress | **[[respiratory distress|Distress]] | ||
*Pain with gentle palpation of larynx and upper trachea | *Pain with gentle palpation of larynx and upper trachea | ||
*Stridor | *[[Stridor]] | ||
*Respiratory distress | *[[Respiratory distress]] | ||
*Often no cough seen or noted | *Often no cough seen or noted | ||
| Line 25: | Line 27: | ||
==Evaluation== | ==Evaluation== | ||
[[File:Compare epiglottis.jpg|thumb|Plain neck XR film showing normal epiglottis (left column) and enlarged epiglottitis, also known as the "thumbprint sign" consistent with epiglottitis (right column).]] | |||
[[File:Epiglottitis endoscopy.jpg|thumb|Swollen epiglottis seen on laryngoscopy.]] | |||
*Bedside nasopharyngoscopy for direct visualization | *Bedside nasopharyngoscopy for direct visualization | ||
*Imaging only required if diagnosis uncertain | *Imaging only required if diagnosis uncertain | ||
| Line 34: | Line 38: | ||
==Management== | ==Management== | ||
*Emergent ENT consult | *Emergent ENT consult | ||
*O2 (humidified) | *[[O2]] (humidified) | ||
*IVF (hydration minimizes crusting in the airway) | *[[IVF]] (hydration minimizes crusting in the airway) | ||
**Avoid attempting IV access in a young child if likely to cause significant agitation and precipitate airway compromise | **Avoid attempting IV access in a young child if likely to cause significant agitation and precipitate airway compromise | ||
*Nebulized [[ | *Nebulized [[epinephrine]] to reduce edema | ||
===Antibiotics=== | ===Antibiotics=== | ||
| Line 43: | Line 47: | ||
===Steroids=== | ===Steroids=== | ||
*[[Methylprednisolone]] 125mg IV | *[[Methylprednisolone]] 125mg IV vs [[dexamethasone]] 0.6mg/kg PO or IM | ||
**Controversial | **Controversial | ||
***Benefit: anti-inflammatory effect, decreases edema | ***Benefit: anti-inflammatory effect, decreases edema | ||
***Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids. <ref> http://bja.oxfordjournals.org/content/92/3/454.1.full </ref> | ***Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids. <ref> http://bja.oxfordjournals.org/content/92/3/454.1.full </ref> | ||
===Airway | ===Airway Management<ref>Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72</ref>=== | ||
*First line therapy is awake fiberoptic [[ | *First line therapy is awake fiberoptic [[intubation]] with patient sitting up. | ||
*Preparation should be made for simultaneous [[Cricothyrotomy|cricothyrotomy]] in case intubation fails | *Preparation should be made for simultaneous [[Cricothyrotomy|cricothyrotomy]] in case intubation fails | ||
Latest revision as of 23:06, 17 January 2024
Background
- Inflammation (typically infection) of epiglottis
- Otolaryngologic emergency
- Can lead to rapid onset of life-threatening airway obstruction
- Most cases are seen in adults (since advent of H. flu vaccine)
Etiology
Clinical Features
- Three D's:
- Pain with gentle palpation of larynx and upper trachea
- Stridor
- Respiratory distress
- Often no cough seen or noted
Differential Diagnosis
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Pediatric stridor
<6 Months Old
- Laryngotracheomalacia
- Accounts for 60%
- Usually exacerbated by viral URI
- Diagnosed with flexible fiberoptic laryngoscopy
- Vocal cord paralysis
- Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
- May have cyanosis or apnea if bilateral (less common)
- Subglottic stenosis
- Congenital vs secondary to prolonged intubation in premies
- Airway hemangioma
- Usually regresses by age 5
- Associated with skin hemangiomas in beard distribution
- Vascular ring/sling
>6 Months Old
- Croup
- viral laryngotracheobronchitis
- 6 mo - 3 yr, peaks at 2 yrs
- Most severe on 3rd-4th day of illness
- Steeple sign not reliable- diagnose clinically
- Epiglottitis
- H flu type B
- Have higher suspicion in unvaccinated children
- Rapid onset sore throat, fever, drooling
- Difficult airway- call anesthesia/ ENT early
- H flu type B
- Bacterial tracheitis
- Rare but causes life-threatening obstruction
- Symptoms of croup + toxic-appearing = bacterial tracheitis
- Foreign body (sudden onset)
- Marked variation in quality or pattern of stridor
- Retropharyngeal abscess
- Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension
Evaluation
- Bedside nasopharyngoscopy for direct visualization
- Imaging only required if diagnosis uncertain
- Lateral neck x-ray
- Obliteration of vallecula
- Edema of prevertebral and retropharyngeal soft tissues
- "Thumb sign" (enlarged epiglottis)
Management
- Emergent ENT consult
- O2 (humidified)
- IVF (hydration minimizes crusting in the airway)
- Avoid attempting IV access in a young child if likely to cause significant agitation and precipitate airway compromise
- Nebulized epinephrine to reduce edema
Antibiotics
Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae
Immunocompetent
- Ceftriaxone 2gm IV once daily (first line) OR
- Cefotaxime 2gm (50mg/kg) IV three times daily OR
- Ampicillin/Sulbactam 3g (50mg/kg) IV q 6 hours OR
- Levofloxacin 750mg IV once daily
- Consider Vancomycin 15-20mg/kg IV to any of the above if risk of MRSA[2]
Immunocompromised
Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans
- Cefepime 2g (50/kg) IV q8 hours AND Vancomycin 15mg/kg IV q6 hours
Steroids
- Methylprednisolone 125mg IV vs dexamethasone 0.6mg/kg PO or IM
- Controversial
- Benefit: anti-inflammatory effect, decreases edema
- Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids. [3]
- Controversial
Airway Management[4]
- First line therapy is awake fiberoptic intubation with patient sitting up.
- Preparation should be made for simultaneous cricothyrotomy in case intubation fails
Disposition
- Admit to ICU
References
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.
- ↑ http://bja.oxfordjournals.org/content/92/3/454.1.full
- ↑ Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72