ACUTE EPIGLOTTITIS

Saturday, August 16, 2008

Essentials of Diagnosis

• Occurs in children between 2 and 6 y , can occur in adults although it presents with less severity.

• Irritable, febrile, sore throat; odynophagia, dysphonia, and dyspnea.

• Sits forward drooling, toxic appearing, tachypneic

• Examination of the larynx should not be attempted. Direct examination should be performed only by a trained person and in a unit where immediate intubation or tracheotomy can be performed.

• Direct laryngoscopic examination reveals a "cherry red" edematous epiglottis.

• Polymorphonuclear leukocytosis is common. Blood and epiglottis cultures are often positive for Haemophilus influenzae type b, Staphylococcus aureus, or other bacteria.

General Considerations

Acute epiglottitis is a true respiratory emergency. An epiglottic infection leads to acute inflammation and edema of the epiglottis and can cause upper airway obstruction. Acute epiglottitis can occur at any age, however it is more common in children between 2-6 y and most often occurs in the winter and spring. Unlike croup, which is predominantly a viral disease, acute epiglottitis is a bacterial disease caused mainly by H influenzae type b, S aureus, or streptococcal species (Box 9-7). H influenzae type b was the most common organism isolated from children with acute epiglottitis, but widespread use of the H influenzae type b vaccine has dramatically decreased the incidence of H influenzae type b acute epiglottitis.

Clinical Findings

A. Signs and Symptoms. The child presents with a short (6- to 12-h) rapidly progressive febrile illness, sore throat, pain on swallowing, and shortness of breath. There is usually no antecedent history of a viral infection. Adults have a similar clinical presentation with sore throat being a predominant symptom.

The patient looks anxious, appears toxic, and assumes a forward-leaning, neck-extended posture. Drooling of oral secretions and muffled voice are the sine qua non. The child has marked tachypnea and may have an inspiratory stridor from the supraglottic mucosa prolapsing into the glottis. Lung auscultation may reveal crepitations or bronchial breath sounds if there is associated pneumonia.

B. Laboratory Findings. The white blood cell count is elevated with a polymorphonuclear reaction. The blood and epiglottis cultures are frequently positive. Bacteremia occurs in almost all of the children with H influenzae type b acute epiglottitis. Serum latex agglutination tests against H influenzae type b may be helpful in making a rapid microbiologic diagnosis in patients from whom cultures were not obtained before starting antibiotics.

C. Imaging. Caution must be exercised in sending these patients for tests or x-rays without adequate supervision and to avoid a delay in intubation. Radiographs of the neck show an enlarged edematous epiglottis with a normal subglottic space. Some x-rays may be negative or show subglottic obstruction, and the diagnosis may be obscured. (Figure 9-3). Chest x-rays may show evidence of pneumonia. Laryngoscopic evaluation should be carried out by trained personnel in a controlled setting such as an operating room or unit equipped for immediate intubation.

Differential Diagnosis

Croup or acute LTB presents with a clinical picture similar to that of acute epiglottitis. Croup has slower-onset, viral prodromal symptoms, a nontoxic appearing child, and absence of drooling. Anterior-posterior x-rays of the neck confirm the diagnosis. Other conditions that have a similar presentation include angioedema, foreign-body aspiration, and retropharyngeal or peritonsillar abscesses. Angioedema and foreign-body aspiration are suspected based on history and imaging or endoscopic evaluation. Radiographs or laryngoscopic evaluation identifies retropharyngeal or peritonsillar abscesses.

Complications

Mortality associated with untreated obstructive acute epiglottitis is ~80%. Respiratory failure from upper-airway obstruction is the most common complication. Occasionally patients will develop pulmonary edema along with the respiratory distress.

Treatment

Acute epiglottitis is a medical emergency. Once acute epiglottitis is suspected, the child should be kept in an upright position and be accompanied at all times by personnel trained in advanced cardiopulmonary life support. Diagnosis should be expeditiously established clinically or radiographically. Laryngoscopic examination should be attempted only in a unit equipped for immediate intubation and only by experienced personnel. Maintenance of a patent airway is of foremost importance in the care of a patient with acute epiglottitis. Patients with impending respiratory failure who cannot be intubated may require an emergency subglottic tracheotomy. All pediatric patients with acute epiglottitis should be intubated preferably via a nasotracheal or an uncuffed endotracheal tube. Observation alone is not recommended in pediatric patients because of high associated mortality. Management of adult patients depends on the severity of clinical symptoms and signs of upper-airway obstruction.

Blood and epiglottic cultures should be obtained once the airway is secured. Patients should be started on parenteral antibiotics that are active against H influenzae type b, S aureus, and streptococci (Box 9-8). Because of the high degree of ß-lactamase-mediated resistance in H influenzae type b, third-generation cephalosporins such as ceftriaxone or cefotaxime or a ß-lactam/ß-lactamase inhibitor combination antibiotic such as ampicillin/sulbactam should be started. Patients with acute epiglottitis usually improve within 12-48 h with appropriate antibiotics, and these should be continued orally or parenterally for 7-10 d. The average period of intubation is ~ 2 d, and direct visualization is the most effective way to determine time of extubation.

Prognosis

Expeditious diagnosis, immediate management of upper-airway obstruction, and institution of antibiotics decreases morbidity and mortality related to acute epiglottitis. Full recovery without sequelae is expected in such patients.

Prevention & Control

H influenzae type b polysaccharide vaccination can further decrease the incidence of acute epiglottitis (Box 9-9). However, patients can still be susceptible to non-type-b H influenzae and other bacterial etiologies of epiglottitis.

The secondary attack rate of H influenzae type b among all household contacts, especially in children < 4 y old, can be decreased by a prophylactic 4-d course of rifampin (20 mg/kg/d in a single daily dose). Rifampin prophylaxis should be given to the patient and all household contacts regardless of previous immunization status, to prevent carriage state.

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