Epiglottitis

Epiglottitis
Classification and external resources
ICD-10	J05.1
ICD-9	464.3, 476.1
DiseasesDB	4360
eMedicine	emerg/169 emerg/375 ped/700
MeSH	D004826

Epiglottitis is an inflammation of the epiglottis — the flap at the base of the tongue that keeps food from going into the trachea (windpipe). Due to its place in the airway, swelling of this structure can interfere with breathing, and constitutes a medical emergency. Infection can cause the epiglottis to obstruct or completely close off the windpipe.

With the advent of the Hib vaccine, the incidence of epiglottitis has decreased, but the condition has not been eliminated.

Signs and symptoms

Epiglottitis commonly affects children, and is associated with fever, difficulty in swallowing, drooling, hoarseness of voice, and stridor. The child often appears acutely ill, anxious, and has very quiet shallow breathing with the head held forward, insisting on sitting up in bed. The early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.^{[citation needed]}

Since the introduction of the Hemophilus influenzae (Hib) vaccination in many Western countries, childhood incidence has decreased while adult incidence has remained the same; the disease is thus becoming relatively more common in adults than children. Modern cases in adults are most typically seen among abusers of crack cocaine, and have a subacute presentation. George Washington is one historical figure thought to have died of epiglottitis.

Cause

Epiglottitis involves bacterial infection of the epiglottis, most often caused by Haemophilus influenzae type B, although some cases are attributable to Streptococcus pneumoniae, Streptococcus agalactiae, Staphylococcus aureus, Streptococcus pyogenes, and Moraxella catarrhalis.

Diagnosis

Neck X-ray shows "thumb sign".

Left column: Normal epiglottis. Right column: Epiglottitis.

Diagnosis is confirmed by direct inspection using laryngoscopy, although this may provoke airway spasm. If epiglottitis is suspected, attempts to visualise the epiglottis using a tongue depressor are STRONGLY discouraged for this reason. A paediatric, anaesthesia or ENT specialist should be alerted immediately. Imaging is rarely useful, and treatment should not be delayed for this test to be carried out.

The epiglottis and arytenoids are cherry-red and swollen. The most likely differential diagnostic candidates are croup, peritonsillar abscess, and retropharyngeal abscess.

On lateral C-spine X-ray, the thumbprint sign (or "thumb sign") describes a swollen, enlarged epiglottis.

Management

Epiglottitis may require urgent tracheal intubation to protect the airway, though this is not always the case. In some cases, epiglottitis requires the use of antibiotics while the patient benefits from a breathing tube. In more serious cases, tracheal intubation is necessary. In such cases, immediate intubation is not advised, because the inflamed epiglottis is very sensitive and the care provider may irritate the epiglottis with the laryngoscope, causing the epiglottis to close off completely and forcing the use of a surgical airway opening (cricothyrotomy). Most children can be managed by keeping lights low and the child calm and in a position of comfort. Intubation may still become necessary if the child begins to rapidly decompensate and show signs of impending respiratory arrest (decreased work of breathing with abnormal skin signs). If the patient's stridor becomes quieter, obstruction is likely to follow, and thus intubation should be expedited even further.

In addition, patients should be given antibiotics, such as second- or third-generation cephalosporins, either alone or in combination with penicillin or ampicillin for streptococcal coverage.

Complications

Some patients may develop pneumonia, lymphadenopathy, or septic arthritis.

External links

• Jordana Marinoff, "Bacteria Grab a Windpipe and Hold it Hostage," Boston Globe, January 10, 2006

• Medscape information [1]