Epiglottitis Disease

BASICS

DESCRIPTION

Acute inflammation of the supraglottic structures with inflammation of the epiglottis, vallecula, aryepiglottic folds and arytenoids

System(s) affected: Pulmonary
Genetics: N/A
Incidence/Prevalence in USA: Incidence has decreased dramatically since the introduction of the Haemophilus b vaccine
Predominant age:
- 3-7 years most common, though any age can be affected
- Generally older than typical croup patient
- Infrequent in adults
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Sudden onset and fulminating course
Fever
Dysphagia, drooling
Sore throat
Cervical adenopathy
Respiratory distress
"Tripod" position (sitting propped up on hands with head forward and tongue out)
Muffled voice/cry (vs. hoarseness in croup)
Minimal cough (vs. barking cough in croup)
Toxic appearance/shock (occasionally, due to associated septicemia)
Stridor softer and less prominent than croup
Usually no history of prodromal upper respiratory infection (vs. positive history in croup)
Bacteremia
Hypoxia. A late symptom usually not present unless totally obstructed.

CAUSES

Haemophilus influenzae in children
Haemophilus influenzae and Group A Streptococcus in adults

RISK FACTORS

N/A

DIAGNOSIS

LABORATORY

Blood culture (positive in over 90%). See under Diagnostic Procedures - should not visualize/swab epiglottis except in controlled environment, i.e., operating room. Blood tests also contraindicated until airway secured.
Epiglottic swab culture (positive in 70%)

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

Neck radiographs are contraindicated if epiglottitis is suspected, due to danger of sudden complete airway obstruction
Chest radiographs are indicated for endotracheal tube placement. Pneumonia can occur as a complication.

DIAGNOSTIC PROCEDURES

Visualization of epiglottis with tongue depressor is contraindicated due to danger of sudden complete airway obstruction
Controlled visualization of epiglottis at intubation in operating room is diagnostic
Lumbar puncture is indicated if there is clinical suspicion of meningitis
In adult, indirect laryngoscopy is generally safe

TREATMENT

APPROPRIATE HEALTH CARE

Hospitalize during acute illness

GENERAL MEASURES

Each institution should have emergency protocol involving a team of emergency room physicians, pediatricians, anesthesiologists, surgeons, pediatric intensivists, and pediatric ICU nurses (principles are similar for pediatric and adult patients)
Call anesthesiologist to bedside
Have equipment for intubation and needle cricothyrotomy or percutaneous tracheostomy at bedside
Notify OR
Notify pediatric surgery or ENT for standby in OR in case tracheostomy becomes necessary
Keep patient quiet, calm, sitting up (in parent's arms)
Avoid venipuncture, blood gases, oxygen masks, intravenous lines, injections, monitors, and radiographs
Avoid sedation
Avoid racemic epinephrine
Avoid examining the pharynx
Transport patient and parent together to OR in a wheelchair
Intubate all patients, preferably in OR under controlled circumstances by experienced anesthesiologist with surgery or ENT on standby for emergency tracheostomy
Tracheostomy not indicated unless intubation unsuccessful
Tape airway securely in place and use a bite block if indicated
Splint elbows and restrain arms to avoid self-extubation
Use humidity in a tent and avoid T-piece (traction increases risk of accidental extubation)
CPAP, mechanical ventilation, and sedation usually unnecessary
Pay attention to supervision and pulmonary toilet/suctioning to minimize risk of endotracheal tube plugs

SURGICAL MEASURES

See General Measures

ACTIVITY

N/A

DIET

IV fluid initially, then nasogastric feedings while intubated

PATIENT EDUCATION

Reassurance about treatment and outcome

FOLLOW UP

PREVENTION/AVOIDANCE

H. influenzae vaccine is effective though not 100% protective
Rifampin prophylaxis (20 mg/kg once daily for 4 days, maximum daily dose 600 mg) for all household and day care contacts. Family and close contacts may be asymptomatic carriers of H. influenzae

POSSIBLE COMPLICATIONS

Pneumonia, meningitis, cervical adenitis, septic arthritis, pericarditis, cellulitis (rare)
Septic shock (in about 1%)
Pneumothorax, pneumomediastinum (very rare)
Death from asphyxia

EXPECTED COURSE AND PROGNOSIS

Most can be extubated after 24 to 48 hours
Morbidity and mortality is low with appropriate intervention

MISCELLANEOUS

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.