Epiglottitis

• Epiglottitis is acute inflammation of the epiglottis, which can rapidly progress to severe airway obstruction, usually associated with significant systemic illness.
• It is most commonly caused by the bacteria Haemophilus influenza type b (Hib) and can occur at any age. With the introduction of the Hib vaccine in the early 1990s, the incidence of epiglottitis has dropped significantly among children.
• Anatomy:

  • Epiglottis is a cartilaginous flap located in the larynx
  • Function is to close over the opening to the airway (glottis) during swallowing - preventing food or liquids from passing into the trachea and the lungs
  • Swelling of the epiglottis can lead to airway obstruction
• Causes:

  • Most commonly infection - Haemophilus influenzae type b (vaccine reduced incidence), Streptococcus pneumoniae, group A streptococci, staphylococcus aureus
  • Rarer infectious causes - HSV, infectious mononucleosis, candida
  • Non infectious - thermal injuries, chemical burns, foreign body ingestion
• Risk factors:

  • Not immunised against Haemophilus influenzae
  • Immunocompromised including diabetics
  • In vaccinated areas, the patient most commonly affected are men in their mid 40s, with additional co-morbidities
• Typical symptoms:

  • Severe and acute onset of sore through
  • Muffled voice
  • Drooling
  • Inspiratory stridor
  • Dysphagia and/or odynophagia
  • Most patients also report a recent URTI
  • Adults often present with a slower onset of symptoms compared to children
• In a child with epiglottitis, no action should be taken to stimulate or irritate them, as this may trigger laryngospasm in an already critical airway. This includes examination of the oral cavity, any form of instrumentation in the airway, and even separating the child from their parent
• Clinical findings:

  • Muffled voice - can be described as a 'hot potato voice' or may be hoarse
  • Tripod position - commonly seen in children
  • Drooling - more common in children
  • Signs of respiratory distress - dyspnoea, tachypnoea, accessory muscle use and cyanosis
  • Inspiratory stridor - indicated advanced upper airway obstruction
  • Hypoxia
  • Tachycardia
  • Fever
• Investigations:

  • Investigations in the immediate period are avoided as the condition is time critical, unless the patient is stable.
  • The main priority is to avoid further agitating the patient and precipitating airway obstruction, particularly in children. 
  • The diagnosis of epiglottitis is mainly clinical. Therefore, it is crucial to have senior support early on, including those with advanced airway skills.
  • If there is a strong clinical suspicion of epiglottitis in an unstable patient, they will likely be taken to a controlled environment, such as the operating theatre, for examination of the airway plus endotracheal intubation or a surgical airway.
  • Only once the airway is secure can other investigations be performed, such as blood tests, blood culture and a culture swab from the epiglottis.
• First-line investigations in a stable patient:

  • Direct flexible (or rigid) laryngoscopy to visualise the airway
  • Should only be performed in a controlled setting, such as an operating theatre with anaesthetics and ENT present
• Relevant laboratory investigations include:

  • Full blood count: raised white cells can indicate infection
  • CRP: often raised in acute infection
  • Liver function tests
  • Urea & electrolytes
  • Blood cultures: to help guide future antibiotic choices.
  • Culture swab from epiglottis: to identify the causative organism and guide antibiotic choice. Only performed by senior members of staff.
• Initial management:

  • Manage the patient in an upright position
  • Have the airway assessed and secured by ENT or anaesthetics:
  • Endotracheal intubation
  • Surgical airway if intubation not possible e.g. tracheostomy or cricothyroidotomy
• Additional management:

  • Nebulised adrenaline
  • High flow oxygen
  • IV broad spectrum antibiotics - usually ceftriaxone or cefuroxime
  • Corticosteroids e.g. dexamethasone
  • Fluid replacement
  • Analgesia
  • Try to give medications orally to children to prevent stress caused by cannulation
• Complications:

  • Epiglottic abscess - may require drainage
  • Deep neck space infection - may be cellulitis or an abscess, such as retro- and parapharyngeal abscesses
  • Mediastinitis - as the epiglottis involves the retropharyngeal space, the infection can spread to the mediastinum (a life-threatening condition)