Pathology

Epiglottitis is inflammation and swelling of the epiglottis and adjacent supraglottic structures.

 

 

Epiglottitis is swells, blocking the flow of air into your lungs.

 

Routine Hib vaccination for infants has made epiglottitis rare, but the condition remains a concern. If you suspect that you or someone in your family has epiglottitis, seek emergency help immediately. Prompt treatment can prevent life-threatening complications.

 

 

Epiglottitis can block the flow of air to the lungs

 

 

 

 

Swelling may be caused by anything from an infection to simply drinking coffee that is too hot.

 

 

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Patients with epiglottitis and severe respiratory distress (eg, "sniffing" or "tripod" posture), stridor, drooling, cyanosis) should undergo prompt placement of an artificial airway.

In those with impending or complete obstruction, endotracheal intubation should be performed immediately in the emergency department.

Patients with suspected epiglottitis and signs of severe upper airway obstruction should be transported to the operating room, if time allows, where an artificial airway can be established surgically if necessary.


 

 

●Patients with epiglottitis and severe respiratory distress (eg, "sniffing" (picture 1) or "tripod" posture (picture 2), stridor, drooling, cyanosis) should undergo prompt placement of an artificial airway. In those with impending or complete obstruction, endotracheal intubation should be performed immediately in the emergency department.

 

•We suggest that most children younger than six years of age with epiglottitis undergo prompt placement of an artificial airway, even in the absence of severe respiratory distress (Grade 2C).

 

•We suggest that adults with epiglottitis without severe respiratory distress and with <50 percent obstruction of the laryngeal lumen be monitored closely in an intensive care unit setting without immediate placement of an artificial airway (Grade 2C).

 

•Additional indications for urgent placement of an artificial airway may include epiglottic abscess, comorbid diabetes mellitus (in adults), and immune deficiency. (See 'Indications' above.)

 

●The type of airway that is established depends upon the clinical situation and the expertise of the clinician(s) performing the procedure. Oro- or nasotracheal intubation is preferred as the first measures. Surgical airways are reserved for patients in whom endotracheal intubation is unsuccessful. (See 'Type of airway' above.)

 

●Criteria for extubation include resolution of epiglottal/supraglottal swelling as indicated by laryngoscopy and/or an air leak around the endotracheal tube, resolution of fever, and ability to swallow comfortably. (See 'Extubation criteria' above.)

 

Children

Initial airway management is based upon the degree of respiratory distress and the likelihood of epiglottitis, as determined by clinical assessment (table 1) [6]. In patients with signs of total or near-total airway obstruction, airway control precedes diagnostic evaluation.

 

Secure airway before diagnostic evaluation if respiratory distress is severe

In the patient with impending or complete obstruction, or with a convincing picture of epiglottitis, the clinician should focus on interventions that may be needed for airway management without attempting any other diagnostic procedures.

 

 
Communicate early with otolaryngologist, anesthesiologist, and intensivist
Keep the patient in a setting where the airway can be rapidly managed if necessary (eg, the emergency department, operating room, or intensive care unit)
Examination:
Defer examination of the pharynx in children when suspicion for epiglottitis is high (abrupt onset, high fever, tripod position, drooling, moderate to severe respiratory distress)
Examine the patient in the upright position
Attempt to visualize the epiglottis (with aid of tongue depressor, direct or indirect laryngoscopy) only when suspicion for epiglottitis is low (hoarseness, cough, mild distress, and fully immunized)
Maintain the child in a position of comfort with parent present
Avoid invasive procedures
Findings:
Stridor, drooling, suprasternal and subcostal retractions
Swollen, erythematous epiglottis, inflammation of the supraglottic structures
Look for signs of extra-epiglottic infection (eg, pneumonia)
Imaging:
Soft-tissue radiograph of the lateral neck (portable if possible) when the clinical diagnosis is in doubt
Defer imaging in patients with severe respiratory distress or in whom it will delay definitive visualization of the epiglottis
Findings:
Enlarged epiglottis ("thumb" sign), loss of vallecular air space, thickened aryepiglottic folds, distended hypopharynx, loss of cervical lordosis
Management
Airway
In patients with moderate to severe respiratory distress, secure the airway in the operating room or similarly equipped setting (endotracheal tube or surgically if necessary) with an anesthesiologist and otolaryngologist present
If abrupt obstruction:
Attempt bag-valve mask ventilation first
During laryngoscopy, pressure on the chest by an assistant may produce bubbling and help indicate the location of the glottis
Perform needle cricothyrotomy or surgical cricothyrotomy if unable to ventilate or intubate*
Laboratory studies:
Epiglottal cultures after establishment of artificial airway
Blood cultures after the airway is secured
Antimicrobial therapy
Administer empiric antimicrobial therapy:

Cefotaxime OR ceftriaxone

PLUS

If community- or hospital-acquired Staphylococcus aureus is suspected, add clindamycin OR vancomycin based upon local antimicrobial susceptibility patterns
Monitor
Monitor patient in the intensive care unit
* Needle cricothyroidotomy may be performed on children of any age. The age at which one can safely perform a surgical cricothyroidotomy on a child is not well established, and recommendations vary from 5 to 12 years old. Surgical cricothyroidotomy is best performed in children in whom external landmarks of the neck (eg, the cricothyroid membrane) are easily palapable. Refer to UpToDate topics on needle cricothyroidotomy with percutaneous transtracheal ventilation and emergent surgical cricothyroidotomy (cricothyrotomy).

 

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Without treatment, epiglottitis can progress to life-threatening airway obstruction.

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