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Epiglottitis
From WikEM
Contents
Background
- Otolaryngologic emergency
- Can lead to rapid onset of life-threatening airway obstruction
- Most cases are seen in adults (since advent of H. flu vaccine)
Etiology
Clinical Features
- Three D's:
- Drooling
- Dysphagia
- Distress
- Pain with gentle palpation of larynx and upper trachea
- Stridor
- Respiratory distress
- Often no cough seen or noted
Differential Diagnosis
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackievirus
- HIV (Acute Retroviral Syndrome)
Noninfectious
- Stevens-Johnson Syndrome
- Pemphigus
- Angioedema
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
Pediatric stridor
<6mo
- Laryngotracheomalacia
- Vocal cord paralysis (weak cry)
- Subglottic stenosis (previous intubation)
- Airway hemangioma (usually regresses by age 5)
- Vascular ring/sling
>6mo
- Croup
- Epiglottitis
- Bacterial tracheitis
- Foreign body (sudden onset)
- Retropharyngeal abscess (muffled voice, fever)
Evaluation
- Bedside nasopharyngoscopy for direct visualization
- Imaging only required if diagnosis uncertain
- Lateral neck x-ray
- Obliteration of vallecula
- Edema of prevertebral and retropharyngeal soft tissues
- "Thumb sign" (enlarged epiglottis)
Management
- Emergent ENT consult
- O2 (humidified)
- IVF (hydration minimizes crusting in the airway)
- Nebulized Epinephrine to reduce edema
Antibiotics
Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae
Immunocompetent
- Ceftriaxone 2gm IV once daily (first line) OR
- Cefotaxime 2gm (50mg/kg) IV three times daily OR
- Ampicillin/Sulbactam 3g (50mg/kg) IV q 6 hours OR
- Levofloxacin 750mg IV once daily
- Consider Vancomycin 15-20mg/kg to any of the above if risk of MRSA[2]
Immunocompromised
Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans
- Cefepime 2g (50/kg) IV q8 hours AND Vancomycin 15mg/kg IV q6 hours
Steroids
- Methylprednisolone 125mg IV
- Controversial
- Benefit: anti-inflammatory effect, decreases edema
- Many studies, however, have shown no reduction in the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids. [3]
- Controversial
Airway Managment[4]
- First line therapy is awake fiberoptic Intubation with patient sitting up.
- Preparation should be made for simultaneous cricothyrotomy incase intubation fails
Disposition
- Admit
References
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.
- ↑ http://bja.oxfordjournals.org/content/92/3/454.1.full
- ↑ Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72
