Acute epiglottitis

Question 1

What is acute epiglottitis?

Answer 1

Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B.

Question 2

Why is prompt recognition and treatment of acute epiglottitis essential?

Answer 2

Prompt recognition and treatment is essential as airway obstruction may develop.

Question 3

Who is more commonly affected by epiglottitis in the UK now?

Answer 3

In the UK, epiglottitis is now more common in adults due to the immunisation programme.

Question 4

What has contributed to the decrease in the incidence of epiglottitis?

Answer 4

The incidence of epiglottitis has decreased since the introduction of the Hib vaccine.

Question 5

What are the features of acute epiglottitis?

Answer 5

Features include rapid onset, high temperature, generally unwell, stridor, drooling of saliva, and ‘tripod’ position.

Question 6

What is the ‘tripod’ position in acute epiglottitis?

Answer 6

‘Tripod’ position is when the patient finds it easier to breathe by leaning forward and extending their neck in a seated position.

Question 7

How is the diagnosis of acute epiglottitis made?

Answer 7

Diagnosis is made by direct visualisation by senior/airway trained staff, but x-rays may also be done.

Question 8

What does a lateral view x-ray show in acute epiglottitis?

Answer 8

A lateral view in acute epiglottitis will show swelling of the epiglottis, known as the ‘thumb sign’.

Question 9

What does a posterior-anterior view x-ray show in croup?

Answer 9

A posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’.

Question 10

What is the management for acute epiglottitis?

Answer 10

Management includes immediate senior involvement, endotracheal intubation if necessary, oxygen, and intravenous antibiotics.

Question 11

What should not be done if acute epiglottitis is suspected?

Answer 11

If suspected, do NOT examine the throat due to the risk of acute airway obstruction.

Question 12

Who should perform the direct visualisation for diagnosis?

Answer 12

Direct visualisation should only be done by senior staff who are able to intubate if necessary.

Question 13

Definition of acute epiglottis

Answer 13

Epiglottitis refers to inflammation of the epiglottis (the flap of cartilage that covers the trachea during swallowing) which usually occurs secondary to bacterial infection. Patients may deteriorate rapidly and it may be fatal if swelling causes airway obstruction.

Question 14

Epidemiology

Answer 14

Epiglottitis has become relatively uncommon in countries such as the UK due to widespread Haemophilus influenzae B (Hib) vaccination of children. Most cases now occur in adults, with an incidence of approximately 1-4 per 100,000 people per year.

Question 15

Aetiology

Answer 15

Epiglottitis is most commonly caused by bacterial infection, including:
- Streptococcus species
- Staphylococcus aureus
- Haemophilus influenzae b
- Pseudomonas species
- Moraxella catarrhalis
Viral infections (such as herpes simplex) can also cause epiglottitis, as well as rarer non-infectious causes:
- Thermal injuries
- Swallowed or inhaled foreign bodies
- Chemotherapy reactions

Question 16

Signs and Symptoms

Answer 16

Symptoms include:
- Sore throat
- Odynophagia
- Dysphagia
- Fevers
- Dyspnoea
On examination, signs include:
- Drooling (in patients unable to swallow secretions)
- ‘Hot potato’ muffled speech
- Tachycardia
- Cervical lymphadenopathy
- Tenderness over the hyoid bone
- ‘Tripod sign’ (leaning forward to help relieve upper airway obstruction)
- Stridor
- Respiratory distress
If epiglottitis is suspected, the throat should not be examined with a tongue depressor as this may exacerbate upper airway obstruction.

Question 17

Differential Diagnosis

Answer 17

1. Viral pharyngitis: Patients may have fevers and odynophagia; cough may be present which is not usually seen in epiglottitis. Features of drooling, stridor, or respiratory distress are not present.
2. Peritonsillar abscess (quinsy): Causes severe sore throat, often worse on one side, can cause drooling and a muffled voice; may also cause trismus and a displaced uvula. The tonsil is swollen on examination unlike in epiglottitis.
3. Bacterial tracheitis: Causes stridor and fevers; clinical course is generally less rapid than in epiglottitis with a viral prodrome over a few days before deterioration. Cough is common unlike in epiglottitis.
4. Croup: Common in children (6 months to 6 years), may cause stridor, respiratory distress, and fevers but the barking cough is classic.

Question 18

Investigations

Answer 18

Diagnosis is clinical but can be confirmed with fibre-optic laryngoscopy to visualise epiglottic inflammation. This should be performed in an area where the airway could be rapidly secured via intubation or tracheostomy if obstruction were to occur.
Lateral neck X-ray may show ‘thumb sign’, referring to thickening of the epiglottis and aryepiglottic folds.
Blood cultures and throat swabs (once the airway is secure) may be taken to identify the cause and target antibiotic therapy.

Question 19

Management

Answer 19

1. Assess using an A to E approach - a medical emergency call may be required if there are signs of impending upper airway obstruction.
2. Emergency referral to ENT and anaesthetics.
3. If airway protection is required, intubate early with front of neck access (tracheostomy or needle cricothyroidotomy) required if endotracheal tube placement is impossible.
4. Patients who are not intubated require close monitoring in case of deterioration.
5. Keep the patient sitting upright.
6. Give high-flow oxygen.
7. Nebulised adrenaline 1:1000 should also be given.
8. IV dexamethasone should also be given to reduce inflammation.
9. IV antibiotics should also be given urgently (e.g., ceftriaxone and metronidazole).
10. IV fluids to maintain hydration whilst unable to swallow.

Question 20

Complications

Answer 20

Complications of epiglottitis include:
- Airway obstruction and death
- Abscess formation (epiglottic, retropharyngeal, or parapharyngeal)
- Sepsis
- Mediastinitis (due to spread of infection to the retropharyngeal space)
- Pneumonia, especially in intubated patients