Epiglottitis

Epiglottitis

General Considerations

• Acute bacterial epiglottitis
• Life-threatening, medical emergency due to infection with edema of epiglottis and aryepiglottic folds
• Organism
• Introduction of Haemophilus influenzae type B vaccine in 1985 has led to marked decrease in number of cases of epiglottitis
• Still remains the most common cause
• Also caused by
• Pneumococcus
• Streptococcus group A
• Viral infection – herpes simplex 1 and parainfluenza
• May also be caused by thermal injury and angioneurotic edema
• Age
• Typically between 3-7 years
• Peak incidence has become older over last decade and is now closer to 6-7 years
• Location
• Purely supraglottic lesion
• Associated subglottic edema in 25%
• Associated swelling of aryepiglottic folds causes stridor

Clinical Findings

• Classical triad is: drooling, dysphagia and distress (respiratory)
• Abrupt onset of respiratory distress with inspiratory stridor
• Sore throat
• Severe dysphagia
• Older child may have neck extended and appear to be sniffing due to air hunger
• Resembles croup clinically, but think of epiglottitis if:
• Child can not breathe unless sitting up
• “Croup” appears to be worsening
• Child can not swallow saliva and drools (80%)
• Cough is unusual

Imaging Findings 

• Patient needs to be accompanied everywhere by a physician experienced in endotracheal intubation
• Imaging studies are not always necessary for the diagnosis and may be falsely negative in early stages
• Lateral radiograph should be taken in the erect position only, as
• Supine position may close off airway
• Enlargement of epiglottis
• “Larger than your thumb”
• Thickening of aryepiglottic folds
• True cause of stridor
• Circumferential narrowing of subglottic portion of trachea during inspiration
• Ballooning of hypopharynx and pyriform sinuses
• Reversal of the normal lordotic curve of the cervical spine
• Fiberoptic-assisted, nasotracheal intubation is procedure of choice, so long as airway is secured

Differential Diagnosis

• Croup 
• Dilatation of the hypopharynx
• Dilation of the laryngeal ventricle
• Narrowing of the subglottic trachea
• Epiglottis is normal
• Enlarged adenoids  
• Compression of nasopharyngeal airway
• Frequently associate with enlargement of the lingual tonsils
• Epiglottis is normal

Treatment

• Secure airway
• May require intubation or emergency tracheostomy
• Some use IV steroids
• Empiric antibiotic therapy

Complications

• Danger of suffocation secondary to complete airway closure
• Pneumonia

Epiglottitis. A lateral radiograph of the neck using soft tissue technique demonstrates an enlarged epiglottis (red arrow) with markedly thickened aryepiglottic fold (white arrow) diagnostic of acute epiglottitis.