Epiglottitis

Synonym: supraglottitis

What is epiglottitis?

Acute epiglottitis is a condition in which there is inflammation of the epiglottis. It may also affect the soft tissues surrounding the epiglottis, particularly in affected adults - hence the term supraglottitis. It is potentially life-threatening if complete obstruction of the airway occurs.¹

How common is epiglottitis? (Epidemiology)¹

• Epiglottitis is rare, affecting around 1/100,000 of children and around 2/100,000 adults in countries which vaccinate against Haemophilus influenzae type B.

• The usual age of presentation in children is 2-5 years. Adults present in their 40s and 50s and it affects more men than women.²³

• Adults who develop epiglottitis are more likely to have other underlying medical conditions that affect their immunity either systemically or locally. These include diabetes, obesity, pneumonia, and Sjögren's syndrome.

Epiglottitis causes (aetiology)¹

• Epiglottitis is usually caused by a bacterium, with 90% being due to Haemophilus influenzae.

• Other bacterial causes include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae type b (Hib), Pseudomonas spp., Moraxella catarrhalis, and Mycobacterium tuberculosis.

• Viruses include herpes simplex virus, with bacterial superinfection.

• Candida spp. and Aspergillus spp. are more common in immunocompromised patients.

• Non-infectious causes of epiglottitis reported include thermal causes (eg, steam, aspiration of hot milk, crack cocaine smoking), caustic insults (eg, dishwasher pellets), foreign bodies and trauma, including traditional Chinese gua sha therapy.⁴⁵

Epiglottitis symptoms¹

Many of the signs and symptoms associated with acute epiglottitis are common and may occur in many less serious disorders. Patients with epiglottitis may present with any of the following and the symptoms may evolve very quickly over a period of a few hours.

The most common symptoms

• Sore throat.

• Odynophagia (painful swallowing).

• Inability to swallow secretions (drooling in children).

• Muffled voice - 'hot potato' voice.

• Fever.

Other symptoms

• High temperature.

• Tachycardia.

• Ear pain.

• Cervical lymphadenopathy.

• The 'tripod sign' - the patient leans forward on outstretched arms to move inflamed structures forward, thereby easing the upper airway obstruction.

With more severe epiglottitis

• Dyspnoea.

• Dysphagia.

• Dysphonia.

• Respiratory distress.

• Stridor - is a sign of upper airways obstruction and is a surgical emergency.

Diagnosis in adults can be difficult, as they may not have signs of respiratory distress (stridor).

Children with epiglottitis do not have cough as a prominent syndrome (if present, it is usually mild) which may help to distinguish it from laryngotracheobronchitis or 'croup'.

Differential diagnosis

The differential diagnosis will depend on the presenting epiglottitis symptoms and age of the patient; however, generally included are:

• Pharyngitis

• Laryngitis

• Inhaled foreign body

• Croup

• Retropharyngeal abscess

Initial management in primary care

Suspected epiglottitis is a medical emergency - the key action is not to upset the child or attempt to examine the throat, as this may precipitate total airway obstruction. Immediate referral to hospital via blue light ambulance should be arranged, making it clear to the receiving team that epiglottitis is suspected, so that they can secure the airway.

Investigations in secondary care¹

• Epiglottitis is a clinical diagnosis in children. Investigation will generally be done after the airway is secured, or in a facility where this can be done rapidly.

• Fibre-optic laryngoscopy remains the 'gold standard' for diagnosing epiglottitis, as the epiglottis can be seen directly.

• Lateral neck X-ray may be useful if laryngoscopy is not possible. Soft-tissue radiograph of the neck may show the 'thumbprint sign'.

• Throat swabs may be taken when the airway is secure, or when intubation/tracheostomy facilities are at hand.

• Blood cultures may be taken if the patient is systemically unwell.

• CT or MRI scans may be performed if abscess formation is suspected.

Epiglottitis treatment¹

• Initial presentation may resemble a viral sore throat, so a high index of suspicion is needed. Emergency referral is required if signs of airway obstruction are present (stridor). Deterioration in symptoms may be rapid, especially in children.

• Management is usually conservative with intravenous or oral antibiotics but intubation may be needed .

• Surgical tracheostomy may be required in patients with severe airway obstruction in whom intubation has not been possible.

• Drainage may be required in some patients with an epiglottic abscess.

Complications

• Abscess formation: 25% in one series.

• Meningitis.

• Sepsis.

• Pneumothorax.

• Pneumo-mediastinitis (very rare).

Prognosis

The great majority of patients with epiglottitis will make a complete recovery with no sequelae. Early diagnosis appears to reduce the need for intubation which, in a series of over 300 cases, was required in only 15%.⁶

Outcomes are generally good for adults, with fewer cases needing intubation than among children.⁷ However, death may occur rapidly if the condition is not recognised and complete airway obstruction occurs.

Epiglottitis prevention¹

Hib vaccination has dramatically reduced the incidence of acute epiglottitis in children in those countries in which the vaccination is included in the routine vaccination protocol for children. Those who have been in contact with someone who has epiglottitis due to H influenzae may need rifampicin prophylaxis. Decisions on prophylaxis, and its prescribing, are the responsibility of public health, unless there is an agreed and resourced enhanced service for this to be done in general practice.