2. PATIENT DETAILS
Referred from casualty with three
days history of sore throat
Difficulty in swallowing
Febrile episodes controlled by
paracetamol
Hypertensive on treatment
No other history of note
54 YEARS MALE PATIENT
3. EXAMINATION
Patient comfortable in room air, afebrile
to touch. No stridor. Voice sounds
muffled but patient reports it has not
changed
Points to submandibular region
bilaterally as area of tenderness
Oral Exam: Hyperaemic oropharynx
No obvious infection in tonsillar crypts
No masses in the oropharynx
Ears: Normal clinical findings
Nose: congested mucosa, turbinates
hyperaemic, no masses no discharge
Differentials:
Acute pharyngitis
Viral tonsillitis
4. Further examination
Epiglottis swollen with inward
curling of lateral borders
Arytenoids hyperaemic
Vallecula and lateral pharyngeal
wall hyperaemic
Vocal cords partially seen
beyond the swollen epiglottis,
appear normal and mobile
Flexible scope examination of larynx Diagnosis:
Acute Epiglottis
5. Management on admission
@15H20
Patient convinced to be admitted for airway
monitoring
Decadron 8mg stat prescribed
Ivi ceftriaxone 1g ivi 12 hrly
Decadron 8mg ivi daily
Paracetamol 1g orally for analgesics
Adrenaline:saline nebs 4 hrly or PRN
Ivi line inserted.
Bloods fbc, cusp taken
Soft tissue view of neck requested.
Special instructions for
nursing staff:
Monitor patient and vitals
2 hourly
Monitor airway and any
abnormal breathing
pattern and inform doctor
if any noticed
6. PATIENT STATUS
6H15 pm patient certified dead
Sister in ward reported that patient got up to go
to toilet and she noticed that patient was not “ok”
She called for assistance when patient collapsed
Code blue – unfortunately no response from any
staff
Dr Gardiner informed, he informed me, when I
got to hospital patient ready for transport to
mortuary.
Resusc not attempted as there was no pulse, no
pupillary reflexes, no attempts at respiration,
patient was cold to touch.
8. EPIGLOTITIS
• Epiglottitis is inflammation of
the epiglottis and adjacent
supraglottic structures.
• Without treatment, epiglottitis
can progress to life-threatening
airway obstruction
Definition:
10. PATHOGENISIS
Infectious epiglottitis is a cellulitis of the epiglottis,
aryepiglottic folds and other adjacent tissues
It results from bacteraemia and or direct invasion of the
epithelial layer by the pathogenic organism
The posterior nasopharynx is the primary source of
pathogens in epiglottitis…
11. PATHPHYSIOLOGY
Swelling of the epiglottis results from edema and accumulation of
inflammatory cells in the potential space between squamous epithelial
layer and epiglottic cartilage
Lingual surface of epiglottis and periepiglottic tissues have abundant
networks of lymphatic and blood vessels that facilitate spread of
infection and subsequent inflammatory response
Once infection begins, swelling rapidly progresses to involve the entire
supraglottis including aryepiglottic folds and arytenoids
Subglottic not affected as swelling is halted by the true vocal cords
Supraglottic swelling reduces calibre of the upper airway, causing
turbulent airflow during inspiration , further airflow obstruction may
be due to posterior and inferior curling of the epiglottis which acts as
ball valve, causing stridor and facilitating aspiration of oropharyngeal
secretions
12. ETIOLOGY
May be caused by number of bacterial, viral and fungal
pathogens
CHILDREN: Haemophilus influenza
ADULTS: broad range of bacteria, viruses, combined
bacterial-viral infections as well as fungi
In most adult cases blood and throat cultures are
negative
Among cases in which pathogen is identified Hib is most
common accounting for 3 – 14 % of all cases
IMMUNOCOMPROMISED: pseudomonas aeruginosa and
candida species, single case reported in adult receiving
steroids and azathroprine for chron’s disease
NONINFECTIOUS CAUSES: Traumatic causes include
thermal injury, foreign body ingestion and caustic
ingestion.
May rarely occur as manifestation of graft versus host
13. EPIDEMIOLOGY
Hib vaccine changed the epidemiology of the disease
Decreased average annual incidence in children. In USA
annual rate prior to availability of Hib vaccine was
5/100000 in less than 5 years, currently immunized
children rates are between 0.6 to 0.8/100000 as herd
immunity improves with time the incidence is expected
to lower
Incidence in adult 0.6 to 1.9 /100000 in Iceland and
Denmark studies similar results in USA
Statistics similar in most developing countries with Hib
vaccination programme.
14. EPIDEMIOLOGY
Increased age of children with Epiglottitis
Median age of children prior to vaccine was 3 years, post
vaccination age has now increased to 6 to 12 years of
age
Epiglottitis historically is somewhat more prevalent in
boys (58%)
15. RISK FACTORS
In children – complete or lack of immunization for Hib
and Immunosupression
In adults epiglottitis has been associate with number of
comorbid conditions: HPT, DM, Substance abuse and
Immune deficiency
Suspected Epiglottitis is a medical emergency….. Prompt
recognition and treatment is critical
16. CLINICAL PRESENTATIONS
Clinical feature of epiglottitis differ with age severity and
etiology
Young children present with respiratory distress, anxiety
and the characteristic “tripod” or “sniffing” posture in
which they assume a sitting position with trunk leaning
forward, heck hyperextended and chin thrust forward in
an effort to maximize the diameter of obstructed airway
They may be reluctant to lie down
Drooling is often present
Older children, and adults may present with a severe
sore throat but relatively normal oropharyngeal
examination
17. CLINICAL PRESENTATION
Abrupt onset and rapid progression of dysphagia, drooling and
distress ( hallmark of epiglottitis)
Sudden onset of high fever between 38.8 to 40 degrees celcius
is common together with severe sore throat, odynophagia and
drooling
Children often appear “toxic”
Older children can describe a “choking sensation” distressed
during inspiration, are often anxious and irritable. Speech is
often muffled
Stridor is frequently present
Quality of voice is still normal
18. CLINCAL FEATURES ADULTS
Sore throat or odynophagia (90 – 100%)
Fever greater than 37.5 degree celcius (26 – 90%)
Muffled voice (50 – 80%)
Drooling (15 – 65%)
Stridor or respiratory compromise (approx. 33%)
Hoarseness (20 – 40%)
19. EXAMINATION
Visualization of epiglottis is an accepted standard for
clinical diagnosis
Radiographs are used to make diagnosis in patients with
a mild disease, who then may be admitted for ivi
antibiotics and close airway monitoring
The approach to diagnosis epiglottitis including flexible
laryngoscopy, depend on patient’s age, degree of illness
and clinician’s suspicion for epiglottitis
20. EXTRA EPIGLOTTIC FOCI OF
INFECTION
Patients should be examined for extra epiglottic foci of
infection
Pneumonia, cervical adenitis, cellulitis, septic arthritis, or meningitis)
If pathogen that frequently causes invasive diseases at
other site is a possibility (eg. S pneumonia, Haemophilus
influenza b)
LAB – Laboratory studies should not be performed in
patients in whom epiglottitis is strongly suspected until
the airway is secured
Agitation caused by pain may worsen resp distress
LAB evaluation should include FBC, blood culture and epiglottal
culture in intubated patients
22. CAUSATIVE ORGANISM
Review of 407 cases of epiglottitis from a single state
over an 18 year period suggests that clinical features
vary depending upon whether or not Hib is the causative
pathogen
Mayo-Smith MF, Spinale JW, Donskey CJ, et al. Acute
epiglottitis. An 18-year experience in Rhode Island.
Chest 1995; 108:1640.
Hib epiglottitis is associated with ‘classic” features ,
more common in young children and is rapidly
progressive, involves epiglottis more than the
surrounding structures and has a high risk of airway
obstruction
Non Hib epiglottitis is more common in adults and
generally has a slower onset, greater involvement of the
25. COMPLICATIONS
Airway obstruction
Epiglotic abscess – May result from coaslescent epiglottic
infection of secondary infection of epiglottic mucocele, occurs
predominantly in adults and may complicate as many as 30% of
cases
Secondary infection – pneumonia, cervical adenitis, cellulitis,
septic arthritis, meningitis may result as a consequensce of
bacteremia or direct extension
Necrotising epiglottitis – rare complication in
immunocompromised patients
Death – mortality rate in children is <1% and in adults <3.3
percent, Death is almost always due to acute airway obstruction.
Most deaths occur en route to the hospital or soon thereafter
26. TREATMENT – GENERAL
PRINCIPLES
Maintainence of the airway
Administration of appropriate antimicrobial agents
May be reasonable to withhold antibiotics in patients whose
epiglottitis is clearly known to be caused by inhalational, chemical or
thermal injury
27. TREATMENT
Close monitoring
Humidified oxygen
The role of glucocorticoids in airway management of
patients with epiglottitis is controversial
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
The role of glucocorticoids in airway management of patients with epiglottitis is controversial
28. 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 patient in the intensive care unit
