II. Epidemiology

  1. Adults
    1. Uncommon, but adults comprise most cases since the HaemophilusInfluenzae B (Hib Vaccine)
  2. Children
    1. Young children were historically the primary cohort for Epiglottitis prior to the HaemophilusInfluenzae B (Hib Vaccine)
    2. Commonly misdiagnosed as croup (20% in some studies)
    3. Average age is older than that seen in Croup (Age 2-5)

III. Definition

  1. Potentially fatal infection of supraglottic tissue

IV. Etiology

  1. Group A beta hemolytic Streptococcus
  2. Streptococcus Pneumoniae
  3. Staphylococcus aureus
  4. Haemophilus Influenzae type B
    1. Previously most common cause of Epiglottitis in children
    2. No longer a common cause in United States (due to Hib Vaccine)
  5. Candida albicans
    1. Immunocompromised patients
  6. Thermal airway Burn Injury

V. Symptoms (Acute onset with rapid progression)

  1. Initial Symptoms
    1. Severe Pharyngitis (82%)
    2. Fever
  2. Mild or subtle Stridor (77%)
    1. "Look worse then they sound" (opposite of Croup)
  3. Shortness of Breath (100%)
  4. Irritability or restlessness (46%)
  5. Dysphagia (64%)
  6. Drooling (41%)
  7. Soft muffled voice or Hoarseness (31%)

VI. Differential Diagnosis

  1. See Airway Obstruction
  2. See Croup Differential Diagnosis

VII. Diagnosis (Differentiate from Croup)

  1. Absence of cough
  2. Dysphagia (difficult swallowing with Drooling)
  3. Toxic appearance
    1. Classically sitting forward with scared expression in tripod position

IX. Imaging

  1. Consider CT Neck for adults with suspected epigottitis
  2. Lateral Neck XRay
    1. Thumb shaped epiglottis (swollen supraglottis)
    2. Diminished vallecula

X. Management: General

  1. Avoid Tongue depressor or other oral instruments
    1. Epiglottis irritation may lead to obstruction
  2. Keep patient calm
  3. Parenteral Antibiotics to cover Bacteria listed above
    1. First-line combination therapy (dual agents)
      1. Vancomycin 15 mg/kg (up to 1 gram) IV every 12 hours AND
      2. Third Generation Cephalosporin (choose one)
        1. Ceftriaxone 50 mg/kg (up to 2 grams) IV every 24 hours OR
        2. Cefotaxime 50 mg/kg (up to 2 grams) IV every 4 to 8 hours
    2. Penicillin Allergy (severe IgE mediated, e.g. Anaphylaxis)
      1. Levofloxacin 100 mg/kg up to 750 mg IV every 24 hours AND
      2. Clindamycin 7.5 mg/kg (up to 600 to 900 mg) IV every 6 to 8 hours
      3. Precautions
        1. MRSA resistance is increasing to Clindamycin (>10% in some communities)
        2. Levofloxacin even in children is justified in severe Penicillin Allergy and Epiglottitis
    3. References
      1. Gilbert (2011) Sanford Guide
  4. Systemic Corticosteroids
    1. Dexamethasone is recommended at high dose (previously avoided)
    2. Swadron and Reverte in Herbert (2014) EM:Rap 14(10): 7-8
  5. Avoid potentially harmful therapies
    1. Avoid Racemic Epinephrine

XI. Management: Airway

  1. Alert patient able to maintain airway
    1. Controlled intubation by anesthesia or otolaryngology in the operating room
    2. Epiglottis inspection under anesthesia (fiery red)
    3. Culture epiglottis if possible
  2. Patient not alert and not able to maintain airway
    1. Bag-valve mask ventilation
    2. Consider prone position
    3. Prepare for emergent Cricothyrotomy or Tracheostomy
    4. Attempt Endotracheal Intubation
    5. Consider Laryngeal Mask Airway

XII. References

  1. Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, Burlington, p. 55-6
  2. Cressman (1994) Pediatr Clin North Am, 41(2):265-76 [PubMed]
  3. Pappas (1997) Consultant, April 1997:857-67

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Epiglottitis (C0014541)

Definition (MSHCZE) Zánět hrtanové příklopky.
Definition (MSH) Inflammation of the epiglottis.
Concepts Disease or Syndrome (T047)
MSH D004826
ICD10 J05.10
SnomedCT 80384002
English Epiglottitides, Epiglottitis, EPIGLOTTITIS, epiglottitis (diagnosis), epiglottitis, Epiglottitis NOS, Epiglottitis [Disease/Finding], Epiglottitis (disorder), Epiglottitis, NOS
French EPIGLOTTITE, Epiglottite SAI, Epiglottite, Épiglottite
Portuguese EPIGLOTITE, Epiglotite NE, Epiglotite
German EPIGLOTTITIS, Epiglottitis NNB, Epiglottitis
Dutch epiglottitis NAO, epiglottitis, Epiglottitis
Italian Epiglottite NAS, Epiglottite
Spanish Epiglotitis NEOM, epiglotitis (trastorno), epiglotitis, Epiglotitis
Japanese 喉頭蓋炎NOS, 喉頭蓋炎, コウトウガイエン, コウトウガイエンNOS
Swedish Struplocksinflammation
Czech epiglotitida, Epiglotitida NOS, Epiglotitida, zánět příklopky hrtanové, laryngitis supraglottica
Finnish Kurkunkannen tulehdus
Russian EPIGLOTTIT, ЭПИГЛОТТИТ
Polish Zapalenie nagłośni
Hungarian epiglottitis, epiglottitis k.m.n.
Norwegian Strupelokkbetennelse, Epiglottitt

Ontology: Acute epiglottitis (C0155814)

Concepts Disease or Syndrome (T047)
ICD9 464.3
ICD10 J05.1
SnomedCT 155509002, 195701009, 29608009
English Acute epiglottitis NOS, Acute epiglott + supraglott, Acute epiglottitis and supraglottitis (disorder), Acute epiglottitis NOS (disorder), acute epiglottitis, epiglottitis acute, acute epiglottitis (diagnosis), Acute epiglottitis, Acute epiglottitis and supraglottitis, Acute epiglottitis (disorder)
Dutch acute epiglottitis, Acute epiglottitis
French Epiglottite aiguë
German akute Epiglottitis, Akute Epiglottitis
Italian Epiglottite acuta
Portuguese Epiglotite aguda
Spanish Epiglotitis aguda, epiglotitis aguda, SAI (trastorno), epiglotitis aguda, SAI, epiglotitis aguda (trastorno), epiglotitis aguda
Japanese 急性喉頭蓋炎, キュウセイコウトウガイエン
Czech Akutní epiglotitida
Korean 급성 후두개염
Hungarian acut epiglottitis