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

Lateral radiograph of the neck demonstrates and enlarged epiglottis (red arrow) and thickening of the aryepiglottic folds (yellow arrow). There is also reversal of the normal lordotic curve in the cervical spine and slight dilatation of the hypopharynx.