Makindo Medical Notes

Related Subjects: |Acute Epiglottitis |Croup |Acute Tracheitis |Stridor

Acute epiglottitis is a life-threatening condition that can cause sudden airway obstruction in both children and adults. It should be managed as a medical emergency with immediate involvement of senior anesthetic and ENT specialists to secure the airway, which may necessitate endotracheal intubation or tracheostomy. Examination of the throat should be avoided in suspected cases until airway protection is ensured, as this can precipitate complete airway obstruction.

About

• Acute epiglottitis is an inflammation of the epiglottis that can rapidly progress to airway obstruction.
• It is considered a pediatric emergency but can occur at any age; cases in adults are increasingly recognized.
• The incidence has decreased significantly in children due to widespread vaccination against Haemophilus influenzae type b (Hib).

Aetiology

• Primarily caused by Haemophilus influenzae type b infection in unvaccinated individuals.
• Other bacterial pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Neisseria meningitidis.
• Risk factors:
  • Lack of Hib vaccination.
  • Immunocompromised states (e.g., HIV infection, chemotherapy).
  • Diabetes mellitus in adults.
  • Trauma or thermal injury to the throat.
• In adults, epiglottitis may be under-recognized and can present atypically.

Clinical Presentation

• Common in children aged 2–6 years but can occur at any age.
• Rapid onset of symptoms over hours.
• Key features:
  • Severe sore throat and painful dysphagia (difficulty swallowing).
  • Dysphonia (muffled or hoarse voice) or aphonia (loss of voice).
  • Stridor—typically soft and inspiratory due to upper airway obstruction.
  • Drooling of saliva due to inability to swallow.
  • High fever (often >38.5°C) and toxic appearance.
  • Anxiety and agitation.
  • Adoption of the "tripod" position: sitting upright, leaning forward with the neck extended and chin thrust forward to maximize airway diameter.
  • In children, refusal to lie down.
• In adults, symptoms may be less pronounced but can rapidly progress to airway obstruction.

Investigations (Avoid until airway is secured)

• Laboratory Tests:
  • Increased white cell count (WCC) indicating infection.
  • Elevated C-reactive protein (CRP).
  • Blood cultures to identify causative organism once airway is secure.
• Imaging:
  • Avoid delaying airway management for imaging.
  • Lateral neck radiograph may show the "thumbprint sign"—an enlarged epiglottis.
  • Neck ultrasound or MRI can be considered once the patient is stable.
• Direct Visualization:
  • Flexible fiber-optic laryngoscopy performed by an experienced specialist in a controlled environment.
  • Throat examination with a tongue depressor is contraindicated prior to airway stabilization.

Comparison of Croup, Epiglottitis, and Bacterial Tracheitis

Management

• Immediate Actions:
  • Administer high-flow humidified oxygen at 15 L/min.
  • Do not attempt to examine the throat or upset the child.
  • Keep the child calm; allow them to remain in a comfortable position (usually sitting up).
  • Call for urgent assistance from senior anesthetists, pediatricians, and ENT surgeons.
• Airway Management:
  • Prepare for possible airway obstruction.
  • Endotracheal intubation is often required and should be performed in a controlled setting like the operating theatre.
  • If intubation fails, surgical airway access (e.g., tracheostomy or cricothyrotomy) may be necessary.
• Medical Treatment:
  • Once the airway is secured, start intravenous antibiotics:
    • Third-generation cephalosporins (e.g., ceftriaxone) are commonly used.
    • Consider adding antistaphylococcal agents if Staphylococcus aureus is suspected.
  • Systemic corticosteroids may be administered to reduce inflammation, though evidence is limited.
  • Monitor vital signs and oxygen saturation continuously.
  • Hydration: Provide intravenous fluids if the child is unable to swallow.
• Supportive Care:
  • Admit to intensive care for close monitoring.
  • Provide antipyretics for fever and analgesia for pain.
• Prevention:
  • Ensure immunization with the Hib vaccine as per national immunization schedules.
  • Educate caregivers about the importance of vaccination.

Key Points

• Epiglottitis is a medical emergency requiring prompt recognition and airway management.
• Avoid any procedures that may distress the patient and worsen airway obstruction.
• Involve multidisciplinary teams early, including anesthesiology, pediatrics, and otolaryngology.
• Prevention through vaccination is highly effective and essential.