Overview
Definition:
Epiglottitis, also known as supraglottitis, is a life-threatening inflammation of the epiglottis and surrounding structures of the oropharynx
While historically dominated by Haemophilus influenzae type b (Hib), the widespread implementation of the Hib vaccine has dramatically reduced its incidence, leading to an increased recognition of epiglottitis caused by atypical pathogens.
Epidemiology:
Before the Hib conjugate vaccine, epiglottitis was predominantly a disease of children aged 2-7 years, with a peak incidence around 3 years of age
In the post-vaccine era, the incidence has significantly declined, but cases still occur, particularly in unvaccinated or under-vaccinated populations
The age distribution has shifted, with a higher proportion of cases now seen in older children and adults
Atypical pathogens are now responsible for a greater percentage of cases.
Clinical Significance:
Despite reduced incidence, epiglottitis remains a medical emergency due to the potential for rapid airway obstruction and death
Prompt recognition and management are crucial
The shift towards atypical pathogens necessitates a broader differential diagnosis and consideration of different epidemiological factors and treatment approaches, posing a challenge for clinicians and impacting DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of sore throat
Dysphagia (difficulty swallowing)
Drooling
Muffled or "hot potato" voice
Respiratory distress including stridor, retractions, and tachypnea
High fever
Restlessness or irritability
Tripod positioning to facilitate breathing.
Signs:
Appearance of toxicity
Pallor or cyanosis
Stridor (inspiratory and expiratory)
Rapid, shallow breathing
Drooling from the mouth
Visible or palpable swollen epiglottis on indirect laryngoscopy or fiberoptic examination (caution is paramount)
Retractions of the chest wall
Tachycardia.
Diagnostic Criteria:
There are no strict diagnostic criteria for epiglottitis
diagnosis is primarily clinical, supported by imaging and direct visualization
However, suspicion should be high in any child with sudden onset of sore throat, dysphagia, drooling, and respiratory distress
Definitive diagnosis is often made by direct visualization of an enlarged, erythematous epiglottis
Rapid clinical deterioration is a hallmark.
Diagnostic Approach
History Taking:
Key history points include the rapidity of symptom onset, severity of sore throat disproportionate to pharyngeal findings, difficulty swallowing saliva, and the presence of drooling
Ask about vaccination status for Hib and other relevant vaccines
Inquire about recent upper respiratory tract infections or contact with sick individuals.
Physical Examination:
A systematic examination should focus on the airway and respiratory status
Avoid unnecessary manipulation of the pharynx, as it can precipitate complete airway obstruction
Assess for stridor, retractions, cyanosis, and the ability to handle secretions
Observe the child's position and level of distress
Direct visualization of the pharynx should be done by experienced personnel with airway management equipment immediately available.
Investigations:
Lateral neck X-ray may show a thickened epiglottis (the "thumb sign"), but a normal X-ray does not rule out epiglottitis
Direct laryngoscopy or fiberoptic examination is the gold standard but carries risks
Blood tests: Complete blood count (CBC) may show leukocytosis
Blood cultures are essential for identifying the pathogen and guiding antibiotic therapy
Throat swab for culture and sensitivity can identify the causative organism.
Differential Diagnosis:
Differential diagnoses include viral croup, retropharyngeal abscess, peritonsillar abscess, bacterial tracheitis, foreign body aspiration, and severe allergic reactions
Key differentiating features include the sudden onset, severe sore throat, drooling, and the characteristic epiglottic swelling seen in epiglottitis, distinguishing it from croup which typically has a barking cough and hoarseness without significant drooling or severe sore throat.
Management
Initial Management:
Immediate airway management is paramount
The child should be transported to a facility equipped for advanced airway management
Do not examine the throat with a tongue depressor if epiglottitis is suspected
Secure the airway early, often requiring intubation
Intubation should be performed by an experienced anesthesiologist or otolaryngologist
Have racemic epinephrine and racemic steroids available
Provide supplemental oxygen.
Medical Management:
Parenteral antibiotics are crucial to treat the bacterial infection and prevent complications
Empiric antibiotic therapy should cover common pathogens, including resistant strains
A third-generation cephalosporin like ceftriaxone (80-100 mg/kg/day IV divided every 12-24 hours) is often used
Coverage for Staphylococcus aureus (e.g., vancomycin if MRSA is suspected or prevalent) is also important
Once the pathogen is identified, therapy can be tailored
Duration of therapy is typically 7-10 days
After clinical improvement and extubation, oral antibiotics can be used.
Surgical Management:
Surgical intervention, primarily tracheostomy or cricothyrotomy, is rarely required if airway management is prompt and successful
It is reserved for cases where intubation is difficult or impossible, or if there is complete airway obstruction that cannot be resolved by other means
Early airway securing usually avoids the need for emergent surgical airway.
Supportive Care:
Intensive care unit (ICU) monitoring is essential for patients with epiglottitis
Maintain adequate hydration, often with intravenous fluids
Pain management should be addressed
Humidified oxygen can be helpful
Monitor vital signs, oxygen saturation, and airway status closely
Weaning from mechanical ventilation should be done cautiously once airway edema has subsided.
Complications
Early Complications:
Complete airway obstruction leading to respiratory arrest
Sepsis and septic shock
Pneumonia
Mediastinal abscess
Meningitis (less common in the post-vaccine era).
Late Complications:
Scarring of the airway leading to chronic stridor or airway compromise
Speech or swallowing difficulties
Prolonged hospitalization
Psychological distress.
Prevention Strategies:
The most effective prevention strategy is routine immunization with the Haemophilus influenzae type b (Hib) conjugate vaccine
Maintaining high vaccination rates within the community is crucial
Prompt recognition and management of upper respiratory symptoms that could herald epiglottitis are also important.
Prognosis
Factors Affecting Prognosis:
The prognosis is generally good if the airway is secured promptly and appropriate medical management is initiated
Factors influencing prognosis include the speed of diagnosis and intervention, the severity of airway obstruction, the presence of complications such as sepsis, and the overall health status of the patient.
Outcomes:
With timely and aggressive management, most children recover completely
Long-term sequelae are uncommon but can include airway issues or psychological effects from the traumatic experience
Early recognition and intervention are key to preventing mortality and severe morbidity.
Follow Up:
Follow-up care should focus on ensuring complete recovery and addressing any residual symptoms
This may include evaluation by otolaryngology for airway integrity, speech therapy if swallowing or voice abnormalities persist, and psychological support
Ensure appropriate catch-up vaccination for any missed immunizations.
Key Points
Exam Focus:
Remember that while Hib is less common due to vaccination, other pathogens like Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus (including MRSA) are now more frequently implicated
The classic "thumb sign" on lateral neck X-ray is suggestive but not definitive, and its absence does not exclude the diagnosis
Airway management is the priority.
Clinical Pearls:
In the vaccination era, think "atypical" when epiglottitis is suspected, especially in older children or adults
The hallmark is rapid deterioration
Never underestimate the potential for airway compromise
Have airway equipment and experienced personnel ready at all times.
Common Mistakes:
Delaying airway intervention due to over-reliance on normal X-ray findings or attempting a thorough pharyngeal examination that precipitates airway collapse
Inadequate empiric antibiotic coverage
Failure to consider epiglottitis in the differential diagnosis of severe sore throat and stridor.