Epiglottitis

Epiglottitis is associated with fever, throat pain, difficulty in swallowing, drooling, hoarseness of voice, and stridor.[10] Onset is typically over a day.[10] The throat itself may appear normal.[10]

Stridor is a sign of upper airways obstruction and is a surgical emergency. The child often appears acutely ill, anxious, and will have very quiet shallow breathing often keeping the head held forward and insisting on sitting up in bed. The early symptoms are usually insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.[11]

Epiglottitis is primarily caused by an acquired bacterial infection of the epiglottis.[1] Historically it was most often caused by Haemophilus influenzae type B, but with the availability of immunization this is no longer the case.[1] Presently the bacteria most often causing infection are Streptococcus pneumoniae, Streptococcus pyogenes, or Staphylococcus aureus.[1] While the overall incidence of epiglottitis has decreased, the incidence of cases caused by Streptococcus pneumoniae has increased in adults.[12] The exact strains of Streptococcus pneumoniae are often those that are covered by the PPV-23 vaccine,[12] but there is no evidence that this vaccine prevents epiglottitis.

There have been many cases of epiglottitis reported in immunocompromised patients, including those undergoing cancer treatment and those who are HIV positive.[13] While a variety of different bacteria can cause disease in these patients, cases often involve the Candida species of fungus, though it is unknown if the fungus causes significant disease on its own.[13]

Alternate risk factors and causes associated with infection include burns and other trauma to the area.[1] Medical research has also identified a link between epiglottitis and crack cocaine usage.[14] Underlying health conditions, such as Graft-versus-host disease and Lymphoproliferative disorders, have also been identified as contributors of increased risk for developing the infection .[4] This is in part caused by the host's decreased immune response coupled with the common sites targeting the soft tissue of the lymphatic system, both of which are already negatively impacted by the pre-existing illnesses.[15]

Diagnosis may be confirmed by direct inspection using a laryngoscope, although this may provoke airway spasm. If epiglottitis is suspected, attempts to visualize the epiglottis using a tongue depressor are discouraged for this reason; therefore, diagnosis is made on basis of indirect fiberoptic laryngoscopy carried out in a controlled environment like an operating room. Imaging is rarely useful, and treatment should not be delayed for this test to be carried out.[16]

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  CT imaging showing the "halloween sign"
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  Left column: Normal epiglottis. Right column: Epiglottitis.
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  Swollen epiglottis in laryngoscopy

An effective vaccine, the Hib vaccine, has been available since the 1980s.[4] The antibiotic rifampicin may also be used to prevent the disease among those who have been exposed to the disease and are at high risk.[5]

The most important part of treatment involves securing the airway.[1] Nebulized epinephrine may be useful to improve the situation temporarily.[10] Corticosteroids are also typically used.[1] Evidence for benefit, however, is poor.[10] Epiglottitis may require urgent tracheal intubation to protect the airway.[1] Tracheal intubation can be difficult due to distorted anatomy and profuse secretions. Spontaneous respiration is ideally maintained until tracheal intubation is successful.[10] A surgical airway opening (cricothyrotomy) may be required if intubation is not possible.[10]

Intravenous antibiotics such as ceftriaxone and possibly vancomycin or clindamycin are given once the airway is secure.[2][4] If the patient has a penicillin allergy, trimethoprim/sulfamethoxazole or clindamycin may be an alternative.

Necrotizing epiglottis is treated similarly to uncomplicated epiglottitis, but usually requires intubation in addition to standard IV antibiotic therapy.[18] If necrotizing fasciitis of the neck is suspected based on clinical exam or CT scan, patients are taken to the operating room for emergency debridement.[18]

With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent.[3] Some people may develop pneumonia, lymphadenopathy, or septic arthritis.[21]

While, historically, young children were mostly affected, it is now more common among older children and adults.[4] Before Hemophilus influenzae (Hib) immunization children of two to four were most commonly affected.[1] With immunization about 1.3 per 100,000 children are affected a year.[1] A 2010 retrospective study revealed the average age of patients admitted to American hospitals for epiglottitis was about 45, but patients under the age of one and over the age of 85 are also particularly vulnerable.[22]

Bill Bixby's 6-year-old son Christopher died of the condition in 1981.[23]

Jeannie Mai spent some time in an ICU with epiglottitis.[24]

Sarah Silverman spent a week in the ICU at Cedars Sinai Hospital with epiglottitis.[25][26][27]

George Washington is thought to have died of epiglottitis.[28] The treatments given to Washington, such as severe bloodletting, an enema, vinegar, sage, molasses, butter, blistering his throat with Spanish fly, requiring him to swallow mercurous chloride and antimony potassium tartrate, and applying wheat poultices to various parts of the body, are no longer used.[29]

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