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Infectious Disease And Microbiology – Epiglottitis
Epiglottitis is a rapidly progressive and potentially life-threatening infection of the epiglottis and surrounding supraglottic structures. It is considered a medical emergency because it can lead to sudden airway obstruction and respiratory failure if not promptly recognized and treated.
The incidence of epiglottitis has declined significantly in countries with widespread vaccination against Haemophilus influenzae type b (Hib). However, it still occurs, particularly in adults, with an incidence of approximately 0.9–3.1 cases per 100,000 individuals. The average age of affected adults is around 45 years. Risk factors include young age (especially under 4 years), lack of vaccination, immunodeficiency, post-splenectomy status, and nonimmune adults. In the post-vaccination era, the average age of affected children has increased.
Prevention primarily involves immunization against H. influenzae type b. In cases where a patient has confirmed Hib epiglottitis and there are unvaccinated children under 4 years in the household, rifampin prophylaxis is recommended for all household members and the patient to eliminate bacterial carriage.
The most common causative organism in children remains H. influenzae type b, accounting for over 90% of pediatric cases. In adults, a wider range of pathogens may be involved, including Streptococcus pneumoniae, group A streptococci, Staphylococcus aureus, and Haemophilus parainfluenzae. In immunocompromised patients, fungal organisms such as Candida and Aspergillus may be implicated. Viral infections, including varicella-zoster virus, herpes simplex virus, HIV, and infectious mononucleosis, may also be associated with epiglottitis.
Clinically, the onset is usually acute. Children typically present within 24 hours with fever, difficulty speaking (dysphonia), difficulty swallowing (dysphagia), irritability, and drooling. Adults may have a less dramatic presentation, often with severe sore throat disproportionate to physical findings and sometimes without fever.
On physical examination, patients may exhibit respiratory distress, inspiratory stridor, and a characteristic muffled “hot potato” voice. Children often adopt a tripod position—sitting upright, leaning forward, and extending the neck—to maximize airway patency. Drooling is common due to difficulty swallowing. Severe cases may present with cyanosis, shock, or altered consciousness. Direct examination of the throat with a tongue depressor in children should be avoided, as it may trigger laryngospasm and complete airway obstruction.
Diagnosis should prioritize airway safety. Laboratory findings may show leukocytosis, and blood or epiglottic cultures may identify the causative organism. Imaging, such as a lateral neck X-ray, may reveal the classic “thumb sign” indicating a swollen epiglottis, but should only be performed when airway management is immediately available. Definitive diagnosis is made by visualization of a swollen, erythematous (“cherry-red”) epiglottis using fiberoptic laryngoscopy in a controlled setting.
The differential diagnosis includes croup, diphtheria, allergic laryngeal edema, foreign-body aspiration, peritonsillar abscess, and retropharyngeal abscess. Croup typically has a more gradual onset and lacks significant drooling, while diphtheria presents with a characteristic pseudomembrane.
Management of epiglottitis is an emergency focused on securing the airway. In children, early intubation is strongly recommended, as observation alone carries a high risk of mortality. If intubation is not possible, an emergency tracheostomy or cricothyrotomy may be required. Adults may sometimes be managed more conservatively, but any signs of respiratory compromise necessitate airway intervention.
Intravenous antibiotic therapy should be initiated promptly, targeting likely pathogens, particularly H. influenzae. Recommended regimens include ceftriaxone, cefotaxime, or ampicillin-sulbactam for approximately 10 days. The use of chloramphenicol is now rare due to toxicity. There is insufficient evidence to support routine use of corticosteroids or epinephrine.
All patients require hospital admission, often to an intensive care unit, for close monitoring. Airway stability is the primary concern during initial management, and intravenous fluids are frequently required. In children, intravenous access should not be attempted before securing the airway to avoid provoking distress.
Patients typically show rapid clinical improvement within 12–48 hours after starting appropriate therapy. Extubation can be considered once the patient is afebrile, clinically stable, and has evidence of reduced airway edema on examination. Adults managed without intubation require close ICU monitoring.
The prognosis largely depends on early airway management. Mortality is low when treated promptly but increases significantly if airway obstruction occurs. Rarely, recurrence may occur.
Complications include complete airway obstruction leading to hypoxia and potential brain injury, bacteremia with metastatic infections such as meningitis or arthritis, and complications related to airway management such as aspiration, pneumothorax, or tracheal injury.
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