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Infectious Disease - Epiglottitis
DESCRIPTION
Accelerated infection of the epiglottis and surrounding supraglottic tissues.
Epidemiology
Occurrence
The incidence has significantly declined in nations with extensive vaccination against Haemophilus influenzae type b (1)[A].
• Incidence ranges from 0.9 to 3.1 per 100,000 individuals in the general population. • The average age of a patient with epiglottitis is 44.9 years.
FACTORS OF RISK
• Age below 4 years
The mean age of pediatric patients in the immunization era has roughly doubled to 11.6 years. • Children who are unvaccinated
• Immunodeficiency • Post-splenectomy • Non-immune adults!
GENERAL PREVENTION • Vaccination for H. influenzae type b (1)[A].
In cases of H. influenzae epiglottitis, if the patient has household contacts that include an unvaccinated child under the age of 4, it is advisable to administer rifampin prophylaxis at a dosage of 20 mg/kg/d (maximum 600 mg/d) orally once daily for 4 days to all household members and the patient to eliminate H. influenzae carriage. ETIOLOGY • Haemophilus influenzae type b accounts for the predominant majority of pediatric cases (exceeding 90%) and is commonly isolated from the bloodstream. In adult patients, blood cultures yield positive results in around 25% of instances.
• Additional pathogens identified in the pharynx of adults with epiglottitis comprise the following:
– Haemophilus parainfluenzae – Streptococcus pneumoniae – Group A Streptococcus – Staphylococcus aureus
In immunosuppressed patients, additional infections, including Candida spp. and Aspergillus spp., may be responsible.
Viral infections, including varicella zoster, infectious mononucleosis, HIV, and herpes simplex, may lead to complications such as epiglottitis.
DIAGNOSTIC HISTORY
• The onset of symptoms is typically acute.
• Young children typically exhibit symptoms such as fever, dysphonia, dysphagia, and irritability within 24 hours after beginning.
• Fever may be absent in adults.
PHYSICAL EXAMINATION
• Respiratory distress, inspiratory stridor, and a muffled voice resembling that of having hot food in the mouth may manifest.
• As many as one-third of pediatric patients present in shock, exhibiting cyanosis and loss of consciousness upon admission.
The patient prefers to sit in a forward-leaning position with the upper limbs extended.
• Oral secretions often result in drooling.
The direct inspection of a child's pharynx with a tongue blade should be avoided due to the risk of laryngospasm and total airway obstruction.
• Adolescents and adults may exhibit a less severe manifestation.
The most notable symptom is a sore throat, absent any indications of pharyngitis.
Neck discomfort and sensitivity over the hyoid bone in adult patients may indicate the diagnosis. DIAGNOSTIC TESTS AND INTERPRETATION Laboratory
• It is imperative that upon suspicion of epiglottitis in a juvenile child, diagnostic testing is conducted only after ensuring airway security.
• Moderate leukocytosis accompanied by a left shift. • Positive cultures of blood and epiglottis.
Imaging
A lateral neck radiograph may reveal an inflated epiglottis (the thumb sign), hypopharyngeal ballooning, and intact subglottic structures.
Radiography should only be conducted in the presence of physicians capable of managing acute airway blockage.
Ultrasound has been infrequently employed in emergency departments to visualize the enlarged epiglottis in adult patients.
A chest X-ray may reveal pneumonia or atelectasis in as many as 50% of instances.
Diagnostic Procedures and Additional Methods
• The patient must be sent to an operating room for epiglottic visualization with a fiberoptic laryngoscope following all preparations for prompt airway management. • The diagnosis is confirmed by observing an edematous, "cherry-red" epiglottis.
Histopathological Observations
Epiglottic edema and leukocytic infiltration. An abscess may be present.
DIFFERENTIAL DIAGNOSIS
• Croup syndrome – Typically has a more gradual onset.
– Is often preceded by an upper respiratory tract infection. – Primarily affects younger children (ages 3 months to 3 years). - Exhibits a viral etiology.
– Children with croup do not exhibit significant drooling or dysphagia and are more inclined to assume a supine position.
• Diphtheria – A pseudomembrane is observable in the pharynx. The smear and culture of the membrane reveal characteristic gram-positive bacilli.
• Allergic laryngeal edema – Patients typically present with minimal toxicity and absence of fever.
• Aspiration of foreign bodies • Lingual tonsillitis • Peritonsillar abscess, retropharyngeal abscess
INITIAL THERAPY MEDICATION
Acute epiglottitis is a medical emergency due to the potential for rapid airway blockage.
• It is inadvisable to observe children with epiglottitis without intubation, as mortality rates may surpass 25% with a careful waiting strategy.
An uncuffed endotracheal or nasotracheal tube should be implanted, and the kid must be monitored in an intensive care unit.
Tracheostomy, or needle cricothyrotomy as a temporary solution, should be executed if an unobstructed airway cannot be preserved by other means. In adult patients, a less aggressive treatment strategy is occasionally used, involving intubation in select cases only. Adhering to this strategy necessitates acknowledging that respiratory distress, stridor, a muffled voice, or laryngoscopic findings indicating less than 50% visibility of the vocal cords are factors linked to the requirement for airway management.
• Intravenous antibiotic treatment targeting H. influenzae should be administered.
Cefotaxime 100–200 mg/kg/day in four split doses (maximum adult daily dosage: 12 g)
Ceftriaxone 50–100 mg/kg/day administered in one or two split doses (maximum adult daily dosage: 2 g)
Ampicillin/sulbactam 200–300 mg/kg/day (of ampicillin) in 4 split doses (maximum adult daily dose: 12 g)
The therapeutic duration is 10 days.
Second Line
The usage of chloramphenicol (50–100 mg/kg/d in 4 split doses) alongside ampicillin has significantly declined due to the risk of toxicity.
SUPPLEMENTARY THERAPY
Supplementary Treatments
No controlled data exist to substantiate the use of corticosteroids or epinephrine in the management of acute epiglottitis.
OPERATIVE INTERVENTIONS/ADDITIONAL PROCEDURES
Tracheostomy, when intubation is unfeasible.
INPATIENT CONSIDERATIONS
Preliminary Stabilization
Maintaining airway patency is the foremost objective.
Criteria for Admission
All individuals diagnosed with epiglottitis should be hospitalized.
Intravenous Fluids
Often required. Do not attempt to establish intravenous access in a child prior to securing the airway.
Nursing
Avoid inducing anxiety in the child.
CONTINUOUS CARE POST-TREATMENT RECOMMENDATIONS
• Patients with epiglottitis typically exhibit quick improvement, specifically within 12–48 hours following the initiation of suitable antibiotic therapy. • Patients may be extubated once they are afebrile, alert, clinically improved, and demonstrate laryngoscopic evidence of edema reduction.
Patient Surveillance
In the adult patient who opts against intubation, ICU surveillance is essential.
PROGNOSIS • Relies on the timely securing of the airway. Hypoxia caused by airway obstruction is the primary factor influencing prognosis.
• The mortality rate in the US is recorded at 0.89%. • Recurrence is exceedingly rare but may occur.
COMPLICATIONS
• Total airway blockage leading to hypoxia/anoxia in multiple organs (anoxemic encephalopathy is the most serious consequence).
H. influenzae bacteremia is infrequently linked to metastatic illnesses, including meningitis and arthritis.
Iatrogenic consequences, primarily linked to intubation.
– Aspiration – Dislodgment of endotracheal tube – Tracheal erosion –
Pneumomediastinum – Pneumothorax – Pulmonary edema
DESCRIPTION
Accelerated infection of the epiglottis and surrounding supraglottic tissues.
Epidemiology
Occurrence
The incidence has significantly declined in nations with extensive vaccination against Haemophilus influenzae type b (1)[A].
• Incidence ranges from 0.9 to 3.1 per 100,000 individuals in the general population. • The average age of a patient with epiglottitis is 44.9 years.
FACTORS OF RISK
• Age below 4 years
The mean age of pediatric patients in the immunization era has roughly doubled to 11.6 years. • Children who are unvaccinated
• Immunodeficiency • Post-splenectomy • Non-immune adults!
GENERAL PREVENTION • Vaccination for H. influenzae type b (1)[A].
In cases of H. influenzae epiglottitis, if the patient has household contacts that include an unvaccinated child under the age of 4, it is advisable to administer rifampin prophylaxis at a dosage of 20 mg/kg/d (maximum 600 mg/d) orally once daily for 4 days to all household members and the patient to eliminate H. influenzae carriage. ETIOLOGY • Haemophilus influenzae type b accounts for the predominant majority of pediatric cases (exceeding 90%) and is commonly isolated from the bloodstream. In adult patients, blood cultures yield positive results in around 25% of instances.
• Additional pathogens identified in the pharynx of adults with epiglottitis comprise the following:
– Haemophilus parainfluenzae – Streptococcus pneumoniae – Group A Streptococcus – Staphylococcus aureus
In immunosuppressed patients, additional infections, including Candida spp. and Aspergillus spp., may be responsible.
Viral infections, including varicella zoster, infectious mononucleosis, HIV, and herpes simplex, may lead to complications such as epiglottitis.
DIAGNOSTIC HISTORY
• The onset of symptoms is typically acute.
• Young children typically exhibit symptoms such as fever, dysphonia, dysphagia, and irritability within 24 hours after beginning.
• Fever may be absent in adults.
PHYSICAL EXAMINATION
• Respiratory distress, inspiratory stridor, and a muffled voice resembling that of having hot food in the mouth may manifest.
• As many as one-third of pediatric patients present in shock, exhibiting cyanosis and loss of consciousness upon admission.
The patient prefers to sit in a forward-leaning position with the upper limbs extended.
• Oral secretions often result in drooling.
The direct inspection of a child's pharynx with a tongue blade should be avoided due to the risk of laryngospasm and total airway obstruction.
• Adolescents and adults may exhibit a less severe manifestation.
The most notable symptom is a sore throat, absent any indications of pharyngitis.
Neck discomfort and sensitivity over the hyoid bone in adult patients may indicate the diagnosis. DIAGNOSTIC TESTS AND INTERPRETATION Laboratory
• It is imperative that upon suspicion of epiglottitis in a juvenile child, diagnostic testing is conducted only after ensuring airway security.
• Moderate leukocytosis accompanied by a left shift. • Positive cultures of blood and epiglottis.
Imaging
A lateral neck radiograph may reveal an inflated epiglottis (the thumb sign), hypopharyngeal ballooning, and intact subglottic structures.
Radiography should only be conducted in the presence of physicians capable of managing acute airway blockage.
Ultrasound has been infrequently employed in emergency departments to visualize the enlarged epiglottis in adult patients.
A chest X-ray may reveal pneumonia or atelectasis in as many as 50% of instances.
Diagnostic Procedures and Additional Methods
• The patient must be sent to an operating room for epiglottic visualization with a fiberoptic laryngoscope following all preparations for prompt airway management. • The diagnosis is confirmed by observing an edematous, "cherry-red" epiglottis.
Histopathological Observations
Epiglottic edema and leukocytic infiltration. An abscess may be present.
DIFFERENTIAL DIAGNOSIS
• Croup syndrome – Typically has a more gradual onset.
– Is often preceded by an upper respiratory tract infection. – Primarily affects younger children (ages 3 months to 3 years). - Exhibits a viral etiology.
– Children with croup do not exhibit significant drooling or dysphagia and are more inclined to assume a supine position.
• Diphtheria – A pseudomembrane is observable in the pharynx. The smear and culture of the membrane reveal characteristic gram-positive bacilli.
• Allergic laryngeal edema – Patients typically present with minimal toxicity and absence of fever.
• Aspiration of foreign bodies • Lingual tonsillitis • Peritonsillar abscess, retropharyngeal abscess
INITIAL THERAPY MEDICATION
Acute epiglottitis is a medical emergency due to the potential for rapid airway blockage.
• It is inadvisable to observe children with epiglottitis without intubation, as mortality rates may surpass 25% with a careful waiting strategy.
An uncuffed endotracheal or nasotracheal tube should be implanted, and the kid must be monitored in an intensive care unit.
Tracheostomy, or needle cricothyrotomy as a temporary solution, should be executed if an unobstructed airway cannot be preserved by other means. In adult patients, a less aggressive treatment strategy is occasionally used, involving intubation in select cases only. Adhering to this strategy necessitates acknowledging that respiratory distress, stridor, a muffled voice, or laryngoscopic findings indicating less than 50% visibility of the vocal cords are factors linked to the requirement for airway management.
• Intravenous antibiotic treatment targeting H. influenzae should be administered.
Cefotaxime 100–200 mg/kg/day in four split doses (maximum adult daily dosage: 12 g)
Ceftriaxone 50–100 mg/kg/day administered in one or two split doses (maximum adult daily dosage: 2 g)
Ampicillin/sulbactam 200–300 mg/kg/day (of ampicillin) in 4 split doses (maximum adult daily dose: 12 g)
The therapeutic duration is 10 days.
Second Line
The usage of chloramphenicol (50–100 mg/kg/d in 4 split doses) alongside ampicillin has significantly declined due to the risk of toxicity.
SUPPLEMENTARY THERAPY
Supplementary Treatments
No controlled data exist to substantiate the use of corticosteroids or epinephrine in the management of acute epiglottitis.
OPERATIVE INTERVENTIONS/ADDITIONAL PROCEDURES
Tracheostomy, when intubation is unfeasible.
INPATIENT CONSIDERATIONS
Preliminary Stabilization
Maintaining airway patency is the foremost objective.
Criteria for Admission
All individuals diagnosed with epiglottitis should be hospitalized.
Intravenous Fluids
Often required. Do not attempt to establish intravenous access in a child prior to securing the airway.
Nursing
Avoid inducing anxiety in the child.
CONTINUOUS CARE POST-TREATMENT RECOMMENDATIONS
• Patients with epiglottitis typically exhibit quick improvement, specifically within 12–48 hours following the initiation of suitable antibiotic therapy. • Patients may be extubated once they are afebrile, alert, clinically improved, and demonstrate laryngoscopic evidence of edema reduction.
Patient Surveillance
In the adult patient who opts against intubation, ICU surveillance is essential.
PROGNOSIS • Relies on the timely securing of the airway. Hypoxia caused by airway obstruction is the primary factor influencing prognosis.
• The mortality rate in the US is recorded at 0.89%. • Recurrence is exceedingly rare but may occur.
COMPLICATIONS
• Total airway blockage leading to hypoxia/anoxia in multiple organs (anoxemic encephalopathy is the most serious consequence).
H. influenzae bacteremia is infrequently linked to metastatic illnesses, including meningitis and arthritis.
Iatrogenic consequences, primarily linked to intubation.
– Aspiration – Dislodgment of endotracheal tube – Tracheal erosion –
Pneumomediastinum – Pneumothorax – Pulmonary edema
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