Causes of Epiglottitis

Etiology

• The cause of epiglottitis is most commonly infectious, with bacterial, viral, or fungal origins.
• In children, Haemophilus influenzae type B (HIB) is the most common cause, but this has decreased dramatically since the widespread availability of immunizations.
• Other agents such as Streptococcus pyogenes, S pneumoniae, and S aureus have been implicated.
• In immunocompromised patients, Pseudomonas aeruginosa and Candida have been named.

Pathophysiology

• The airway in the pediatric population is markedly different compared to that of an adult.
• The epiglottis is located more superiorly and anteriorly in children, with a more oblique angle with the trachea.
• The narrowest portion of the infant and pediatric airway is the subglottis, while in adults it is the glottis.
• The infant epiglottis is comprised of cartilage that is more pliant, allowing for a ball-valve effect, where each inspiration pulls an edematous epiglottis over the laryngeal airway, causing symptoms.

History and Physical

• The history will often reveal an antecedent URI, but not always.
• Symptoms may be mild for a period of hours to days, until they dramatically worsen, mimicking a sudden onset.
• The patient will appear very uncomfortable, and possibly overtly toxic.
• Most children have no prodromal symptoms.
• The 3 Ds - drooling, dysphagia, and distress, or anxiety - may be present.
• Swelling of the upper airway results in turbulent airflow during inspiration or stridor.

Evaluation

• An oropharyngeal exam is usually not performed to evaluate a suspected case of epiglottitis.
• A lateral neck radiograph will show swelling of the epiglottis, also referred to as the "thumb sign".
• A flexible fiberoptic laryngoscopy can be performed in a controlled setting, but only in the most stable and cooperative patients.
• Ultrasonography may reveal an "alphabet P sign" in a longitudinal view.

Treatment/Management

• The singular, most important aspect of treatment is to secure the airway.
• Experienced providers should intubate these patients, as their airways are regarded as difficult.
• The patient should be admitted to the intensive care unit after the airway is secured.
• Empiric antimicrobials should be initiated, and adjusted once culture and sensitivity results are available.
• Corticosteroids may be used to reduce edema.

Prognosis

• For most patients with epiglottitis, the prognosis is good when the diagnosis and treatment are prompt.
• When the diagnosis is delayed in children, airway compromise can occur, and death is possible.
• A mortality rate of 3% to 7% has been reported in patients with unstable airways.

Prevention and Deterrence

• Close contacts of patients with H.influenzae who are not immunized should be prescribed rifampin prophylaxis.
• Vaccination should be encouraged to prevent epiglottitis.
• Children should be immunized according to the schedule prescribed by the WHO.

Healthcare Team Outcomes

• Epiglottitis is a relatively common fear in the emergency department, but actually rather rare.
• The disorder should be managed by an interprofessional team that includes an intensivist, pulmonologist, infectious disease consult, anesthesiologist, and ENT surgeon.
• The triage nurse and emergency room physician should be familiar with the signs and symptoms of the disorder.
• Nurses should be educated about not placing the patient supine and the importance of monitoring oxygenation.