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26 Epiglottitis
Primary Differential Considerations
• Early consideration in patients with symptoms referable to epiglottitis should
also be given to the following differential diagnoses:
• Peritonsillar or retropharyngeal abscess
• Angioedema
• Laryngitis
• Tonsillitis
• Laryngeal diphtheria
History andPhysical Exam
Findings That Conrm Diagnosis
• In the purest sense, the diagnosis is conrmed by direct visualization of the
epiglottis in the operating room.
395
Direct laryngoscopy ndings in a 10-year-old presenting with epiglottitis [Hughes
AL, Karter N, Swanson DS.Laryngeal Infections. In: Valdez T, Vallejo J, editors.
Infectious Diseases in Pediatric Otolaryngology [Internet]. Cham: Springer
International Publishing; 2016 [cited 2016 Aug 3]. p. 151–61. Available from:
http://link.springer.com/10.1007/978-3-319-21744-4_11] Caption from original
• Indirect diagnosis may be obtained by visualization of a swollen epiglottis on
lateral neck radiographs (“thumb print sign”).
396
R. M. Cantor et al.
(a, b) Acute epiglottitis. Note the swollen epiglottis with a thumb-like appearance.
Radiography is unnecessary in acute epiglottitis and must not be undertaken lightly
but occasionally may be performed to exclude a foreign body. It is best performed
with the patient in a sitting position to keep the airway open. Epiglottitis can be lifethreatening and resources to secure the airway must be available at all times. The
CT image shows an edematous epiglottis containing an abscess (arrow). CT is
unnecessary for acute epiglottitis. (c) Croup– “steeple” like narrowing of the subglottic airway (arrowheads) [Raghavan P, Shonka DC, Wintermark M, Mukherjee
S.Larynx and Hypopharynx. In: Raghavan P, Mukherjee S, Jameson MJ, Wintermark
M. Manual of Head and Neck Imaging [Internet]. Berlin, Heidelberg: Springer
Berlin Heidelberg; 2014 [cited 2016 Aug 2]. p.109–36. Available from: http://link.
springer.com/10.1007/978-3-642-40377-4_5] Caption from original
26 Epiglottitis
Factors That Suggest Diagnosis
• Many studies have highlighted the following ndings:
• Difculty breathing (80 %)
• Stridor (80 %)
• Mufed or hoarse voice (79 %)
• Pharyngitis (73 %)
• Fever (57 %)
• Sore throat (50 %)
• Difculty swallowing (26 %)
• Change in voice (20 %)
397
Presenting symptoms and signs in 288 acute supraglottitis adult patients [Ovnat
Tamir S, Marom T, Barbalat I, Spevak S, Goldfarb A, Roth Y.Adult supraglottitis:
changing trends. European Archives of Oto-Rhino-Laryngology. 2015
Apr;272(4):929–35.] Caption from original
Factors That Exclude Diagnosis
• A normal epiglottitis on direct view in the surgical suite is the only way to
exclude the diagnosis fully in patients suspected of having epiglottitis.
398
R. M. Cantor et al.
Ancillary Studies
Laboratory
• Note: It is advisable to wait until denitive equipment and personnel are at the
bedside (or in the OR) before negatively stimulating the child.
• Although the diagnosis is a clinical one, leukocytosis is common, as are posi-
tive blood cultures.
Imaging
• Radiographs should only be obtained at no risk to the child.
• No patient should leave the Emergency Department without adequate airway
personnel and equipment.
26 Epiglottitis
399
Epiglottitis as seen by xeroradiography. A, Anteroposterior view of the neck of a
child with documented epiglottitis shows narrowing in the diameter of the trachea,
which can be confused with acute viral croup. The lateral neck view is preferable
because it can demonstrate the enlarged epiglottis, or “thumb sign.” B,
Xeroradiograph showing a lateral neck view of the same child demonstrates the
acute epiglottic and aryepiglottic swelling seen in acute epiglottitis. Direct visualization in the operating room revealed a markedly swollen epiglottis. [Tristram
D.Chapter 07. In: Brook I, editor. Atlas of Upper Respiratory and Head and Neck
Infections, 2e. Philadelphia: Current Medicine; 2000. (Mandell GL, editor. Atlas of
infectious diseases; vol. 4). ISBN: 1-57340-140-4] Caption from original
400
Epiglottitis. Lateral radiograph of the neck demonstrates gross enlargement of the
epiglottis (arrowhead) as well as the aryepiglottic fold, resulting in narrowing of the
supraglottic laryngeal airway [Singh A.Imaging of Neck Emergencies. In: Singh A,
editor. Emergency Radiology [Internet]. NewYork, NY: Springer NewYork; 2013
[cited 2016 Aug 2]. p.183–98. Available from:
1-4419-9592-6_15] Caption from original
http://link.springer.com/10.1007/978-
R. M. Cantor et al.
Special Populations
Age
• Epiglottitis can present at all ages. Adult epiglottitis is generally less acute
and is certainly less life-threatening than the pediatric issue.
• Pediatric epiglottitis is much less common in areas where the Hib vaccine is
widely given; kids who are not immunized are at higher risk.
Co-morbidities
• Immune-compromised patients are at higher risk of developing epiglottitis.
This is particularly true in adult cases.
Most common co-morbidities among 288 acute supraglottitis adult patients [Ovnat
Tamir S, Marom T, Barbalat I, Spevak S, Goldfarb A, Roth Y.Adult supraglottitis:
changing trends. European Archives of Oto-Rhino-Laryngology. 2015
Apr;272(4):929–35.] Caption from original
26 Epiglottitis
Pitfalls inDiagnosis
• The two most signicant pitfalls in diagnosis are:
• failing to consider the diagnosis altogether
• being cavalier in the workup and sending a child suspected of epiglottitis
to radiology without denitive airway assistance.
• Failing to consider signicant differential diagnoses such as peritonsillar
abscess is a problem.
401
Peritonsillar abscess [Endicott J, Seper J.Chapter 10. In: Brook I, editor. Atlas of
Upper Respiratory and Head and Neck Infections, 2e. Philadelphia: Current
Medicine; 2000. (Mandell GL, editor. Atlas of infectious diseases; vol. 4). ISBN:
1-57340-140-4]
402
R. M. Cantor et al.
Peritonsillar abscess. Axial (a, b) and coronal (c) CECT images demonstrate a rimenhancing left-sided peritonsillar abscess (A) in this child with odynophagia and
fever. There is resultant narrowing of pharynx and “kissing” appearance of the
enlarged tonsils. There is inltration of left parapharyngeal fat (white arrows).
Medial pterygoid muscle (mpm, a), mandible (man, a, b, c), masseter muscle (mm,
a), oropharynx (orp, a, c), lateral pterygoid plate (lpp, b), nasopharynx (nap, b)
[Pawha P, Jiang N, Shpilberg K, Luttrull M, Govindaraj S.Gross and Radiographic
Anatomy. In: Levine AI, Govindaraj S, DeMaria, S, editors. Anesthesiology and
Otolaryngology [Internet]. NewYork, NY: Springer New York; 2013 [cited 2016
Aug 2]. p. 3–33. Available from: http://link.springer.com/10.1007/978-1-4614-
4184-7_2] Caption from original
26 Epiglottitis
Critical Steps Not toMiss
• If a diagnosis of epiglottitis is suspected, all efforts should be directed toward
obtaining the personnel and equipment necessary for intubation.
• Without question, intubation is best carried out in the OR by medical caregivers expert in Pediatric airway management (i.e., ENT or Anesthesia).
Mimics
• Most other causes of upper airway disease in children do not present in a manner similar to that of epiglottitis.
Time-Dependent Interventions
• Early conrmation of the diagnosis and expectant airway management by
expert operators is essential to good outcomes in acute epiglottitis.
403
Overall Principles ofTreatment
• The management of epiglottitis has 3 phases:
• Recognition
• Intubation
• Intravenous antibiotics
Disease Course
• The prognosis is excellent if surgical correction is carried out.
Related Evidence:
Papers of particular interest have been highlighted as:
** Of key importance
404
R. M. Cantor et al.
Cohort Study
Hermansen MN, Schmidt JH, Krug AH, Larsen K, Kristensen S.Low incidence of
children with acute epiglottis after introduction of vaccination. Dan Med J. 2014
Apr;61(4):A4788. PMID: 24814584. http://www.ncbi.nlm.nih.gov/pubmed/
24814584
Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances,
prognosis, and management. Laryngoscope. 2010 Jun;120(6):1256-62. https://
doi.org/10.1002/lary.20921. PMID: 20513048. http://www.ncbi.nlm.nih.gov/
pubmed/20513048 **
Acevedo JL, Lander L, Choi S, Shah RK.Airway management in pediatric epi-
glottitis: a national perspective. Otolaryngol Head Neck Surg. 2009
Apr;140(4):548- 51. https://doi.org/10.1016/j.otohns.2008.12.037. PMID:
19328345. http://www.ncbi.nlm.nih.gov/pubmed/19328345 **
Briem B, Thorvardsson O, Petersen H.Acute epiglottitis in Iceland 1983-2005. Auris
Nasus Larynx. 2009 Feb;36(1):46-52. https://doi.org/10.1016/j.anl.2008.03.012.
PMID: 18502071. http://www.ncbi.nlm.nih.gov/pubmed/18502071 **
Guldfred LA, Lyhne D, Becker BC.Acute epiglottitis: epidemiology, clinical pre-
sentation, management and outcome. J Laryngol Otol. 2008 Aug;122(8):818-23.
PMID: 17892608. http://www.ncbi.nlm.nih.gov/pubmed/17892608 **
Glynn F, Fenton JE.Diagnosis and management of supraglottitis (epiglottitis). Curr
Infect Dis Rep. 2008 May;10(3):200-4. PMID:18510881. http://www.ncbi.nlm.
nih.gov/pubmed/18510881 **
Shah RK, Roberson DW, Jones DT.Epiglottitis in the Hemophilus inuenzae type
B vaccine era: changing trends. Laryngoscope. 2004 Mar;114(3):557-60. PMID:
15091234. http://www.ncbi.nlm.nih.gov/pubmed/15091234 **
McEwan J, Giridharan W, Clarke RW, Shears P.Paediatric acute epiglottitis: not a
disappearing entity. Int J Pediatr Otorhinolaryngol. 2003 Apr;67(4):317-21.
PMID: 12663101. http://www.ncbi.nlm.nih.gov/pubmed/12663101 **
Mayo-Smith MF, Spinale JW, Donskey CJ, Yukawa M, Li RH, Schiffman FJ.Acute
epiglottitis. An 18-year experience in Rhode Island. Chest. 1995 Dec;108(6):
1640-7. PMID: 7497775. http://www.ncbi.nlm.nih.gov/pubmed/7497775 **
Comparative Study
Comparative Study. McVernon J, Slack MP, Ramsay ME.Changes in the epidemi-
ology of epiglottitis following introduction of Haemophilus inuenzae type b
(Hib) conjugate vaccines in England: a comparison of two data sources.
Epidemiol Infect. 2006 Jun;134(3):570-2. PMID: 16288684.
nlm.nih.gov/pubmed/16288684 **
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Epiglottitis”[Mesh] OR “Epiglottitis” OR “Supraglottitis”
http://www.ncbi.