May 15, 2019

REBEL Core Cast 11.0 – Epiglottitis

Take Home Points on Epiglottitis

  • Epiglottitis has demonstrated a resurgence in the adult population. It is no longer a pediatric only disease.
  • The classic presentation of epiglottitis (3Ds of drooling, dysphagia and distress) is uncommon
  • Epiglottitis should be high on your differential for the bounce-back patient who continues to complain of worsening sore throat
  • Definitive diagnosis is made by flexible fiberoptic laryngoscopy
  • Be ready for a difficult airway

REBEL Core Cast 11.0 – Epiglottitis

Definition: Acute infection and inflammation of the supraglottic soft tissue structures which can lead to airway occlusion. Develops over 2-7 days and is considered an ENT emergency.

Epidemiology:

  • Incidence of 3 – 5:100,000 per year. Mortality between 7-20%.
  • Mean age of those affected is 55. Child:adult ratio of 0.3:1 (due to vaccines)
  • Risk factors include smoking, diabetes, immunocompromised.
  • Broad range of causative organisms, but most commonly caused by various strep and staph species.
  • Traditionally taught as a children’s disorder caused by Haemophilus influenzae type B with the 3 D’s, drooling, dysphagia and distress. However due to life saving vaccines we went from a child:adult ratio of 2.6:1 to 0.3:1. (Shah 2010)

Diagnosis

Can be difficult to diagnose and some studies say that it is missed as often as 80% of the time. Initial presentation may mimic symptoms of your garden variety URI or strep throat. Think about this disease when patient presents to the ER for a second time for worsening sore throat, pain to palpation of neck, dysphagia and hoarseness.

  • Fiberoptic nasal layngoscopy
    • Gold standard diagnostic test
  • Lateral neck xray
    • 90% sensitivity
    • Classic finding of “thumbprint” sign due to epiglottis thickened with inflammation
  • CT scan
    • Equally as sensitive as lateral neck x-ray. May be useful if diagnosis unclear.

Airway Management

  • Refrain from using supraglottic devices as it could compress swollen epiglottis
  • Fiberoptic awake intubation may be ideal if you have necessary equipment and skill set
  • Consult ENT, surgery, anesthesia early to help with airway if needed

Adjunct Treatment

  • Ampicillin-sulbactam or Amoxicillin-clavulanate are the preferred initial antibiotic recommendations
  • Vancomycin for patients that are critically ill and suspicion for MRSA infection
  • NSAID/Corticosteroids for pain control and inflammation

Disposition

  • Consider admission for observation though not always necessary
  • If advanced inflammation or respiratory symptoms should go to ICU

Links:

Show Notes Written By: Miguel Reyes, MD (Twitter: @Miguel_ReyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 11.0 – Epiglottitis", REBEL EM blog, May 15, 2019. Available at: https://rebelem.com/rebel-core-cast-11-0-epiglottitis/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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