Adult Epiglottitis Update

Author: Vivian Lau, DO // Editor: Alex Koyfman, MD (@EMHighAK)

General Info/Intro

• Localized inflammation to epiglottis, base of tongue, lingual tonsils, vallecula, aryepiglottic fold, and arytenoids
• Incidence rate 1-1.6/100,000, more common than peds cases after Hib vaccine implemented
  • Ratio of peds:adults 0.4:1
• Mortality rate ~7%
• Causes:
  • Infectious (bacterial, viral, fungal) most common, thermal (inhalation, caustic), trauma
  • Bugs: Haemophilus, Strep, Staph, HSV, CMV
• Male predominance 2.5:1
• Mean age: 30-50yo
• No seasonal variance

Recap Basics

• Typically with 1-2 day URI prodrome
• Complaints: Sore throat/odynophagia (most common), dysphagia, dysphonia, muffled voice, stridor, drooling, +/- fever, tender hyoid region
• Complications: epiglottic abscess, airway compromise
• Work-up
  • Direct (flexible laryngoscopy) / indirect visualization
  • Imaging
    • Thumb sign and vallecula sign on lateral soft tissue XR
    • CT soft tissue neck
    • US: alphabet “P” sign
  • Blood cultures
  • Throat cultures (if possible)
  • CBC

• Treatment
  • IV antibiotics
    • 3^rd gen cephalosporins, ampicillins, vancomycin if concerned for MRSA
  • Airway support
    • Orotracheal/nasotracheal intubation, surgical airway
    • needle jet insufflation as temporizing
  • Abscess drainage
  • Humidified oxygen
  • Bronchodilators may be supportive
  • Corticosteroids are controversial

• Disposition
  • Admit to a monitored bed (typically ICU)
  • ENT consult

Bottom Line/Pearls & Pitfalls

• IV antibiotics early
• Be prepared to intubate, early if in severe distress
• Have a backup airway plan (video laryngoscopy, surgical airway)

Further Reading

• Woods CR. (2013). Epiglottitis (supraglottitis). UpToDate.
• http://www.ncbi.nlm.nih.gov/pubmed/22896936
• http://www.ncbi.nlm.nih.gov/pubmed/17452262
• http://www.ncbi.nlm.nih.gov/pubmed/19282760
• http://www.ncbi.nlm.nih.gov/pubmed/17355704
• http://www.ncbi.nlm.nih.gov/pubmed/15708873
• http://www.ncbi.nlm.nih.gov/pubmed/15460587
• Adult Epiglottitis Update

Discussion Questions/Future Exploration

• When to intubate? Patients in severe respiratory distress
• Corticosteroids and bronchodilators are controversial, no randomized control trials to date