Acute Epiglottitis Flashcards
What is the median age at presentation for acute epiglottitis?
In children, the median age at presentation has increased to 6-12 years (traditionally affected children 2-5 years old).
Basic anatomy of the epiglottis and surrounding area
What was the classical cause of epiglottitis in children before widespread vaccination was available?
Haemophilus influenzae type B (Hib) was the classical cause of epiglottitis in children before widespread vaccination was available.
Acute epiglottitis may be caused by a number of infectious microorganisms, such as…
Bacteria (Haemophilus): Hib most common. Other Haemophilus species (e.g. A, F) can occur.
Bacteria (Non-Haemophilus): group A Streptococcus, Staphylococcus and Neisseria meningitidis.
Viruses: human herpes virus, Parainfluenza virus, Influenza B virus.
Fungal: consider if immunocompromised. Candidia spp. Aspergillus spp.
Non-infectious: inflammation may occur due to trauma (e.g. thermal injury or ingestion of caustic substances). Other rare causes include graft vs host disease and systemic granulomatous conditions.
Children with acute epiglottitis classically present with the three ‘D’s’:
dysphagia, drooling, distress (respiratory). Cough is usually lacking (or a less prominent feature) and more characteristic of croup. Other features can include:
Fever
Sore throat
Restless and irritable
Muffled or hoarse voice
‘Tripod’ positioning: leaning forward, hyperextended neck, chin forward (an attempt to maximise airflow)
Stridor
3 D’s of acute epiglottitis
dysphagia, drooling, distress (respiratory).
Acute epiglottitis requires rapid assessment and clinical diagnosis to prevent further airway compromise.
How is it usually diagnosed?
There should be a low threshold for the suspicion of acute epiglottitis due to the risk of rapid deterioration. Diagnosis is based on visualisation of the inflamed epiglottis, however, this should only be attempted by a clinician who is trained to deal with the airway.
Inflamed epiglottis, suggestive of acute epiglottitis
There is concern that attempts to visualise the back of the throat by an untrained clinician could lead to cardiorespiratory arrest by a variety of mechanisms (e.g. functional obstruction, laryngospasm). Therefore, if a child has classical signs of epiglottitis prompt involvement of a clinician with paediatric airway skills is needed before visualisation. This is so the airway can be secured if deterioration during, or after, visualisation occurs.
Other investigations in acute epiglottitis
The initial priority is airway management. Subsequent investigations may include blood tests, blood cultures, epiglottic cultures (only if airway secure), or imaging. Imaging may have a role (e.g. MRI/CT for suspected abscess). Lateral radiographs of the neck can be used to look for oedema of the epiglottis (the classic ‘thumb sign’), but direct visualisation is the standard of care.
Management of acute epiglottitis
All patients require review from senior members of the anaesthetic and ENT teams. The key aspects of treatment include airway management and antibiotics.
Airway management: clinician with paediatric airway skills. Maintain oxygenation. Intubation if respiratory arrest or compromise. Do NOT use supraglottic airways.
Antibiotics: refer to local guidelines. Intravenous (IV) broad-spectrum antibiotics should be commenced in all patients.
Other treatments: IV steroids and adrenaline nebulisers are often given. IV fluids should be given as appropriate.
Other measures: try to prevent agitation of the child. Referral to the paediatric intensive care unit. Monitor for complications (e.g. abscess), if intubated will need reassessment of epiglottis prior to extubation
What vaccination has dramatically decreased the incidence of acute epiglottitis?
All children should have the Hib vaccination as part of the usual childhood vaccination programme. This has dramatically decreased the incidence of acute epiglottitis.
What are the potential complications of acute epiglottitis?
Complications may include abscess formation, sepsis, respiratory arrest and death. Early recognition and treatment can prevent the need for intubation and development of complications.
