Epiglottitis

Question 1

Define epiglottitis

Answer 1

Cellulitis of the epiglottis (supraglottis) that may cause airway compromise. It is an airway emergency in children that should be treated as such until the airway is examined and secured

Question 2

What is the aetiology of epiglottitis

Answer 2

Infection of the supraglottis:
- Haemophilus influenzae
- Strep. Pneumoniae
- Staph. Aureus
- MRSA
- Pasteurella
- Multocida
Rarely: Parainfluenza, candida

Inflammatory pathways lead to localised oedema of the airway, exponentially increasing airway resistance while narrowing the effective supraglottic aperture. The glottis is usually not inflamed or affected as the process affects the supraglottic structures. Further compromise can occur from secretions potentially resulting in complete airway obstruction.

Question 3

What are the risk factors for epiglottitis

Answer 3

Non-vaccination with Hib vaccine
Immunocompromise
Middle age

Question 4

What are the symptoms of epiglottitis

Answer 4

2-6yo

Sore throat (rapid progression)
Dysphagia
Drooling
Difficulty breathing
Feeding issues
Muffled voice
Acute distress/”Toxic appearance”
Fever
Irritability

Question 5

What are the differentials for epiglottitis

Answer 5

Peritonsillar abscess (quinsy)
Tonsillitis
Foreign body aspiration
Retropharyngeal abscess
Croup
Diphtheria

Question 6

What are the signs of epiglottitis on examination

Answer 6

General
- Drooling
- “toxic appearance”
- Acute distress
- Tripod position (neck and head anterior, hands on knees)
- Difficulty breathing
- Muffled voice or “hot potato” voice
Obs: Fever
Respiratory: Stridor

Question 7

What investigations should be done for epiglottitis

Answer 7

Clinical diagnosis

bedside: oropharynx swab for culture
Bloods: FBC (leucocytosis with left shift), blood cultures
Other:
- Direct laryngoscopy (rigid or flexible): swelling of supraglottic structure
- Lateral neck radiograph: markedly large epiglottis “thumbprint” sign

Question 8

What is the management for epiglottitis

Answer 8

Admit to emergency services
1. Secure airway
- Direct rigid laryngoscopy and intubation
- Mask ventilation followed by intubation
- Should be done before any investigations - includes examination, IV line insertion, blood draws
2. IV antibiotics: cefotaxime 150mg/kg/day
3. Supplemental oxygen
4. Consider steroids e.g. dexamethasone

Once stable and extubated: oral antibiotics at home - amoxicillin/clavulanate
Emergency (intubation not possible) → tracheotomy/cricothyroidotomy

Question 9

What are the complications of epiglottitis

Answer 9

Mediastinitis (tachycardia and chest pain) - 50% mortality rate
Neck infection e.g. cellulitis or tonsilitis
Pneumonia

Question 10

What is the prognosis for epiglottitis

Answer 10

Prognosis is excellent for a quick and complete recovery
If vaccinated or immunocompetent, there is no theoretical increase in risk for future episodes of the disease
UNTREATED - can lead to death, mediastinitis, neck infection, necrotising fasciitis, pneumonia, aspiration, asphyxiation