Epidemiology

• Acute epiglottitis is most common in children between the ages of 2 and 8, although it can occur at any age
• Males are more commonly affected than females with a ratio of 2.5:1¹
• In adults, smoking and reduced levels of immunity appear to be risk factors, and there is some evidence to suggest an increased risk in diabetics²
• Since the advent of vaccination against Hib in children, the incidence of acute epiglottitis in children has reduced
• Over the last few years the presence of epiglottitis in adults is being increasingly seen^1,3

Aetiology

• Haemophilus influenzae type b (Hib) (most common)
• Pneumococci
• Group A beta-haemolytic streptococci
• Pseudomonas spp.
• Mycobacterium tuberculosis
• Viruses
• Local trauma, e.g. following inhalation of foreign bodies or post intubation

Presentation

Many of the signs and symptoms associated with acute epiglottitis are common, and may occur in many less serious disorders. Patients with epiglottitis may present with any of the following, and the symptoms may evolve very quickly over a period of a few hours.⁴

Commonest symptoms

• Sore throat
• Odynophagia
• Muffled voice
• Drooling
• Fever
• Anterior neck tenderness

Other features

• Irritability
• Cough
• Ear pain
• Cervical lymphadenopathy
• The " tripod sign" - patient leans forward on outstretched arms to move inflamed structures forward thereby easing the upper airway obstruction²

With more severe epiglottitis

• Dyspnoea
• Dysphagia
• Dysphonia
• Stridor (late finding-indicates airway obstruction)
• Respiratory distress

Differential diagnosis

The differential diagnosis will depend on the presenting symptoms and age of the patient, but generally include:

• Pharyngitis
• Laryngitis
• Inhaled foreign body
• Croup
• Retropharyngeal abscess

Investigations

• Fibreoptic laryngoscopy remains the "gold standard" for diagnosing epiglottitis, as the epiglottis can be seen directly. Laryngoscopy in these patients should only be performed in areas such as operating theatres which are prepared for intubation or tracheostomy in the event of upper airway obstruction.
• Lateral neck X-ray may be useful if laryngoscopy is not possible. Soft-tissue radiograph of the neck may show the "thumbprint sign".⁵
• Throat swabs may be taken when the airway is secure, or when intubation/tracheostomy facilities are at hand. Streptococci are becoming the major pathogens in acute epiglottitis now.⁶
• Blood cultures may be taken if the patient is systemically unwell.
• CT or MRI scans may be performed if abscess formation is suspected.

Management

• Intubation is required in over 30% of all cases of acute epiglottitis, and prophylactic intubation may be carried out in patients with dyspnoea or stridor, as deterioration in symptoms may be rapid (usually if >50% airway obstruction present).⁷
• Treatment with antibiotics should be initiated without waiting for swab/blood culture results. The chosen antibiotic should have a broad spectrum of action which covers both Haemophilus influenzae type b and Streptococcus spp. Due to increasing resistance to ampicillin, third generation cephalosporins such as cefotaxime are now preferred as first line agents.
• Corticosteroids are often given for their anti-inflammatory properties, although there is as yet little evidence that their use influences the course of the disease.²
• Surgical tracheostomy may be required in patients with severe airway obstruction in whom intubation has not been possible.
• Abscess formation is being increasingly seen as epiglottitis cases in adults increase.⁸ Drainage may be required in some patients.

Complications

Epiglottitis, if not adequately treated, may occasionally result in

• Abscess formation
• Meningitis
• Septicaemia
• Pneumothorax
• Pneumo-mediastinitis (very rare)

Prognosis

The great majority of patients will make a complete recovery with no sequelae if early and appropriate treatment are given. Death may occur rapidly if the condition is not recognised and complete airway obstruction occurs.⁹

Prevention

Vaccination against Hib has dramatically reduced the incidence of acute epiglottitis in children in those countries in which the vaccination is included in the routine vaccination protocol for children.

Future considerations

It is becoming increasingly obvious that vaccination of children with Hib is resulting in resurgence of Hib-associated infections in older age patients. This requires further observation and surveillance methods to determine how best to manage this.¹⁰