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:

• CoreEM: Epiglottitis
• Pediatric EM Morsels: Epiglottitis
• EM Docs: Epiglottitis @ 3 AM

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