Adult Epiglottitis: Not just a hot

potato
July 21, 2014

In Medical Concepts by Tanya ViaznikovaLeave a Comment

It was an early morning shift at Janus General when I picked up the

chart of a 36-year-old female with a two-week history of sore throat.

I walked into the room and see a healthy looking 36 year old woman. Her
vitals were stable, but she was febrile. She was reclining on a stretcher,
breathing normally and did not appear to be in respiratory distress. She
presented with a two-week history of sore throat with intermittent fever, no
cough, no dyspnea, and her voice sounds were a bit high pitched but not
exactly muffled.

Looking at her, sitting on the bed, I was thinking viral URI or perhaps strep
throat. I certainly was NOT thinking “epiglottitis,” a diagnosis I associate
with stuff like this:
As I considered her differential she told me that she came into ED because
she has been feeling increasingly uncomfortable for the past 2 days. She
was taking naproxen for pain but has found that her “throat spasms” when
she drinks water which has made swallowing pills hard. That gave me pause
as I started my exam.

The left side of her neck was very tender and mildly edematous. She could
only open her mouth a bit because her “throat spasms” every time she
tries. I grabbed for a tongue depressor to get a better look and almost sent
her into a chocking fit! That left me with no better of a look and an even
more distressed patient.

The super-star staff physician working the ED that day noted that the
presentation was not typical but that “We should scope to make sure he
does not have epiglottitis.” ENT was consulted and she was quickly whisked
away for flexible laryngoscopy. Twenty minutes later, I got a page from a
very excited ENT physician, “You were so right! It’s epiglottitis!”

The lesson I took from this is that while children are not little adults, adults
are not big children either. The presentations of “pediatric” diseases can be
subtler and less typical the rare times they present in adults.

Quick and Dirty Facts About Adult Epiglottitis

The incidence of epiglottitis is 1-4 per 100 000 (Solomon 1998) with a
mortality of 7-20% (Carey 1996). Common causes can include bacteria (H.
Flu type B), viruses (herpes simplex), fungi (candida albicans), and non-
infectious irritation (trauma, chemicals, heat, inhalation of heated objects
(smoking illicit drugs). Common clinical features include sore throat and
painful dysphagia. Less frequent causes that may be predictrors of airway
loss (this is controversial) include drooling and stridor.

Differential Diagnosis
 Deep space abscesses
Lingual tonsillitis
Laryngeal tumors
Toxic/caustic inhalation, aspiration, or ingestion
Acute angiodema
Aortic dissection

Radiographic evidence

The thumb-print sign is the classical radiographic finding in epiglottitis and

is named because the epiglottis seems to swell to the size/shape of a
thumb print!

Stanford University Medical Center and Kaiser Permanente, Stanford, CA

Pediaatricimaging.wikispaces.com

Laryngoscopy evidence

This picture shows an incredibly swollen epiglottis. Note that direct

laryngoscopy is not advised because it may provoke airway spasm. This
photo was taken with a fiberoptic laryngoscope.

Department of Anesthesia and Intensive Care, Chinese University of Hong Kong

Treatment

Patients are typically admitted to a monitored bed for close airway

monitoring and intravenous antibioitics. Antibiotics should be started
immediately and cover haemophilus influenza, staph aureus, streptococcus,
and pneumococus. The drugs of choice are generally amoxicillin/clavulanic
acid or a third generation cephalosporin (Ward 2002). NSAIDS can be used
for symptomatic relief and corticosteroids are often recommended although
the evidence is controversial. Two separate studies, Dort (1994) and
Mayo-Smith (1995), have shown that their use does not reduce the need
for and the duration of intubation, or the duration of ICU stay.

The role of airway intervention in adults is controversial and a more

conservative approach is recommended (antibiotics, corticosteroids, and
humidified oxygen). Some studies suggest basing the decision on patient’s
clinical signs and symptom. Factors to consider include respiratory distress,
stridor, sitting erect, inability to swallow secretions, and deterioration within
8-12 hours. Other studies propose management based on laryngoscopy
findings. Intubate if signs of severe constriction of the supraglottic space
and/or vocal cords not visible and/or endotracheal intubation not possible
(Wick 2002).

For intubating a patient with epiglottitis, check out Dr. Rich Levitan’s great
article from 2011 which offers the following tips:

Rescue ventilation (LMA, King LT, mask ventilation) may not work in a
patient with laryngeal pathology
Supraglottic airways (LMA, King LT) may obstruct the airway further by
pushing the swollen epiglottis over the laryngeal inlet
If orotracheal or nasotracheal intubation fails, a rapid surgical airway
might be required
Mark the neck in an event that surgical airway becomes necessary
Flexible fiberoptics are ideal for intubating a patient with laryngeal
pathology
Pharmacological adjuncts (small doses of benzodiazepines and
ketamine) should be used to aid in intubation
Topical medication can be used to help relax the surrounding
structures (lidocaine 20cc of 2% can be nebulized)
 Maximize oxygenation efforts throughout the intubation by applying
nasal oxygen
After intubation, take care in preventing unintended extubation through
the use of sedatives and muscle relaxants
Equipment for a surgical airway should be kept at bedside, even after
intubation, in case of unexpected extubation

Conclusion

Childhood incidence of epiglottitis has decreased significantly since the

routine use of HiB vaccine. Despite an increase in adult cases, it still
remains a rare presentation seen in the ED.Adult presentations tend to be
subtler than that of children with sore throat, dysphagia, and odynophagia
being the more common symptoms (Durell 2011). Often, adult patients not
present with signs of airway obstruction, leading to an overall delay in
diagnosis (Ng 2008). Prognosis is good, but it’s important to keep it on
your differential diagnosis for an adult with a history of sore throat.

This post was edited and peer-reviewed by Teresa Chan (@TChanMD) and
Brent Thoma (@Brent_Thoma).

—–

Addendum – Added September 2, 2014

We are proud to announce that this piece by Dr. Viaznikova has been
awarded an endorsement by the ALiEM.com website as a certified
“Approved Instructional Resource” (AIR). Click here to find out more about
the AIR series. Congrats to Tanya on her great work!

(Visited 2,985 times, 3 visits today)

Tanya Viaznikova

PGY2 at The Department of Family Medicine, Queen's University

BoringEM has been 'bringing the boring' to emergency medicine since

2012. In 2016 this Canadian blog brought its content to CanadiEM.