CONTENTS

• Signs & symptoms
• Differential diagnosis
• Diagnosis
• Management
  • Medical Management
  • Epiglottic abscess
  • Airway management
    • Indications for intubation
    • Intubation procedure
    • Extubation procedure
• Podcast
• Questions & discussion
• Pitfalls

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signs & symptoms

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symptoms

• Sore throat (92%)(31173373)
• Swallowing problems
  • Odynophagia (82%)
  • Dysphagia (80%)
  • Drooling (18%)
• Voice change (43%)
  • Hoarseness (26%)
  • Muffled voice (30%)
• Respiratory dysfunction
  • Stridor (8%)
  • Dyspnea (33%)
  • Inability to lie flat, sitting upright in “sniffing” or “tripod” position

signs

• Pharyngitis is reported in 38% of patients. (31173373)
  • Classic presentation of epiglottitis is sore throat with unremarkable throat exam. ~90% of adults with epiglottitis will have a normal oropharyngeal examination. (35489220)
  • However, epiglottitis can involve pharynx and uvula. Thus, erythema seen on throat exam doesn't exclude epiglottitis. (27031010)
• Anterior neck tenderness may occur with palpation of the larynx.

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differential diagnosis

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• Peritonsillar or retropharyngeal abscess.
• Deep neck space infection (e.g., Ludwig's angina, parapharyngeal space infection).
• Foreign body.
• Epiglottitis plus simultaneous pneumonia or pharyngitis (the presence of epiglottitis doesn't protect against infection elsewhere.)
• Streptococcal pharyngitis.
• Caustic ingestion.
• Lemierre's syndrome. (35489220)

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diagnosis

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lateral neck radiograph

• Findings
  • Swollen epiglottis may be seen as a “thumb sign” (normally, epiglottis profile should look like a finger).
  • Obliteration of the vallecula (“vallecula sign”) may be seen (figure below, white arrow).
• Performance?
  • ~88% sensitive, so a negative X-ray doesn't exclude epiglottitis. (27247205)

neck CT scan

• Roles of CT scan:
  • [1] Diagnosis of epiglottitis. Contrasted CT scan of the neck has a sensitivity of 88-100% and specificity of ~96% for epiglottitis. (35489220)
  • [2] Detection of an an epiglottic abscess.
  • [3] Global survey tool to exclude other serious neck infections or anatomic lesions (e.g., deep neck space infections).
• Transportation to the scanner may be appropriate for a reasonably stable patient, who isn't at risk of immediate airway loss.

bedside nasolaryngoscopy

• Flexible fiberoptic exam allows visualization of the larynx at the bedside.
• This may be preferable for a tenuous patient, since it doesn't require transportation out of the department.
• In addition to diagnosing epiglottitis, nasolaryngoscopy should provide additional information about the airway (How much airway compromise is there? How difficult or easy would it be to intubate the patient?).

blood cultures

• Positive in ~25% of cases.
• May assist in narrowing antibiotics.

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medical management

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[1/3] antibiotics

• Pathogens in adult epiglottitis: (31173373)
  • #1 = Streptococcal species (~30%) – may include pneumococcus or group A streptococci.
  • #2 = Haemophilus (~5% in post-vaccine era).
  • #3 = Staphylococcus (~5%).
  • Gram-negatives can occur in immunocompromised patients. (29564363)
  • (Unfortunately, it's often unclear whether cultures obtained from pharyngeal swab represent truly invasive infection, or bystander organisms.)
• Preferred antibiotics:
  • 🏆 Third-generation cephalosporin is generally the front-line choice (e.g., ceftriaxone 2 gram IV Q24hr for seven days).
  • Ampicillin-sulbactam is also a good choice.
• Other options (e.g., in the context of antibiotic allergies 📖).
  • Piperacillin-tazobactam.
  • Levofloxacin 750 mg IV daily.
• MRSA coverage is generally unnecessary, but there is little data on this.

[2/3] steroid

• Intermediate dose steroid is generally used (e.g., 125 mg methylprednisolone IV once, then lower doses daily for a few days). (30207030) A 2-3 day course might be reasonable.
• There is no solid data on this, nor is there likely to be any in the near future (given the rarity of epiglottitis). However, steroid has been demonstrated to be beneficial for pharyngitis – which involves a similar anatomy and range of pathogens. (28931508)

[3/3] nebulized (racemic) epinephrine

• Racemic epinephrine might be a reasonable consideration to temporize edema, allowing time for steroid and antibiotic to take effect. (35489220)
• Racemic epinephrine is contraindicated in children, due to concerns regarding the potential to precipitate laryngospasm.

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epiglottic abscess

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diagnosis

• May be identified on CT scan of the neck or nasolaryngoscopy.

management implications

• There is no definitive evidence regarding how to manage epiglottic abscess.
  • One tiny RCT found that abscess drainage under local anesthesia in awake patients reduced the hospital length of stay. (25931293) Likewise, another small series reported that pre-emptive abscess drainage without intubation was feasible. (18728917)
• In retrospective studies, abscess was associated with 27% likelihood of requiring airway intervention. (31173373)
• Bottom line?
  • Don't assume that an abscess necessarily mandates drainage or intubation (many patients may respond to medical therapy alone).
  • Consult ENT surgery regarding optimal management.

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indications for intubation

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general concepts regarding airway management in epiglottitis

• [1] ~90% of adults with epiglottitis don't require intubation. (31173373) Adults might do better than children for two reasons:
  • With aging, the epiglottis may get smaller and more rigid; meanwhile the larynx may grow larger. Overall, this makes epiglottitis less likely to obstruct the adult airway, compared to the pediatric airway. (30613442)
  • Adults may be less prone to development of laryngospasm.
• [2] With steroid and antibiotic, most patients will gradually improve. So when in doubt, meticulous observation with aggressive preparation may be reasonable.
  • If there is any concern regarding the airway, patients should be monitored in a setting where there is immediate ability to manage the airway.
• [3] Laryngospasm?
  • Some patients with epiglottitis could theoretically develop laryngospasm, leading to rapid airway loss. (3042183)
  • This seems to be extremely rare in adults, with hardly any cases reported. As such, it's doubtful whether the existence of this entity should affect airway management in adults with epiglottitis.

role of flexible nasolaryngoscopy to determine need for intubation?

• >50% obstruction of the laryngeal lumen is suggested as an indication for intubation. However, this seems to be arbitrary and not based on any particular evidence.
• Some practitioners will use serial nasolaryngoscopy to evaluate the disease course, but this practice is of dubious value. One series of ICU patients found that among 528 examinations, only 3% demonstrated deterioration. (34792627) That study also found that the indication for intubation was invariably increasing dyspnea, rather than deterioration in nasolaryngoscopy. Thus, careful clinical evaluation over time seems to be more relevant than nasolaryngoscopy.

possible indications for intubation

• [1] True airway compromise:
  • Significant dyspnea, tachypnea.
  • Stridor.
  • Tripoding, inability to lie flat.
• [2] Clinical course:
  • Rapidly progressive symptoms prior to admission.
  • Progressive deterioration despite medical therapy.

not necessarily indications for intubation

• [1] Voice change.
• [2] GI dysfunction – odynophagia, dysphagia, or difficulty handling secretions are not associated with the need for intubation. (27031010) However, some sources do recommend intubation for patients with difficulty handling secretions.

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intubation procedure

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intubation in epiglottitis is fraught with hazard

• Airway manipulation may worsen swelling.
• Epiglottic edema will often preclude the use of a laryngeal mask airway.
• In severe epiglottitis, orotracheal intubation may simply be impossible.
• ⚠️ Don't perform traditional RSI (rapid sequence intubation) in epiglottitis – this is likely to provoke a can't-intubate-can't-oxygenate situation.

intubation tips

• Consult early with any available airway experts (e.g., anesthesiology, ENT surgery).
• Try to utilize awake intubation strategies if possible (e.g., with fiberoptic intubation).
• Try to utilize a double-setup if possible (one operator is attempting to intubate while a second operator is prepared to immediately perform cricothyrotomy if necessary).
• Have a low threshold for performing cricothyrotomy if there is difficulty securing the airway.

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extubation procedure

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• It often takes 2-3 days for swelling to improve. However, some patients are intubated preemptively, so they may be extubated earlier.
• The decision to extubate may be assisted by visualizing the epiglottis as follows:
  • Deeply sedate the patient (e.g., with high-dose propofol). Paralysis may be needed in some patients as well (e.g., 10 mg vecuronium bolus).
  • Very gently insert a hyperangulated video laryngoscope (e.g., Glidescope or CMAC D-blade) until you see the epiglottis.
  • This isn't perfect, but it may give you some concept of how inflamed the epiglottis is. For example, the image below shows a normal-appearing epiglottis.
  • This is especially useful for patients who were intubated at an outside hospital, who often didn't actually require intubation to begin with.

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podcast

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questions & discussion

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To keep this page small and fast, questions & discussion about this post can be found on another page here.

• Missed diagnosis: consider this especially in a patient complaining of sore throat whose throat actually looks OK.
• Consider early IV steroid to reduce inflammation.
• Most patients won't require intubation. When in doubt, watchful waiting is generally best, as patients will tend to improve with medical therapy.
• 🛑 DO NOT USE RAPID SEQUENCE INTUBATION IN AN EPIGLOTTITIS PATIENT.
• Don't try to secure the airway of an epiglottitis patient unless there is someone present who is ready, willing, and able to perform a scalpel-finger-bougie cricothyrotomy. No matter how skilled you or your anesthesiologist may be, many of these patients will be impossible to intubate from the top end.

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