Acute epiglottitis

Introduction

Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures.
It can progress rapidly to life threatening airway obstruction if not treated.
The condition is commonest in children.
Pathogens in children include H. influenza type B, types A, F, Streptococci and Staph. aureus.
The commonest is H. influenzatype B.
In adults, a wide range of pathogens
including viruses, bacteria, fungi are
involved but H. influenza type B appears to be the most common.
In immunocompromised hosts, epiglottitis may be caused by Pseudomonas aeruginosa and Candida.
Non-infectious causes include thermal
injury, corrosive ingestion, foreign body
ingestion.
Rarely may occur as a result of graft-versus host disease in transplantation.

Symptoms and clinical features of acute epiglottitis

A. Common presentation in children

  1. Difficulty with breathing
  2. Stridor
  3. Hoarse voice
  4. Pharyngitis
  5. Fever
  6. Sore throat
  7. Tenderness of anterior neck
  8. Cough
  9. Difficulty swallowing
  10. Change in voice

B. Adult presentation usually less fulminant

  1. Sore throat
  2. Fever
  3. Muffled voice
  4. Drooling
  5. Stridor
  6. Hoarseness
  7. Difficulty swallowing
  8. Difficulty breathing

Differential Diagnosis

  • Laryngotracheitis or spasmodic croup
  • Uvilitis
  • Bacterial tracheitis
  • Peritonsillar or retropharyngeal abscesses
  • Foreign body lodged in the larynx
  • Angioedema
  • Upper airway congenital anomalies
  • Diphtheria

Complications of acute epiglottitis

  1. Airway obstruction
  2. Epiglottic abscess
  3. Secondary infection
  4. Necrotizing epiglottitis (rare, in
    immunodeficiency)
  5. Death

Investigations

  • Radiograph (lateral neckx-ray)
  • “Thumb sign” appearance of the enlarged epiglottitis
  • Ultrasound
  • Microbiology

Treatment objectives

  • Safeguard airway
  • Control infection.

Drug treatment

Amoxicillin/Clavulinic acid

  • Adult:
    • Mild to moderate: 625 mg orally 12 hourly or 375 mg orally 8 hourly for 10 days
    • Severe: 1000 mg orally 12 hourly or 625 mg orally 8 hourly or 2000 mg (2 extended-release tabs) orally 12 hourly for 7-10 days
  • Child
    • < kg body weight: 45 mg/kg/day PO divided q8hr or 90 mg/kg/day PO divided q12hr
    • > kg body weight: Dose according to adult recommendations

OR

Cefuroxime

  • Adult : 250mg orally every 12hours for 5 – 10days
  • Child :30 mg/kg/day suspension PO divided q12hr for 5 – 10 days; not to exceed 1000 mg/day

OR

Ceftriaxone

  • Adult : 250mg-500mg IM/IV for 5 – 10days
  • Child:
    • neonate, infuse over 60mins, 20 – 50mg/kg daily
    • Child under 50kg : 20 -50 mg/kg daily by deep im injection or by IV injection over 2 – 4 minutes or by IV infusion; up to 80mg/kg
      daily in severe infections.

Supportive measures

  • Oxygen
  • Steam inhalation
  • Nasotracheal intubation may be necessary
  • Maintain adequate caloric intake and hydration

Notable adverse drug reactions, caution

Cefuroxime

  • Avoid in pregnancy and in patients with renal impairment.

Ceftriaxone:

  • Rashes, fever, GIT disturbances
  • Dose reduction in the elderly.

Prevention

Haemophilus influenza vaccine

  • Child 2months-18years: 0.5mls

Should be part of childhood immunization.