Epiglottitis

Notes

## Basic introduction

  • Epiglottis is a flap of cartilage at the root of the tongue that is depressed during swallowing to cover the opening of the trachea.
  • Epiglottitis (or supraglottitis) is an inflammation (mainly due to infections) of the epiglottis and adjacent tissues that may result in abrupt respiratory obstruction and death.

## Causes of epiglottitisd,e

  • Hemophilus influenza Type B (its role has diminished due to the wide-spread immunization)
  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Beta-hemolytic streptococci
  • Branhamella catarrhalis
  • Klebsiella pneumoniae
  • Candida ssp
  • Trauma by foreign objects
  • Inhalation burns
  • Chemical burns
  • Systemic disease
  • Reactions to chemotherapy

## Statistics

  • Globally, 1.3 in 100,000 children and 1-4 in 100,000 adults are affected by epiglottitis in a yeara
  • The disease fatality rate is 6% without intubation and 1% with early intubationc

## Complications of epiglottitis

  • Abscess formation
  • Meningitis
  • Sepsis
  • Pneumothorax
  • Pneumo-mediastinitis
Symptoms
  • Severe sore throat
  • Cherry red epiglottis
  • Inspirational stridor
  • Difficulty breathing
  • Tripod position (the position relieves the pain)
  • Dysphagia (difficulty in swallowing)
  • Odynophagia (painful swallowing)
  • Drooling (because of difficulty and pain on swallowing)
  • Fever (often high)
  • Muffled voice
  • Fatal asphyxia
Diagnosis
  • Clinical review especially direct visualization of the supraglottic structures. (Due to the risk of inducing laryngeal spasm and/or total airway obstruction, examination of the pharynx and larynx should be tried in a facility with equipment and staff prepared for possible intervention)
  • “Thumb up sign” in X-ray
  • Throat culture
  • Flexible fiberoptic laryngoscopy with endotracheal intubation (sometimes)
Differential
  • Croup (in croup there is neither drooling, nor tripod sign nor cough)
  • Foreign body aspiration
  • Diphtheria
  • Tonsillitis
  • Retropharyngeal abscess
  • Foreign body aspiration
  • Bacterial tracheitis
Prevention
  • Vaccinating children against Hib and pneumococcal infections.
Reference

a. Richards, AM (February 2016). "Pediatric Respiratory Emergencies". Emergency medicine clinics of North America. 34 (1): 77–96.

b. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259

c. Infectious Diseases. Lippincott Williams & Wilkins. 2004. p. 461. ISBN 9780781733717.

d. Abdallah, C. (2012). Acute epiglottitis: Trends, diagnosis and management. Saudi journal of anesthesia, 6(3), 279.

e. Kornak, Jodi M., James E. Freije, and Bruce H. Campbell. "Caustic and thermal epiglottitis in the adult." Otolaryngology--Head and Neck Surgery 114.2 (1996): 310-312.

f. Tibballs, J., & Watson, T. (2011). Symptoms and signs differentiating croup and epiglottitis. Journal of pediatrics and child health, 47(3), 77-82.

g. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

h. Shankar, P. R. (2014). Essential medicines and health products information portal. Journal of Pharmacology and Pharmacotherapeutics, 5(1), 74.

Management
  • Airway protection (main goal of management) e.g. nasotracheal intubation or tracheotomy / cricothyrotomy
  • Supplemental oxygen
  • Do not place a child in a supine position as airway obstruction can easily occur
  • Corticosteroid therapy:

_Tabs Dexamethasone: children: 0.08 to 0.3 mg/kg/day in divided doses every 6-12 hours. Adults: 0.75 to 9 mg/day in divided doses every 6-12 hours.

  • Antibiotics (started and observed in hospital) such as;

_Adults and children > 2 months : IV Chloramphenicol 1g (children >2 months: 25mg/kg; maximum 1g) or i.m. QID x 5/7h;

_In case of  suspected H. influenzae serotype b infection ADD a course of Rifampicin 600mg (neonates <1 month: 10mg/kg (maximum 300mg); children ≥1 month: 20mg/kg (maximum 600mg)) orally every 24 hours for 4 days

OR

_Inj IM or IV Ceftriaxone: children: 50-100 mg/kg/day in divided doses every 12-24 hours. Adults: 1-2 g in divided doses every 12-24 hours; maximum 4 g/day;

OR

_Inj Cefotaxime: children: 150-200 mg/kg/day in divided doses every 6-8 hours. Adults: 1-2 g every 6-12 hours; maximum 12 g/day

OR

IV Clindamycin: children: 15-25 mg/kg/day in divided doses every 6 hours. Adults: 600 mg QID

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