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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Acute epiglottitis is a condition in which there is inflammation of the epiglottis. It may also affect the soft tissues surrounding the epiglottis, particularly in affected adults - hence the term supraglottitis.It is potentially life-threatening if complete obstruction of the airway occurs.
- Epiglottitis is rare, affecting 1-4/100,000 population..
- Since the widespread introduction of Haemophilus Influenza type B (Hib) vaccination, acute epiglottitis is now extremely rare in children.
- There is controversy over whether the incidence in adults may or may not be rising; the evidence is conflicting..
- The usual age of presentation in children is 2-5 years. Adults present in their 40s and 50s and it affects more men than women.
- Adults who develop epiglottitis are more likely to have other underlying medical conditions that affect their immunity either systemically or locally.
- In a series of 308 patients, the causative organism in the majority of cases was Streptococcus spp.
- Other bacterial causes include Staphylococcus aureus, Haemophilus influenzae type b (Hib), Pseudomonas spp., Moraxella catarrhalis and Mycobacterium tuberculosis.
- Viruses include herpes simplex virus, with bacterial superinfection.
- Candida spp. and Aspergillus spp. in immunocompromised patients.
- Non-infectious causes of epiglottitis reported include thermal causes (eg, steam, crack cocaine smoking), caustic insults (eg, dishwasher pellets), foreign bodies and trauma, including traditional Chinese gua sha therapy.
- Reactive epiglottitis may also occur as a reaction to head and neck chemotherapy.
Many of the signs and symptoms associated with acute epiglottitis are common and may occur in many less serious disorders. Patients with epiglottitis may present with any of the following and the symptoms may evolve very quickly over a period of a few hours.
The most common symptoms
- Sore throat.
- Odynophagia (painful swallowing).
- Inability to swallow secretions (drooling in children).
- Muffled voice - 'hot potato' voice.
- High temperature.
- Anterior neck tenderness over the hyoid bone.
- Ear pain.
- Cervical lymphadenopathy.
- The 'tripod sign' - the patient leans forward on outstretched arms to move inflamed structures forward, thereby easing the upper airway obstruction.
With more severe epiglottitis
- Respiratory distress.
- Stridor - is a sign of upper airways obstruction and is a surgical emergency.
Diagnosis in adults can be difficult, as they may not have signs of respiratory distress (stridor). Patients with a significant sore throat with no obvious aetiology should be referred to ENT for direct visualisation of their larynx by flexible laryngoscopy. More than 90% of patients will have a normal oropharyngeal cavity and the diagnosis should be suspected when the severity of the symptoms does not correlate with the findings on examination.
Children with epiglottitis rarely have a cough, which may help to distinguish it from laryngotracheobronchitis or 'croup'.
The differential diagnosis will depend on the presenting symptoms and age of the patient; however, generally included are:
- Fibre-optic laryngoscopy remains the 'gold standard' for diagnosing epiglottitis, as the epiglottis can be seen directly. Laryngoscopy in these patients should only be performed in areas such as operating theatres which are prepared for intubation or tracheostomy in the event of upper airway obstruction.
- Lateral neck X-ray may be useful if laryngoscopy is not possible. Soft-tissue radiograph of the neck may show the 'thumbprint sign'.
- Throat swabs may be taken when the airway is secure, or when intubation/tracheostomy facilities are at hand.
- Blood cultures may be taken if the patient is systemically unwell.
- CT or MRI scans may be performed if abscess formation is suspected.
- Initial presentation may resemble a viral sore throat, so a high index of suspicion is needed. Emergency referral is required if signs of airway obstruction are present (stridor). Deterioration in symptoms may be rapid, especially in children.
- Management is usually conservative with intravenous or oral antibiotics but intubation may be needed .
- Surgical tracheostomy may be required in patients with severe airway obstruction in whom intubation has not been possible.
- Abscess formation is increasing in incidence. This may partly be explained by advances in imaging (CT and MRI).Drainage may be required in some patients.
Epiglottitis, if not adequately treated, may occasionally result in:
- Abscess formation: 25% in one series.
- Pneumo-mediastinitis (very rare).
The great majority of patients will make a complete recovery with no sequelae. Early diagnosis appears to reduce the need for intubation which, in a series of over 300 cases, was required in only 15%.Outcomes are generally good for adults, with fewer cases needing intubation than among children.However, death may occur rapidly if the condition is not recognised and complete airway obstruction occurs.
Vaccination against Hib has dramatically reduced the incidence of acute epiglottitis in children in those countries in which the vaccination is included in the routine vaccination protocol for children.
Further reading and references
Revised recommendations for the prevention of secondary Haemophilus influenzae type b (Hib) disease; Public Health England, 2013
Hermansen MN, Schmidt JH, Krug AH, et al; Low incidence of children with acute epiglottis after introduction of vaccination. Dan Med J. 2014 Apr61(4):A4788.
Guardiani E, Bliss M, Harley E; Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: evolving principles in diagnosis and management. Laryngoscope. 2010 Nov120(11):2183-8. doi: 10.1002/lary.21083.
Hindy J, Novoa R, Slovik Y, et al; Epiglottic abscess as a complication of acute epiglottitis. Am J Otolaryngol. 2013 Jul-Aug34(4):362-5. doi: 10.1016/j.amjoto.2013.01.003. Epub 2013 Feb 5.
Glynn F, Fenton JE; Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep. 2008 May10(3):200-4.
Bizaki AJ, Numminen J, Vasama JP, et al; Acute supraglottitis in adults in Finland: review and analysis of 308 cases. Laryngoscope. 2011 Oct121(10):2107-13. doi: 10.1002/lary.22147. Epub 2011 Sep 6.
Tsai KK, Wang CH; Acute epiglottitis following traditional Chinese gua sha therapy. CMAJ. 2014 May 13186(8):E298. doi: 10.1503/cmaj.130919. Epub 2013 Nov 25.
Parsons DS, Smith RB, Mair EA, et al; Unique case presentations of acute epiglottic swelling and a protocol for acute airway compromise. Laryngoscope. 1996 Oct106(10):1287-91.
Al-Qudah M, Shetty S, Alomari M, et al; Acute adult supraglottitis: current management and treatment. South Med J. 2010 Aug103(8):800-4.
Kudchadkar SR, Hamrick JT, Mai CL, et al; The heat is on... thermal epiglottitis as a late presentation of airway steam injury. J Emerg Med. 2014 Feb46(2):e43-6. doi: 10.1016/j.jemermed.2013.08.033. Epub 2013 Oct 7.
Tan CK, Chan KS, Cheng KC; Adult epiglottitis. CMAJ. 2007 Feb 27176(5):620.
Price IM, Preyra I, Fernandes CM, et al; Adult epiglottitis: a five-year retrospective chart review in a major urban centre. CJEM. 2005 Nov7(6):387-90.