Acute epiglottitisAcute epiglottitisR.NandiniiR.NandiniiGroup K1Group K1

Anatomy: • Leaf like, yellow, elastic cartilage forming anterior wall of laryngeal inlet.

• Attached to body of hyoid bone by hyoepiglottic ligament which divides it into suprahyoid & infrahyoid epiglottis.

• Stalk like process of epiglottis to the thyroid angle.

• Anterior surface of epiglottis is separated from thyrohyoid membrane & upper part of thyroid cartilage by a potential space filled with fat- pre-epiglottic space .

• Space can be invaded in carcinoma of supraglottic larynx or base of tongue.

Supraglottic structures, eg epiglottis, aryepiglottic folds and arytenoids.

Acute Epiglottitis (Syn. Supraglottic laryngitis)

Definition:

Acute inflammatory condition confined to supraglottic structures:-

-epiglottis

-aryepiglottic folds

-arytenoids

There is marked edema of these structures which may obstruct the airway.

Aetiology:• Classically described as a

Haemophilus Influenzae type b bacterial infection of the epiglottis in children. In adults only 20% of epiglottitis is caused by haemophilus influenzae.

Figure 3.0: Organisms that can cause acute epiglottitis in adults.

Symptoms:

• Odynophagia

• Inability to swallow secretions

• Sore throat

• Muffled voice- “hot potato voice”

• hoarseness

• cough

• dyspnoea

Signs:• Fever (>37.2 °C)

• Tachycardia (100 bpm)

• Pharyngitis

• Swelling of the epiglottis

• Cervical lymph nodes

• Swelling of supraglottic tissue

• Inspiratory stridor

• Drooling/inability to handle secretion

Examination:

• Depressing the tongue with a tongue depressor may show red & swollen epiglottis.

• Indirect laryngoscopy may show oedema & congestion of supraglottic structures. This examination is avoided for fear of precipitating complete obstruction. (Better done in OT where facilities for intubation are available.

• Lateral soft tissue X-ray of neck may show swollen epiglottis (thumb sign)

Examination:

• CT & MRI helpful to evaluate the complications of this disorder, which include spread of the infection and abscess formation. Thickening of the epiglottis, obliteration of the pre-epiglottic fat and thickening of the subcutaneous tissue and muscles are common radiological findings in epiglottic abscess

A lateral soft-tissue radiographof the neck showed a “thumb sign” (arrow). This radiographic sign is a manifestation of anenlarged and edematous epiglottis, and it suggests a diagnosis of acute infectiousepiglottitis.

In this view of the larynx obtained with nasopharyngoscope, the larynx is shown with breathing (left image, cords abducted) and the with phonation (cords adducted):• the wide arrowheads mark the left aryepiglottic fold• the asterisk is at the interarytenoid notch• the round dots mark the right posterior cartilages (cuneiform and corniculate cartilages) The normal orientation for a nasopharyngoscope is to have the epiglottis (anterior) at the bottom of the image, and the posterior cartilages at the top. This image has been flipped to match the perspective with direct laryngoscopy (epiglottis at top). The small black notch on the bottom perimeter of the image is part of the scope eyepiece; it lets the operator determine the orientation of the scope, and an endoscopic camera on the eyepiece.Source: Airway Cam Technologies,2011)

Differential Diagnosis:• DDx of adult epiglottitis includes:

• Infectious processes:

Mononucleosis, diphtheria, pertussis, croup, tonsillitis, Ludwig’s angina with retropharyngeal, Peripharyngeal and peritonsillar abscesses, tracheobronchitis, subglottic laryngitis.

• Non-infectious diseases

Allergic reactions, angioneurotic oedema, foreign body aspiration, reflex laryngospasm, laryngeal trauma, tumours, hydrocarbon aspiration, systemic lupus erythematosis and inhalation of toxic fumes or superheated steam

Complications

• In some  cases, an infection can spread from the epiglottis to nearby parts of the body, including the:

• inner ear (otitis media)

• brain (meningitis)

• heart lining (pericarditis)

• lungs (pneumonia)

Treatment1. Hospitalisation danger of respiratory obstruction

2. Antibiotics Ampicillin

third gen.cephalosporin

- effective against

H.influenzae

- given by parenteral route

(i.m/i.v)

3. Steroids hydrocortisone/dexamethasone (i.m/i.v)

4. Adequate hydrationparenteral fluids

5. Humidification and oxygen

6.Intubation or tracheostomy respiratory obstruction

Algorithme for management of epiglottitis

Source: Acute Adult Supraglottitis: Current Management and Treatment Mohannad Al-Qudah, MD, FAAOHNS, Shetty, S. MD, M. Alomari, MD, Maen Alqdah, FRCPC, FCCP South Med J. 2010;103(8):800-804.-Medscape-

Prognosis:• The prognosis in adults with acute epiglottitis is good with appropriate and timely

treatment.

• Most patients can be extubated within several days.

• However, unrecognized epiglottitis may rapidly lead to airway compromise and resultant death.

• In spite of acute epiglottitis generally having a good prognosis, the risk of death for persons is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures.

• Reported cases do include sudden fatal cardiorespiratory arrest occurring in patients without previous evidence of respiratory obstruction while in an intensive care unit (ICU) setting, emphasizing the importance of providing close monitoring and adequate airway protection in these patients. The adult mortality rate is around 7%.

Source: Emedicine, 2013