Epiglottitis

Introduction

Epiglottitis is a rare life threatening upper airway infection. The acute bacterial infection of supraglottic structures manifests as rapidly progressing stridor on presentation, and may result in severe airway obstruction. Epiglottitis requires immediate advanced airway management.

Classification

Upper airway infections are common pediatric illnesses. Children presenting with fever, sore throat and dysphagia may have tonsillitis, laryngitis, aspiration of a foreign body, tracheitis, laryngeal diphtheria or croup. The presence of stridor excludes tonsillitis and laryngitis. Croup generally presents gradually, with low-grade fever a stereotypical barky cough, and is responsive to steroid therapy. Laryngeal diphtheria has largely been eliminated by vaccination, but this rare clinical finding evolves more insidiously with web occlusion of the airway. Epiglottitis shows rapid symptom progression, with drooling, forward seated position to optimize air flow, and toxemia with high fever. Cough is not generally seen Tracheitis may present similarly to epiglottitis and may require rigid bronchoscopy to differentiate the two. Bacterial tracheitis carries a significant mortality rate as high as 40%, while prompt intervention in epiglottis proves a definitive rescue.

Incidence

The incidence of pediatric epiglottitis has fallen substantially with the introduction of the Haemophilus influenzae type b vaccine in 1985, to less than 1 case per 100000 mean annual incidence. A multi-year retrospective review completed in 2006 identified a higher incidence in infants < 1year, with 34% of cases occurring in this group. Another case series completed in 2006 identified bacterial tracheitis, another rare entity, as 3 times more likely to cause respiratory failure than epiglottitis and croup combined.

Pathophysiology

Acute epiglottitis involves the lingular surface of the epiglottis, the aryepiglottic folds and the arytenoids. With the decrease in incidence of Haemophilus influenzae type b, group A B-hemolytic Streptococci is now the more common bacterial cause of epiglottitis. Other pathogens include Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumoniae. Epiglottitis may manifest as a negative reaction to chemotherapy or super-imposed Candida infection in the immunosuppressed. Acute inhalational injury and chemical burns may also precipitate epiglottitis, with illicit inhalation of cocaine associated with severe presentation.

Clinical Presentation and Diagnosis

Preoperative Evaluation and Therapy

Anesthetic Management

Preoperative management

History

Physical Examination

Laboratory Evaluation

Preoperative Preparation

Premedication

Intraoperative Management

Monitoring, Vascular Access

Anesthetic Agents and Technique

Physiology of the Operative Position

Anticipatory Management

Airway, Bleeding, Hemodynamics

Postoperative Management

Ventilation Strategies

Pain Management

Postoperative Care

Morbidity/Mortality

Long Term Follow-up

Case Presentation

References

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Relevant Article Depot:

https://emedicine.medscape.com/article/763612-overview

https://pubmed.ncbi.nlm.nih.gov/638834/

https://pubs.asahq.org/anesthesiology/article/124/6/1404/14501/EpiglottitisIt-Hasn-t-Gone-Away

https://www.openanesthesia.org/epiglottitis_airway_management/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/