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 (Hib) vaccine in 1985, to less than 1 case per 100000 mean annual incidence. Hib related epiglottitis was predominately seen in children ages 2 to 6 years. However, a multi-year retrospective review completed in 2006 now identifies a higher incidence in infants < 1year, with 34% of cases having occurred 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, highlighting the rarity of presentation.

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

Children with epiglottitis appear toxic and present with high fever, odynia, a thick, muffled voice, and stridor. The severity of the sore throat is such that children refuse oral intake, and children will drool rather than swallow oral secretions. Classically, the four D's are described, dysphagia, dysphonia, dyspnea ad drooling. The stridor associated with epiglottitis may be present in other common childhood acute upper airway infections, croup among the most common. Epiglottitis is distinguished by its rapid progression, with severe airway obstruction evolving within 6 to 12 hours. As the severity progresses, the child may refuse to lie down, and sit leaning forward, using the upper extremities in a tripod fashion, with forward chin thrust to optimize airflow. The inspiratory phase will be marked by obstructive stridor.

Historically, epiglottitis was a clinical diagnosis based on presenting symptoms, but with its decreasing incidence, it may be less readily recognized. Cervical neck anterior posterior and lateral films may distinguish epiglottitis, which presents with a hallmark thumb-sign of the epiglottis on the lateral film, from croup, characterized by a steeple sign on anterior view. Bacterial tracheitis may share characteristics of both croup and epiglottitis, with less definitive findings on imaging but similar rapid progression to airway distress as seen in epiglottitis. Bacterial tracheitis may require diagnostic bronchoscopy to visualize the thick purulent secretions and edema with associated plaques and possible pseudomembrane formation. Bedside diagnostic evaluation prior to prompt airway management may risk airway loss as minimal stimulation in both epiglottitis and bacterial tracheitis can devolve into severe airway compromise.

Lab characteristics

Preoperative Evaluation and Therapy

Epiglottitis is a true airway emergency. While a perfunctory history and evaluation is recommended, the urgency of establishing a secure airway must take precedence and care must be expedited. Limiting anxiety provoking procedures is encouraged, however, establishing intravenous access prior to anesthesia is critical. An anesthetic plan may involve parental presence at induction to limit patient agitation, but parents must be educated as to the severity of airway compromise expected during this period including the risk of cardiovascular collapse. Heliox therapy may be of significant benefit facilitating care in the emergency room and transporting to the operating room, as the helium component improves linear airflow and reduces respiratory work. Hiflow may also be beneficial in the absence of heliox availability.

An otolaryngologist ideally is actively engaged throughout, with a plan to support anesthesia services with rigid bronchoscopy, suspension laryngoscopy and possible emergent tracheostomy if needed.

Anesthetic Management

A robust difficult airway setup is recommended prior to induction of anesthesia. Visualization of airway structures likely will be obscured by the engorged epiglottis, with the a challenged view both by direct laryngoscopy and video laryngoscopy. The age appropriate endotracheal tube may meet significant resistance due to edematous changes, and smaller sizes may be required, this despite characterizing epiglottis as primarily the inflammation of supraglottic structures.

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/