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Epiglottitis: Difference between revisions
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=== '''Incidence''' === | === '''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. | : 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. | ||
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:Clinical Presentation and Diagnosis | :Clinical Presentation and Diagnosis | ||
:Children with epiglottitis present with high fever, odynia, and | :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. | |||
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:Preoperative Evaluation and Therapy | :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. | |||
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:Anesthetic Management | :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. | ||
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:Intraoperative Management | :Intraoperative Management | ||
::Monitoring, Vascular Access | ::Monitoring, Vascular Access | ||