Epiglottitis

Epiglottitis Overview

Epiglottitis is a medical emergency that may result in death if not treated quickly. The epiglottis is a flap of tissue at the base of the tongue that keeps food from going into the trachea, or windpipe, during swallowing. When it gets infected or inflamed, it can obstruct, or close off, the windpipe, which may be fatal unless promptly treated.

Respiratory infection, environmental exposure, or trauma may result in inflammation and infection of other structures around the throat. This infection and inflammation may spread to the epiglottis as well as other upper airway structures. Epiglottitis usually begins as an inflammation and swelling between the base of the tongue and the epiglottis. With continued inflammation and swelling of the epiglottis, complete blockage of the airway may occur, leading to suffocation and death. Even a little narrowing of the windpipe can dramatically increase the resistance of an airway, making breathing much more difficult.

Autopsies of people with epiglottitis have shown distortion of the epiglottis and its associated structures, including the formation of abscesses (pockets of infection). For unknown reasons, adults with epiglottic involvement are more likely than children to develop epiglottic abscesses.

Epiglottitis was first described in the 18th century but was first accurately defined by Le Mierre in 1936. In fact, although George Washington's death in 1796 was attributed by some to quinsy (today we call it peritonsillar abscess), which is a pocket of pus behind the tonsils, it could have actually been due to epiglottitis.

In the past, epiglottitis was more common in children than in adults. This difference was believed to be because of the smaller diameter of children's epiglottic opening when compared to adults. Epiglottitis in the very young (younger than 1 year of age) is unusual.

In the past, Haemophilus influenzae type b (or Hib) was the most common organism related to epiglottitis. Although it still occurs in unvaccinated children, since 1985, with the widespread vaccination against Hib, the overall incidence of the disease among children has dropped dramatically.

A conservative estimate of the incidence of epiglottitis is 1 case per 100,000 people in the U.S. each year.

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Epiglottitis Causes

Most epiglottitis is caused by bacterial, fungal or viral infection, especially among adults.

  • Common infectious causes are Haemophilus influenzae, Streptococcus pneumoniae and other strep species, respiratory tract viruses. The infectious causes increase in immunocompromised patients.
  • Other types of epiglottitis are caused by heat damage. Thermal epiglottitis occurs from drinking hot liquids; eating very hot solid foods; or using illicit drugs (i.e., inhaling the tips of marijuana cigarettes or metal pieces from crack cocaine pipes). In these cases, the epiglottitis from thermal injury is similar to the illness caused by infection.
  • Unusual causes of epiglottitis include brown recluse spider bites to the ear, which may result in swelling, or eating buffalo fish, which may cause an allergic-like reaction and swelling. Blunt trauma or something blocking the throat may also lead to epiglottitis.

Epiglottitis Symptoms

When epiglottitis strikes, it usually occurs quickly, from just a few hours to a few days. The most common symptoms include sore throat, muffling or changes in the voice, difficulty speaking, fever, difficulty swallowing, fast heart rate, and difficulties in breathing.

Fever is usually high in children but may be lower in adults or in cases of thermal epiglottitis.

  • Signs of respiratory distress, or trouble breathing, are seen with epiglottitis. Signs include drooling, leaning forward to breathe, taking rapid shallow breaths, "pulling in" of muscles in the neck or between the ribs with breathing, a high-pitched whistling sound when breathing, and trouble speaking. Someone with acute epiglottitis usually looks very ill.
  • Children may sit in a "sniffing position" with the body leaning forward and the head and nose tilted forward and upward.
  • People with epiglottitis may appear restless and breathing with their neck, chest wall, and upper belly muscles. 80% of people with epiglottis will have stridor, a high-pitched whistling sound when they breathe in (during inspiration).
  • Typically, a child who comes to the hospital with epiglottitis has a history of fever, difficulty talking, irritability, and problems swallowing for several hours. The child often sits forward and drools. In infants younger than 1 year of age, signs and symptoms such as fever, drooling, and upright posturing may all be absent. The infant may have a cough and a history of an upper respiratory infection. So, it is very difficult to know if an infant has epiglottitis.
  • In contrast, adolescents and adults have more recognizable symptoms, with the main complaints being sore throat, fever, difficulty breathing, drooling, and stridor (noise with breathing).
  • Doctors have characterized adult epiglottitis into 3 categories:
    • Category 1: Severe respiratory distress with imminent or actual respiratory arrest. People typically report a brief history with a rapid illness that quickly becomes dangerous. Blood cultures, which are tests that check for bacteria in the blood, are often positive for Hib.
    • Category 2: Moderate-to-severe clinical symptoms and signs of considerable risk for potential airway blockage. Symptoms and signs usually include sore throat, inability to swallow, difficulty in lying flat, muffled "hot potato" voice (speaking as if they have a mouthful of hot potato), stridor, and the use of accessory respiratory muscles with breathing.
    • Category 3: Mild-to-moderate illness without signs of potential airway blockage. These people often have a history of illness that has been occurring for days with complaints of sore throat and pain upon swallowing.

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When to Seek Medical Care

Call 911 or go to the nearest emergency room if you have a sore throat accompanied by any of the following signs and symptoms:

  • Muffled voice
  • Swallowing problems
  • Difficulty speaking
  • Fast heartbeat
  • Irritability
  • Bluish skin
  • Respiratory distress characterized by drooling, shortness of breath, rapid shallow breathing, very ill-looking appearance, upright posturing with tendency to lean forward, and stridor (high-pitched sound when breathing in)

Epiglottitis is a medical emergency. Someone who is suspected of having epiglottitis should be taken to the hospital immediately. Try to keep the person as calm and comfortable as possible. Make no attempt at home to inspect the throat of a person suspected of having epiglottitis. This can cause the windpipe and surrounding tissues to close and an irregular heart beat, which can lead to respiratory and/or cardiac arrest (stopping of breathing and/or heart) and death.

Exams and Tests

  • The doctor may perform x-rays or simply look at the epiglottis and the windpipe by laryngoscopy.
    • The doctor may find that the pharynx is inflamed with a beefy cherry-red, stiff, and swollen epiglottis.
    • Because manipulation of the epiglottis may result in sudden fatal airway obstruction and because irregular slow heart rates have occurred with attempts at intubation (putting a tube down the throat and placing the person on a machine that helps with breathing), the doctor will likely use the controlled environment of an operating room or intensive care unit to see the throat structures.
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  • Other laboratory tests may include the following:
    • Blood tests to look for infection or inflammation
    • Complete Blood count with differentialArterial blood gas, which measures oxygenation of the blood
    • Blood cultures (blood samples that may grow bacteria), which can indicate the cause of the epiglottitis
    • Other immunologic tests looking for antibodies to specific bacteria or viruses
    • In intubated patients, epiglottal culture

These laboratory tes

ts may not be useful in diagnosing epiglottitis until the person is stable. Also, the anxiety from having blood drawn or cultures taken from the throat may cause the unstable epiglottis to close off, completely obstructing the airway and creating an emergency with only a few minutes to correct.
Even with all of our modern technology, epiglottitis is not easy to diagnose. It is often mistakenly diagnosed as strep throat or croup. Epiglottitis differs from croup by its worsening progress, lack of a barking cough, and a cherry-red swollen epiglottis versus a red nonswollen epiglottis in croup. One way doctors can tell epiglottitis from croup is by taking X-rays of the neck, which can show the swollen epiglottis.

Still, there are other misdiagnoses of epiglottitis. They include diphtheria, peritonsillar abscess, and infectious mononucleosis.

Noninfectious causes have been mistaken as angioedema (swelling of the tissues in the airway), laryngeal inflammation or spasm, laryngeal trauma, cancerous growths, allergic reactions, thyroid gland infection, epiglottic hematoma (trapped blood pocket), hemangioma (abnormal collection of blood vessels), or inhalational injury.

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Epiglottitis Treatment: Medical Treatment

Immediate hospitalization is required whenever the diagnosis of epiglottitis is suspected. The person is in danger of sudden and unpredictable closing of the airway. So doctors must establish a secure way for the person to breathe. Antibiotics may be given.

  • Initial treatment of epiglottitis may consist of making the person as comfortable as possible. For instance, an ill child may be placed in a dimly-lit room with the parent holding the child. Then humidified oxygen may be added while the child is closely monitored. If there are no signs of respiratory distress, IV fluids may be helpful. It is important to prevent anxiety, because it may lead to an acute airway obstruction especially in children.
  • People with possible signs of airway obstruction require laryngoscopy in the operating room or intensive care unit with proper staff and airway intervention equipment. In very severe cases, the doctor may need to perform a cricothyrotomy (cutting the neck to insert a breathing tube directly into the windpipe).
  • IV antibiotics may effectively control inflammation and get rid of the infection from the body. Antibiotics are usually prescribed to treat the most common types of bacteria. Blood cultures are usually obtained with the premise that any organism found growing in the blood can be attributed as the cause of the epiglottitis. However, in many cases, blood cultures may fail to yield this information. If patient is intubated, direct cultures taken from the epiglottis can be higher yield
  • Corticosteroids and epinephrine have been used in the past. However, many experts now doubt that these medications are helpful in most cases of epiglottitis.

Prevention

Epiglottitis can often be prevented with proper vaccination against H influenza type b (Hib). Adult vaccination is not routinely recommended, except for people with immune problems such as sickle cell anemia, splenectomy (removal of the spleen), cancers, or other diseases affecting the immune system.

If there is a house with a Hib-infected person, preventive medication such as rifampin (Rifadin) should be given to anyone else in the house who is:

  • Under age 4 years and has not received all the Hib vaccinations
  • Under 12 months and has not finished the first series of Hib vaccine
  • Under age 18 with a weakened immune system

This is to make sure that both the person with the illness and the rest of the household have the bacteria completely eradicated from their bodies. This prevents formation of a "carrier state" in which a person has the bacteria in the body but is not actively sick. Carriers can still spread the infection to other family members.

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Next Steps: Follow-up

Follow-up involves continuing to take all antibiotics until the full course is completed, keeping all follow-up appointments with the doctor and with the surgeon if a breathing tube had to be placed through the neck. The surgeon will remove the tube and make sure the site is healing well. Most people improve significantly before leaving the hospital, so taking the antibiotics and returning to the hospital if there are any problems are the most important parts of follow-up.

Outlook

A person with epiglottitis can recover very well with a good prognosis if the condition is caught early and treated in time. In fact, a good majority of people with epiglottitis do well and recover without problems. But if the person was not brought to the hospital early and was not appropriately diagnosed and treated, the prognosis may range from long-range illness to death.

  • Before 1973, about 32% of adults with epiglottitis died from the disease. With current vaccination programs along with earlier recognition and treatment, the overall death rate from epiglottitis is estimated to be less than 1%. The death rate from epiglottitis in adults is higher than that of children because the condition can be misdiagnosed.
  • Epiglottitis can also occur with other infections in adults, such as pneumonia. Most commonly, it is misdiagnosed as a strep throat. However, if it is caught early and treated appropriately, a person can expect to fully recover. Most of the deaths come from failure to diagnose it in a timely fashion and obstruction of the airway. As with any serious infection, bacteria may enter the blood, a condition called bacteremia, which may result in infections in other systems and sepsis (severe infection with shock, often with respiratory failure).

Multimedia

Media file 1: Location of the epiglottis.

Media type: Illustration

Synonyms and Keywords

epiglottis, acute supraglottitis, thermal epiglottitis, peritonsillar abscess, croup, H influenzae type b, Hib, Streptococcus pneumoniae, Haemophilus parainfluenzae, varicella-zoster, herpes simplex virus type 1, Staphylococcus aureus, inspiratory stridor, laryngoscopy, epiglottitis

WebMD Medical Reference from eMedicineHealth Reviewed by Sabrina Felson, MD on October 14, 2019

Sources

Authors and Editors

Author: Gerald E Maloney, Jr, DO, Attending Physician, Clinical Instructor of Emergency Medicine, Department of Emergency Medicine, John Stroger Hospital of Cook County.

Coauthor(s): William R Fraser, DO, Associate Clinical Professor, Department of Emergency Medicine, Ohio University College of Osteopathic Medicine; Program Director, Department of Emergency Medicine, Doctors Hospital.

Editors: Marian Gambrell, MD, Clinical Assistant Professor, Department of Emergency Medicine, St Lukes-Roosevelt Hospital Center, Columbia University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James S Cohen, MD, Consulting Staff, James Cohen, PC.

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