Epiglottitis

What is Epiglottitis?

Epiglottitis is a medical emergency. If not treated quickly, it can be fatal.  

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 (block) or close off your windpipe, which makes you unable to breathe.

Respiratory infection, things in the environment, or trauma may cause inflammation and infection of other areas around the throat. The infection and inflammation may spread to the epiglottis and other areas. 

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 with those of adults. Epiglottitis in children under the age of 1 year is unusual.

In the past, Haemophilus influenzae type b (or Hib) was the most common organism related to epiglottitis. Since 1985, with the widespread vaccination against Hib, far fewer children have gotten the disease. 

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, and respiratory tract viruses. People who have immune system problems are in greater danger of infection.

  • 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 includebrown 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, swallowing or breathing, fever, and fast heart rate.

Symptoms in children often happen within hours. They include:

  • Upper respiratory infections 

  • Sudden, very sore throat 

  • Fever  

  • Stridor, a high-pitched whistling sound when your child breathes in

  • Muffled voice 

  • Drooling

  • No coughing

  • Anxiety or restlessness  

  • Leaning forward while seated

  • Keeping their mouth open

  • Not being able to talk

  • Trouble breathing

  • Blue skin, a condition called cyanosis  

Adults and older children often have symptoms that come on over a few days, such as:

  • Very sore throat

  • Fever 

  • Hoarse or muffled voice 

  • Stridor 

  • Pain or difficulty in swallowing 

  • Drooling

  • Irritability or restlessness 

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 with drooling, shortness of breath, rapid shallow breathing, very ill-looking appearance, sitting upright with a tendency to lean forward, and stridor (high-pitched sound when breathing in)

Epiglottitis is a medical emergency. Anyone who might have 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.

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Epiglottitis Diagnosis

  • The doctor may perform X-rays or simply look at the epiglottis and the windpipe bylaryngoscopy.

    • The doctor may find that the pharynx is inflamed with a beefy, cherry-red, stiff and swollen epiglottis.

    • Manipulating the epiglottis may result in sudden fatal airway obstruction, and 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). That’s why the doctor will likely use an operating room or intensive care unit to examine the throat.

  • Other laboratory tests may include:

    • Blood tests to look for infection or inflammation

    • Tests to measure oxygen in the blood

    • Blood cultures (blood samples that may grow bacteria), which can indicate the cause of the epiglottitis

    • Other tests to find antibodies to specific bacteria or viruses (immunologic tests)

    • In intubated patients, epiglottal culture

These laboratory tests 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 blocking 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 mistaken for strep throat or croup. Epiglottitis differs from croup by its worsening progress, lack of a barking cough, and a cherry-red, swollen epiglottis (unlike a red, unswollen 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.

Other misdiagnoses of epiglottitis include diphtheria, peritonsillar abscess, andinfectious mononucleosis.

Non-infectious 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.

Epiglottitis 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.

  • Treatment of epiglottitis may start with 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, the child may get humidified oxygen while being closely watched. 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 taken to show whether an organism is growing in the blood that could be causing the epiglottitis. In many cases, blood cultures may not show if this is the problem. If a patient is intubated, cultures taken directly from the epiglottis may work better.

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Corticosteroids and epinephrine have been used in the past. However, many experts now doubt that these drugs are helpful in most cases of epiglottitis.

Treatment follow-up 

Take all antibiotics until the full course is completed. Keep 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 feel much better 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.

Epiglottitis Complications

Possiblecomplications of epiglottitis include: 

  • A swollen, narrowed airway that can causerespiratory failure 

  • Infections that can spread to other parts of your body 

Epiglottitis Prevention

Epiglottitis can often be prevented with proper vaccination against H influenza type b (Hib). Adults usually do not need the vaccine unless they have immune problems like sickle cell anemia, splenectomy (removal of the spleen), cancers, or other diseases affecting the immune system.

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

  • Under the age of 4 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 done to make sure that both the person with the illness and the rest of the household do not have the bacteria. This prevents a "carrier state" from forming 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.

Epiglottitis 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 and earlier recognition and treatment, the 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 aspneumonia. If it is caught early and treated, a person can expect to fully recover. Most of the deaths come from failure to diagnose it quickly 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).

WebMD Medical Reference Reviewed by Minesh Khatri, MD on July 19, 2020

Sources

 

SOURCES:

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.

Epiglottitis from eMedicineHealth

Mayo Clinic: “Epiglottitis.” 

Boston Children’s Hospital: “Epiglottitis Symptoms & Causes.”

Children’s Hospital of Philadelphia: “Epiglottitis.” 

Cleveland Clinic: “Epiglottitis.”

 
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