Epiglottitis

Follow-up Rounds
1/13/2017
Article inspired by: Dr. Maninder Singh, PGY-3

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THE CASE

37 y/o M with no significant PMHx who p/w “allergic reaction” after taking the first dose of PCN 2 hours ago prescribed for Strep Throat diagnosed at an urgent care center. He endorses a sore throat and fever x 2 days but denies any hives or lip/tongue swelling. Denies any prior allergic reactions.

Physical Exam:

• Vitals: BP: 133/76, HR: 107, RR: 15, Temp: 99F, SpO2: 100%
• General: Appears well
• HEENT: NC/AT, PERRL, EOMI, Uvula is midline, Moist mucous membranes, No tonsillar abscesses, Muffled voice, No visible upper oral airway obstruction, Increased saliva production noted; Neck supple, Some lymph node swelling to left precervical nodes
• Cardiovascular: RRR, No murmurs/rubs/gallops
• Chest: CTA b/l, No wheezes/rales/rhonchi
• Abdominal: Soft, NT/ND, BS+ x4
• Extremities: FROM

 

Soft Tissue Neck X-ray:

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THE TALK

What is an epiglottis?

• Back wall of the vallecular space below base of tongue
• Infectious epiglottitis = cellulitis of epiglottis
  • Progresses to involve entire supraglottic larynx (including aryepiglottic folds and arytenoids) leading to difficulty breathing

Isn’t epiglottitis a pediatric diagnosis?

• Incidence decreased in children since haemophilus influenza vaccination
• Incidence in adults (2006): 1.6 cases per 100,000 adults
  • Usually a/w HTN, DM, Substance abuse or immune deficiency

How do I diagnose it?

• Fiberoptic nasal laryngoscopy = gold standard
• Lateral neck x-ray: look for the “thumbprint” sign
• CT neck (if diagnosis unclear)

What do I do if I suspect/diagnose it?

• MANAGE AIRWAY- Be prepared for a cricothyrotomy!
• Have patient sitting up in bed
• Consider prophylactic intubation
  • Risk of laryngospasm with scope
• Heliox (mixture of Helium and Oxygen) can be used as a temporizing measure
• Augmentin or Ampicillin-sulbactam (Unasyn) are preferred initial antibiotics
• Consider Vancomycin if patient is critically ill and MRSA a possible etiology
• NSAIDS for pain control
• +/- Steroids for symptomatic relief

This was too long and I didn’t read it- what should I know?

• Patient with sore throat and muffled voice but no obvious signs of upper airway obstruction need further work up
• Have your triple set up ready (direct laryngoscope, video laryngoscope and cricothyroidectomy) and have backup (ENT/Anesthesia) available for a difficult airway

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REFERENCES/FURTHER READING:

• Frantz TD, Rasgon BM, Quesenberry CP. Acute Epiglottitis in Adults: Analysis of 129 Cases. 1994;272(17):1358-1360.
• Woods, Charles. “Epiglottitis (supraglottitis): Clinical Features and Diagnosis.” UpToDate, 23 June 2015. Web.
• Rogers, Matt. “Epiglottitis.” Core EM, 26 Aug. 2015. Web.