More Than a Sore Throat: Acute Epiglottitis

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Not every sore throat you encounter in the emergency department is strep throat. Keeping your differential broad for the patient with sore throat can help to prevent a clinician from missing a deadly presentation of sore throat – acute epiglottitis.

The epidemiology of epiglottitis has changed significantly in the past several decades due to the introduction of the vaccination and widespread immunization of children against Haemophilus influenza type B (HIB) [1]. Although cases of pediatric acute epiglottitis have decreased, they have not disappeared. Furthermore, cases of acute epiglottitis in adults continue to persist as many have not been vaccinated against HIB and the causative agents in adults are much more diverse, with Streptococcus pneumoniae contributing to a majority of identified adult cases [2].

Presentation and Work-Up

Fig 1. Lateral Soft Tissue Neck X-Ray Depicting Edema of the epiglottis [9]

Fig 1. Lateral Soft Tissue Neck X-Ray Depicting Edema of the epiglottis [9]

The clinical presentation of a patient with epiglottitis can vary, but a few cardinal features may help to solidify this potentially disastrous diagnosis. Sore throat and pain with swallowing are the most common symptoms of patients presenting with acute epiglottitis, with sore throat present in 81.5% of cases and odynophagia reportedly in 94.3% of cases [3,4]. Other symptoms include fever, drooling, hoarseness with the classic “hot potato” voice, and respiratory difficulty. In patients with epiglottitis, the most common medical comorbidities were smoking, hypertension and diabetes [5].

On physical examination, pediatric patients will often be febrile, sit in a “sniffing position”, and have audible stridor due to upper airway obstruction. However, in adult patients, epiglottitis can present insidiously with symptoms of sore throat and dysphagia; if stridor or dyspnea are present, patients are likely to have imminent airway compromise and will need to be moved to a high acuity area of the emergency department [6]. Laboratory studies typically show a leukocytosis and elevated inflammatory markers such as C-Reactive Protein (CRP) [4]. Obtaining blood cultures early in the clinical course of these patients can help tailor antibiotics to the appropriate causative organism and therefore should be ordered as part of the patient’s initial workup.

Soft tissue neck radiographs may also be helpful in aiding with diagnosis, however are not required in patients of which you have a high clinical suspicion of epiglottis. On lateral neck radiography, patients with acute epiglottitis will classically have the “thumb print” sign which is seen due to the edema of the epiglottis (Fig. 1). Lateral neck radiographs can also be used to measure the width of the epiglottis. Epiglottis width of >6.3mm had a sensitivity of 75.8% and specificity of 97.8% for the diagnosis of acute epiglottitis [7]. If soft tissue neck radiographs are equivocal and there is concern for possibility of retropharyngeal abscess, CT imaging of the neck can be used to further delineate the cause of the patient’s presentation.

Management

FIG. 2. Severe Epiglottitis with Edema/Erythema visualized by NP Scope [10]

FIG. 2. Severe Epiglottitis with Edema/Erythema visualized by NP Scope [10]

Managing the airway is of the utmost importance in patients with epiglottitis. In children with suspected epiglottitis and evidence of respiratory distress, it is important to minimize procedures which will agitate them or cause anxiety until their airway can be secured. In adults who are protecting their airway, warmed and humidified supplemental oxygen can be used to assist with oxygenation. A recent study suggests that in the post-HIB vaccination era, approximately 10.9% of cases require securing of the airway [5]. It is preferred to directly visualize the epiglottis via a nasopharyngeal scope to assess for edema/erythema and secure the airway of these patients in a controlled setting such as the operating room if possible (Fig. 2.) In all circumstances when intubating a patient with epiglottis, the clinician managing the airway must be fully prepared to perform an emergent surgical airway if rapid sequence intubation is unsuccessful. Patients without respiratory distress and are protecting their airway may be managed with close observation in an intensive care setting.

Antibiotics are also indicated in the setting of acute epiglottitis, and antibiotic selection should be based on the patient’s age, vaccination status, and suspected pathogen causing their presentation. The most frequently used antibiotic regimen for acute epiglottitis includes a third generation cephalosporin and metronidazole [8]. Steroids are also commonly used, however, the benefit of steroid use in these patients remains controversial at this time [5].

 Authored by Stephanie Winslow, MD

Dr. Winslow is a PGY-1 in Emergency Medicine at the University of Cincinnati

Post and Peer Editing by Shan Modi, MD

Dr. Modi is a PGY-3 in Emergency Medicine at the University of Cincinnati and Resident Editor of the ‘Minor Care Series’

Faculty Editing by Edmond Hooker, MD, DRPH

Dr. Hooker is an Assistant Professor of Emergency Medicine at the University of Cincinnati and Faculty Editor of the ‘Minor Care Series’

References:

  1. McVernon, J et al. “Changes in the epidemiology of epiglottitis following introduction of Haemophilus influenzae type b (Hib) conjugate vaccines in England: a comparison of two data sources.” Epidemiology and infection vol. 134,3 (2006): 570-2. doi:10.1017/S0950268805005546

  2. Isakson, M, and S Hugosson. “Acute Epiglottitis: Epidemiology and Streptococcus Pneumoniae Serotype Distribution in Adults.” The Journal of Laryngology & Otology, vol. 125, no. 4, 2010, pp. 390–393., doi:10.1017/s0022215110002446.

  3. Wu, I. Ying, et al. “Clinical Features of Patients with Acute Epiglottitis in the Emergency Department.” Hong Kong Journal of Emergency Medicine, vol. 26, no. 5, Sept. 2019, pp. 268–274, doi:10.1177/1024907918773217.

  4. Guldfred, L-A, et al. “Acute Epiglottitis: Epidemiology, Clinical Presentation, Management and Outcome.” The Journal of Laryngology & Otology, vol. 122, no. 8, 2008, pp. 818–823., doi:10.1017/S0022215107000473.

  5. Sideris, Anders, et al. “A Systematic Review and Meta‐Analysis of Predictors of Airway Intervention in Adult Epiglottitis.” The Laryngoscope, vol. 130, no. 2, 2019, pp. 465–473., doi:10.1002/lary.28076.

  6. Ames WA, Ward VMM, Tranter RMD, Street M. Adult epiglottitis: an under‐recognized, life‐threatening condition. Br J Anaesth. 2000;85(5):795-797. doi:10.1093/bja/85.5.795

  7. Lee, Sun Hwa, et al. “Do We Need a Change in ED Diagnostic Strategy for Adult Acute Epiglottitis?” The American Journal of Emergency Medicine, vol. 35, no. 10, 2017, pp. 1519–1524., doi:10.1016/j.ajem.2017.04.039.

  8. Baird, Samantha M., et al. “Review of Epiglottitis in the Post Haemophilus Influenzae Type-b Vaccine Era.” ANZ Journal of Surgery, vol. 88, no. 11, 2018, pp. 1135–1140., doi:10.1111/ans.14787.

  9. Epiglottitis.jpg (400×628). https://upload.wikimedia.org/wikipedia/commons/5/5c/Epiglottitis.jpg. Accessed April 26, 2020.

  10. Epiglottitis Endoscopy; 2013. Accessed May 9, 2020. https://commons.wikimedia.org/wiki/File:Epiglottitis_endoscopy.jpg