epiglottitis

Epiglottitis 

Definition

Epiglottitis is an infection of the epiglottis, which can lead to severe airway obstruction.

Description

When air is inhaled (inspired), it passes through the nose and the nasopharynx or through the mouth and the oropharynx. These are both connected to the larynx, a tube made of cartilage. The air continues down the larynx to the trachea. The trachea then splits into two branches, the left and right bronchi (bronchial tubes). These bronchi branch into smaller air tubes that run within the lungs, leading to the small air sacs of the lungs (alveoli).

Either food, liquid, or air may be taken in through the mouth. While air goes into the larynx and the respiratory system, food and liquid are directed into the tube leading to the stomach, the esophagus. Because food or liquid in the bronchial tubes or lungs could cause a blockage or lead to an infection, the airway is protected. The epiglottis is a leaf-like piece of cartilage extending upwards from the larynx. The epiglottis can close down over the larynx when someone is eating or drinking, preventing these food and liquids from entering the airway.

Epiglottitis is an infection and inflammation of the epiglottis. Because the epiglottis may swell considerably, there is a danger that the airway will be blocked off by the very structure designed to protect it. Air is then unable to reach the lungs. Without intervention, epiglottitis has the potential to be fatal.

Epiglottitis is primarily a disease of two to seven-year-old children, although older children and adults can also contract it. Boys are twice as likely as girls to develop this infection. Because epiglottitis involves swelling and infection of tissues, which are all located at or above the level of the epiglottis, it is sometimes referred to as supraglottitis (supra, meaning above). About 25% of all children with this infection also have pneumonia.

Causes and symptoms

The most common cause of epiglottitis is infection with the bacteria called Haemophilus influenzae type b. Other types of bacteria are also occasionally responsible for this infection, including some types of Streptococcus bacteria and the bacteria responsible for causing diphtheria.

A patient with epiglottitis typically experiences a sudden fever, and begins having severe throat and neck pain. Because the swollen epiglottis interferes significantly with air movement, every breath creates a loud, harsh, high-pitched sound referred to as stridor. Because the vocal cords are located in the larynx just below the area of the epiglottis, the swollen epiglottis makes the patient's voice sound muffled and strained. Swallowing becomes difficult, and the patient may drool. The patient often leans forward and juts out his or her jaw, while struggling for breath.

Epiglottitis strikes suddenly and progresses quickly. A child may begin complaining of a sore throat, and within a few hours be suffering from extremely severe airway obstruction.

Diagnosis

Diagnosis begins with a high level of suspicion that a quickly progressing illness with fever, sore throat, and airway obstruction is very likely to be epiglottitis. If epiglottitis is suspected, no efforts should be made to look at the throat, or to swab the throat in order to obtain a culture for identification of the causative organism. These maneuvers may cause the larynx to go into spasm (laryngospasm), completely closing the airway. These procedures should only be performed in a fully-equipped operating room, so that if laryngospasm occurs, a breathing tube can be immediately placed in order to keep the airway open.

An instrument called a laryngoscope is often used in the operating room to view the epiglottis, which will appear cherry-red and quite swollen. An x-ray picture taken from the side of the neck should also be obtained. The swollen epiglottis has a characteristic appearance, called the "thumb sign."

Treatment

Treatment almost always involves the immediate establishment of an artificial airway: inserting a breathing tube into the throat (intubation); or making a tiny opening toward the base of the neck and putting a breathing tube into the trachea (tracheostomy). Because the patient's apparent level of distress may not match the actual severity of the situation, and because the disease's progression can be quite surprisingly rapid, it is preferable to go ahead and place the artificial airway, rather than adopting a wait-and-see approach.

Because epiglottitis is caused by a bacteria, antibiotics such as cefotaxime, ceftriaxone, or ampicillin with sulbactam should be given through a needle placed in a vein (intravenously). This prevents the bacteria that are circulating throughout the bloodstream from causing infection elsewhere in the body.

Prognosis

With treatment (including the establishment of an artificial airway), only about 1% of children with epiglottitis die. Without the artificial airway, this figure jumps to 6%. Most patients recover form the infection, and can have the breathing tube removed (extubation) within a few days.

Prevention

Prevention involves the use of a vaccine against H. influenzae type b (called the Hib vaccine). It is given to babies at two, four, six, and 15 months. Use of this vaccine has made epiglottitis a very rare occurrence.

Resources

Organizations

American Academy of Otolaryngology-Head and Neck Surgery, Inc. One Prince St., Alexandria VA 22314-3357. (703) 836-4444. http://www.entnet.org.

Key terms

Epiglottis — A leaf-like piece of cartilage extending upwards from the larynx, which can close like a lid over the trachea to prevent the airway from receiving any food or liquid being swallowed.

Extubation — Removal of a breathing tube.

Intubation — Putting a breathing tube into the airway.

Laryngospasm — Spasm of the larynx.

Larynx — The part of the airway lying between the pharynx and the trachea.

Nasopharynx — The part of the airway into which the nose leads.

Oropharynx — The part of the airway into which the mouth leads.

Supraglottitis — Another term for epiglottitis.

Trachea — The part of the airway that leads into the bronchial tubes.

Tracheostomy — A procedure in which a small opening is made in the neck and into the trachea. A breathing tube is then placed through this opening.

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epiglottitis /epi·glot·ti·tis/ (ep″ĭ-glŏ-ti´tis) supraglottitis.

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ep·i·glot·ti·tis (p-gl-tts)

n.

Inflammation of the epiglottis.

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ep·i·glot·ti·di·tis (-glti-dts) n.

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epiglottitis

[ep′iglotī′tis]

Etymology: Gk, epi + glossa, tongue, itis, inflammation

an inflammation of the epiglottis. Acute epiglottitis is a severe form of the condition, which primarily affected children 2 to 7 years of age before a significant decrease in the occurrence of the disease resulting from the introduction of the Haemophilus influenzae B vaccine in 1985. It is characterized by fever; sore throat; drooling; stridor; croupy cough; and an erythematous, swollen epiglottis. The patient may become cyanotic and require an emergency tracheostomy to maintain respiration. The causative organism is usually Haemophilus influenzae, type B, but it can also be caused by Streptococcus, groups A, B, and C; S. pneumoniae; Klebsiella pneumoniae; Candida albicans; Staphylococcus aureus; Neisseria meningitides; Varicella zoster; and other viruses. Antibiotics, rest, oxygen, and supportive care are usually included in treatment. Also called epiglottiditis. See also acute epiglottitis.

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epiglottitis

Pediatrics Inflammation of epiglottis and oropharyngeal region Clinical Abrupt high fever, dysphagia, drooling, muffled speech, cyanosis, stridor, inspiratory retractions, sniffing dog position, ±respiratory arrest Imaging Thumbprint sign DiffDx Angioneurotic edema, bacterial tracheitis, croup, foreign body aspiration, retropharyngeal abscess Etiology In pre-HIB vaccination era, H influenzae; newer culprits include group A streptococci, S pneumoniae, Corynebacterium diphtheriae, TB Management Stat intubation; antibiotics–eg, ceftriaxone, ampicillin. See Thumbprint sign.