Acute epiglottitis

Acute epiglottitis is an acute inflammatory condition of the epiglottis and nearby structures like the arytenoids, aryepiglottic folds, and vallecula.It is a life-threatening infection that causes profound swelling of the upper airways which can lead to asphyxia and respiratory arrest.Bacterial etiology is the most common cause of epiglottitis. Soft tissue lateral xray of neck shows thumb sign. Airway management is the main concern of epiglottitis.

1. Acute Epiglottitis Insp Dr Mahadev Deuja Thursday, October 11, 2018

2. Outlines Introduction Anatomy Epidemiology Clinical presentation Evaluation Treatment Prognosis Prophylaxis

3. Introduction Epiglottitis is an inflammatory condition of the epiglottis and nearby structures like the arytenoids, aryepiglottic folds, and  vallecula . It is a life-threatening infection that causes profound swelling of the upper airways which can lead to asphyxia and respiratory arrest

4. Anatomy Leaf like, yellow, elastic cartilage forming anterior wall of laryngeal inlet. Attached to body of hyoid bone by hyoepiglottic legament

5. Cont.. Supraglottic structures Epiglottis Aryepiglottic folds and Arytenoids

6. Etiology Infectious (common) It can be bacterial or fungal in origin Haemophilus influenzae   type B (HIB) Most common cause. This has decreased since the widespread use of immunization. However, even vaccinated children can develop epiglottitis due to non – type b  H influenzae Other agents include  Streptococcus pyrogenes , S. pneumoniae ,  and  S. aureus   In immunocompromised hosts,  Pseudomonas aeruginosa   and  Candida  Noninfectious Thermal inhalational injury or thermal ingestion Trauma to the upper airway, such as foreign bodies, and chemical irritation.

7. Epidemiology Addition of the HIB vaccine immunization has decreased the overall incidence of epiglottitis in children. However, the incidence in adults has remained stable. Additionally, the age of children who have had epiglottitis has increased from 3 years old to about 6 to 12 years old

8. Clinical presentation Onset and progression of symptoms is rapid (George Washington woke up with a sore throat and died the same night), Usually occurred within the last 12 to 24 hours. The patient will appear toxic. They will likely be sitting upright with their mouth open in tripod position and possibly have a muffled voice.   D rooling, d ysphagia , and d istress, or anxiety in children ( 3 Ds ) are common presenting symptoms Fever may go upto 40 ·c.

9. Cont.. Swelling of the upper airway results in turbulent airflow during inspiration causing stridor . Signs of severe upper airway obstruction such as Intercostal or suprasternal retractions Tachypnea cyanosis (concerning for impending respiratory failure)

10. Examination Diagnosis is primarily one of clinical suspicion. An oropharyngeal exam is performed to evaluate a suspected case of epiglottitis . Depressing the tongue with tongue depressor may show red and swollen epiglottis. A flexible fiberoptic laryngoscopy May show edema and congestion of supraglottic structures. Performed only in a very controlled setting such as the operating room due to the risk of inducing laryngospasm .

11. Xray of neck Lateral soft tissue X-ray of neck may show swollen epiglottis (thumb sign) It is a manifestation of an enlarged and edematous epiglottis.

12. Usg Has been mentioned as another way to evaluate these patients, revealing an “alphabet P sign” in a longitudinal view. Measurement of the anterior posterior diameter of the epiglottitis was effective in making the diagnosis.

13. Other investigations CBC with differential, blood culture. An epiglottal culture should only be obtained in patients with a secured ET tube.

14. CT & MRI Helpful to evaluate the complications Including spread of the infection and abscess formation. Thickening of the epiglottis, obliteration of the pre- epiglottic fat and thickening of the subcutaneous tissue and muscles are common radiological findings in epiglottic abscess  CT:-hypo-attenuating area (A) is suggestive of fluid or the early formation of an abscess. E - epiglottis

15. DD’S Infectious processes: Mononucleosis, diphtheria, pertussis , croup, tonsillitis Ludwig’s angina with retropharyngeal, Peripharyngeal and peritonsillar abscesses, tracheobronchitis , subglottic laryngitis. Non-infectious diseases Allergic reactions, angioneurotic oedema , foreign body aspiration, Reflex laryngospasm , laryngeal trauma, tumours , hydrocarbon aspiration, systemic lupus erythematosis and inhalation of toxic fumes or superheated steam

16. Complications In some cases, infection can spread to nearby parts of the body, including : Inner ear ( otitis media) Brain (meningitis) Heart lining ( pericarditis ) Lungs (pneumonia)

17. Treatment/management Avoid agitating the patient, take a position in which he or she feels comfortable. The mainstay of treatment is to secure the airway. Unstable patients require immediate airway management Experienced providers should intubate these patients since their airways are regarded as difficult. An individual capable of performing a tracheotomy should be available if needed. Patients without signs of airway compromise, respiratory difficulty, stridor , or drooling, and who have only mild swelling on laryngoscopy , may be managed without immediate airway intervention by close monitoring in ICU Patient should be admitted to the ICU  after the airway is secured. Corticosteroids (hydrocortisone or dexamethasone ) To reduce edema To reduce ICU stay.

18. Treatment Empirically antimicrobials should be initiated. Ampicillin Third gen.cephalosporin - effective against H.influenzae given by parenteral route ( i.m / i.v ) Once culture and sensitivity results are available, the regimen should be adjusted. Adequate hydration - parenteral fluids Humidification and oxygen

19. Prophylaxis Close contacts of patients with  H. influenzae  should be prescribed rifampin prophylaxis. Although  H influenzae  vaccine is available, it is not 100% effective Patients having recurrent episodes of acute epiglottitis warrant investigation of the immune system.

20. Prognosis Good with appropriate and timely treatment. Most patients can be extubated within several days. However, unrecognized epiglottitis may rapidly lead to airway compromise and resultant death. The risk of death is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures.

21. Take home message Epiglottitis is an inflammatory condition of the epiglottis and nearby structures. It is usually an infectious process of bacterial etiology directly or from bacteremia Diagnosis is primarily one of clinical suspicion. Lateral xray neck shows thumb sign. Airway management is the most urgent consideration.

22. Mcq’s Which is true of acute epiglottitis ?    It is commonly seen in the elderly It can be treated as an outpatient with antibiotics It is a cause of stridor Oral examination is necessary for these patients

23. What is the most common cause of epiglottitis ?   E coli Staphylococcus  H influenza Streptococcus

24. Which of the following symptoms associated with acute epiglottitis is INCORRECT? Sudden onset Drooling Better when lying flat Fever

25. Refrences emedicine.com. Accessed October 9, 2018]. Diseases of EAR, NOSE & THROAT. Elsevier India; https://knowledge.statpearls.com/chapter/0/21236?utm_source=pubmed

26. Thank you Next presentation : Insp Dr Subash Chandra Gautam AKI