Epiglottitis

What is Epiglottitis?

Epiglottitis is a condition where the epiglottis (a flap that covers the windpipe during swallowing) and nearby structures become inflamed, usually due to an infection. It can be life-threatening as it causes severe swelling in the upper part of the airway, which can lead to choking or difficulty breathing. In the past, most cases of epiglottitis were caused by a bacteria called Haemophilus influenzae, but this has become less common with the introduction of the vaccine against it.

Now, a variety of germs can cause this inflammation and it can even be caused by multiple germs at once. For this reason, the term ‘supraglottitis’ is sometimes used instead, as it refers to infections that affect the upper part of the windpipe more generally. The swelling caused by these infections can gradually get worse until it becomes very serious, and causes difficulty in breathing, which can lead to death.

Symptoms can be heightened if a patient is uncomfortable or anxious, especially in children. That’s why, if epiglottitis is suspected, it is extremely important to help the patient remain calm and comfortable until doctors can ensure the airway is not blocked. Avoid poking or prodding the throat area for exams or scopes (endoscope) in a regular doctor’s office or the emergency room. Moreover, a patient with a potentially unstable breathing passage should not be sent for imaging tests, like x-rays, until their airway is secured.

What Causes Epiglottitis?

Epiglottitis, an inflammation of the epiglottis (a flap of tissue that sits at the base of the tongue and keeps food from going down the windpipe), can be a result of bacterial, viral, or fungal infections. Among children, the bacteria Haemophilus influenzae type B (HIB) plays a significant role. However, since vaccines against this type of bacteria have been widespread, cases involving it have dramatically decreased. Other agents such as Streptococcus pyogenes, S pneumoniae, and S aureus can also lead to the illness. People with a weakened immune system might develop the disease due to the bacteria Pseudomonas aeruginosa and Candida.

While it’s not typically caused by viruses, having a prior viral infection can set the stage for a bacterial “superinfection” to develop. This situation can occur with viruses like varicella-zoster, herpes simplex, and Epstein-Barr virus. Epiglottitis can also result from non-infectious causes such as injuries caused by heat, strong chemicals, or swallowing a foreign object.

Risk Factors and Frequency for Epiglottitis

Since we started giving the HIB vaccine to infants in many countries around the world, the yearly rate of epiglottitis – an inflammation of the part in the throat that prevents food from going into the windpipe – has gone down in children. Unfortunately, the number of adults getting it hasn’t changed. Moreover, the age of children suffering from epiglottitis has increased from three years old to between six and twelve years old after the introduction of the vaccine. While we used to think of epiglottitis as a disease that mainly affected young children, these days it’s more common to see it in adults.

Signs and Symptoms of Epiglottitis

Often, a preceding upper respiratory infection can hint at the onset of the condition, although this is not always the case. Typically, one might only experience mild symptoms for hours or even days before a sudden, drastic increase in severity occurs. Such a situation usually unfolds in less than 24 hours, sometimes only 12 hours. It’s common for patients to feel incredibly uncomfortable and possibly exhibit signs of toxicity. Most kids with this condition don’t exhibit early symptoms. When seen in an emergency unit, they are likely to be sitting upright, mouths open, forming a so-called ‘tripod position’, and might have a ‘muffled’ voice.

Adults may downplay their symptoms but it’s likely that they would avoid laying flat or show discomfort if they do so. Key symptoms can be referred to as the three Ds: drooling, difficulty in swallowing, and distress or anxiety. This is prevalent in both children and adults. Swelling in the upper airway can cause noisy breathing when inhaling (known medically as stridor).

• Signs of severe blockage in the upper airway like inward pulling of the chest or neck muscles
• Rapid breathing (tachypnea)
• Blue or purple skin color (cyanosis)

These are serious signs hinting at possible respiratory failure, and immediate medical intervention is crucial. Observe caution and refrain from conducting a throat examination using a tongue depressor or a flexible viewing instrument (laryngoscope), as it may obstruct the airway.

Upon examining the front of the neck, enlarged lymph nodes might be detected. If there’s cyanosis (blue or purple coloration of the skin), it could mean the infection is advanced and the prognosis is poor.

Testing for Epiglottitis

An oral exam is normally not done if a doctor thinks a patient could have epiglottitis, as it could potentially lead to difficulty breathing. Diagnosis of epiglottitis is mainly based on the doctor’s observation and understanding of the symptoms. A type of X-ray, known as a lateral neck radiograph, can show swelling of the epiglottis – a part in the throat, which may appear like a “thumb sign.”

This X-ray isn’t needed to diagnose epiglottitis but can help doctors better understand what might be causing the symptoms. However, it should only be done if the patient is stable, comfortable, and willing to cooperate. Another type of examination that can be done is flexible fiberoptic laryngoscopy (a way to see the voice box), but it’s rarely done – only in a very controlled environment like the operating room, because it could lead to spasms in the larynx, causing difficulty in breathing.

Another way of looking at the throat is by using ultrasound, but this method also depends on the patient’s condition and is not usually recommended for children. Once the doctors establish a secure breathing tube (endotracheal tube), they can do complete blood count, grow germs from a blood sample to identify the cause (blood culture), and take a sample from the epiglottis to see what germ is causing the infection.

A CT scan, another type of imaging test, for the neck is rarely used due to the risk of causing breathing problems. If a CT scan unexpectedly shows this condition, the person should instantly be taken to an operating room for further tests and a procedure to help them breathe (intubation).

An X-ray of the chest can show if pneumonia is also present in 10-15% of patients having epiglottitis. And as mentioned, a lateral neck X-ray can be done but with great care and only if the patient is willing to cooperate. There are instances where a chest X-ray can show a “steeple sign” which could be confused with another illness called bronchitis (croup). Despite these tests, the diagnosis mainly depends on the physician’s clinical judgment.

Treatment Options for Epiglottitis

The most crucial part of treating a patient with a severe airway condition is making sure they can breathe safely. Highly experienced medical professionals are needed to perform a procedure called intubation. This involves inserting a flexible tube into the patient’s windpipe (or trachea) to maintain an open airway or to deliver drugs. In some cases, this might not be enough, and a surgeon capable of performing a tracheotomy may be required. A tracheotomy is a surgical procedure to create an opening through the neck into the trachea.

After intubation, the patient is generally admitted to the intensive care unit. A swab from the patient’s airway is taken for culture testing. This will help identify what organism is causing the infection and guide the choice of antibiotics to treat it. Steroid medications may also be used to reduce swelling in the airway, and have been found to lessen the time patients spend in the intensive care unit.

Meanwhile, broad spectrum antibiotics, medications that target a wide range of bacteria, are started. Once the results of the culture test are available, these might be swapped for more targeted antibiotics.

When the doctors are confident that the patient’s airway is secure even when the tube is not inflated, they can consider removing the tube, a process called extubation.

Patients who don’t require intubation still need close monitoring. Procedures to secure their airway could be needed suddenly. Healthcare providers must be prepared for this situation, and appropriate equipment for emergency tracheostomy should be on hand. A key aspect of care for these patients is that they should never be placed on their back, to prevent choking.

If an emergency airway becomes necessary, it’s best performed in an operating room with direct visualization of the airway using a laryngoscope, a tool to view the voice box. If intubation isn’t possible, a tracheostomy may be required.

The antibiotics commonly used for these patients, like cefuroxime, ceftriaxone, and cefotaxime, are aimed at the bacteria often found in the respiratory system and mouth.

What else can Epiglottitis be?

Epiglottitis, an inflammation of the tissue that covers the windpipe, used to be mostly caused by H. influenzae bacteria. However, since the release of the HIB vaccine, this has become less common. This does not mean it has disappeared, in fact, due to some misunderstandings about vaccinations, cases are slowly increasing again. H. influenzae is still the main cause of epiglottitis in adults and children. However, because of the reduction in cases, some healthcare professionals may be less familiar with the condition. This unfamiliarity can lead to delays in starting antibiotic treatment. Remember, acute epiglottitis can lead to sudden blockage in the airways. Hence, if there’s even a small suspicion of this diagnosis, the patient should be kept under close watch with all necessary emergency equipment ready.

Do note, other conditions can show similar symptoms to epiglottitis. These include blockage by a foreign object stuck in the throat, sudden swelling in the mouth or throat (acute angioedema), burns to the throat from swallowing a caustic or corrosive substance, diphtheria, and certain types of throat abscess:

• Foreign object airway blockage
• Acute angioedema
• Caustic ingestion
• Diphtheria
• Peritonsillar abscess
• Retropharyngeal abscess

What to expect with Epiglottitis

In general, if diagnosed and treated quickly, most people with epiglottitis (an inflammation of the epiglottis situated at the entrance of the windpipe, which can block airflow to the lungs when swollen) have good outcomes. Even those who need tube insertion for assistance in breathing, which is called intubation, usually only require it for a few days and then recover fully.

However, if the diagnosis is delayed in children, it can lead to a critical issue where the airway is obstructed, and this could potentially be fatal. The cause of death is often due to sudden blockage of the upper airway and difficulty in inserting the breathing tube due to swollen structures of the voice box (larynx).

Therefore, all patients diagnosed with acute epiglottitis should be examined by an ear, nose, and throat specialist or an anesthesiologist. Also, a special kit for creating an alternative airway, known as a tracheostomy tray, should always be nearby. Worldwide, there is a 3% to 7% fatality rate reported in patients where the stability of their airway is in question.

Possible Complications When Diagnosed with Epiglottitis

Epiglottitis, an inflammation of the flap at the base of the tongue, can lead to several complications including:

• Skin infection (cellulitis)
• Infection of the neck glands (cervical adenitis)
• Potential death
• Collection of pus in the body cavity (empyema)
• Abscess on the epiglottis
• Inflammation of the protective membranes of the brain and spinal cord (meningitis)
• Infection of the lungs (pneumonia)
• Accumulation of fluid in the lungs (pulmonary edema)
• Failure of the respiratory system
• A severe infection causing low blood pressure and organ failure (septic shock)
• Lack of sufficient oxygen (hypoxia)
• Prolonged use of a machine to assist with breathing (prolonged ventilation)
• Surgical procedure to create an opening in the windpipe (tracheostomy)
• Potential death

Recovery from Epiglottitis

If you’re admitted to the hospital, caring for you usually involves several steps:

* You should not be disturbed or stressed out while you’re recovering.

* Oxygen that has been moistened (humidified) will be given to you. This can help ease breathing problems.

* You’ll be allowed to choose the most comfortable position for you. This is to help make you feel at ease.

* Inhalers and sedatives are usually not used. These can sometimes cause side effects or complications.

* The medical staff will be alert for any sudden changes in your health condition.

* To be on the safe side, doctors will always have a tracheostomy cut down set, which is a special kit for emergency throat surgery, nearby at the bedside.

With the right treatment, most patients get better within 48 to 72 hours, but it is still important to complete a 7-day course of antibiotics to prevent the infection from returning. Patients that no longer have a fever can go back home.

Preventing Epiglottitis

If someone has been in close contact with a patient infected by H. influenzae, and they haven’t received the required immunizations, they should be given a medicine known as rifampin as a precaution. Alternatively, they could be given the HIB vaccine. However, it’s important to note that the vaccine does not guarantee 100% protection against the infection.

Those who experience repeated bouts of a throat condition called acute epiglottitis need further medical examinations. These are to check if their immune system is not working properly, as it might be the cause of these recurrent episodes.

To prevent getting acute epiglottitis, getting vaccinated is highly recommended. Children should receive their immunizations following the schedule recommended by the World Health Organization (WHO).