Epiglottitis
Epiglottitis | |
---|---|
Other names | Acute supraglottitis |
Prognosis | 5% risk of death[3] |
Frequency | ~2 per 100,000 per year[1][6] |
Epiglottitis is the
Epiglottitis was historically mostly caused by infection by
An effective vaccine, the
With the use of the Hib vaccine, the number of cases of epiglottitis has decreased by more than 95%.
Signs and symptoms
Epiglottitis is associated with fever, throat pain, difficulty in swallowing, drooling, hoarseness of voice, and stridor.[10] Onset is typically over a day.[10] The throat itself may appear normal.[10]
Stridor is a sign of upper airway obstruction and is a surgical emergency. The child often appears acutely ill, anxious, and will have very quiet shallow breathing often keeping the head held forward and insisting on sitting up in bed, commonly called the "
Adults commonly present with less dramatic breathing symptoms than children due to them having wider airways to begin with, so their main symptoms are usually a severe sore throat and difficulty swallowing.[11] The back of the throat appears normal in 90% of adult patients, so epiglottitis should considered when there is pain out of proportion to exam or when pain is caused by pressing on the external windpipe.[11] Adult epiglottitis is often referred to as supraglottitis. In contrast to children, the symptoms are non-specific, sub-acute and can be unpredictable. [13]
Causes
Epiglottitis is primarily caused by an acquired bacterial infection of the epiglottis.[1] Historically it was most often caused by Haemophilus influenzae type B, but with the availability of immunization this is no longer the case.[1] H. influenzae type B contains a capsule which helps it avoid being destroyed by macrophages and also contains surface proteins that allow it to stick to the lining of the upper respiratory tract.[14] Presently, the bacteria most often causing infection are other encapsulated organisms including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus.[1] These bacteria spread in respiratory droplets or aerosols produced from coughing and sneezing.[15][16] While the overall incidence of epiglottitis has decreased, the incidence of cases caused by Streptococcus pneumoniae has increased in adults.[17] The exact strains of Streptococcus pneumoniae are often those that are covered by the PPV-23 vaccine,[17] but there is no evidence that this vaccine prevents epiglottitis.
There have been many cases of epiglottitis reported in immunocompromised patients, including those undergoing cancer treatment and those who are HIV positive.[18] While a variety of different bacteria can cause disease in these patients, cases often involve the Candida species of fungus, though it is unknown if the fungus causes significant disease on its own.[18]
Alternate risk factors and causes associated with infection include burns and other trauma to the area.[1] Medical research has also identified a link between epiglottitis and crack cocaine usage.[19] Underlying disorders of the immune system, such as graft-versus-host disease and lymphoproliferative disorders, have also been identified as contributors of increased risk for developing the infection .[4]
Diagnosis
Diagnosis may be confirmed by direct inspection using a
-
CT imaging showing the "halloween sign"
-
Left column: Normal epiglottis. Right column: Epiglottitis.
-
Swollen epiglottis in laryngoscopy
-
Normal appearance of epiglottis (label 3) as seen on laryngoscopy
Imaging
On
On
Necrotizing Epiglottitis
If there is visual or radiologic evidence that the infection has caused tissue destruction, the disease is called "necrotizing epiglottitis" (NE).[23] The feared complication of NE is the bacteria spreading to the surrounding neck muscles and causing cervical necrotizing fasciitis which is a surgical emergency.[23]
Differential Diagnosis
The differential diagnosis includes other infectious causes of acute airway obstruction, as well as acute or subacute mechanical causes. It includes, but is not limited to, the conditions below.[24][25]
- Retropharyngeal abscess
- Peritonsillar abscess
- Croup
- Infectious mononucleosis
- Diphtheria
- Pertussis
- Bacterial tracheitis
- Ludwig's angina
- Granulomatosis with polyangiitis
- Foreign body obstruction
- Obstructing tumor
- Allergic reaction, including angioedema
- Inhalation injury
- Laryngospasm
- Congenital structural defects in pediatric patients, including laryngomalacia
Prevention
An effective vaccine, the Hib vaccine, has been available since the 1980s.[4] Modern Hib vaccines are mainly conjugate vaccines, with the key component being the polysaccharide found in the bacteria's capsule which is its primary virulence factor.[26] Currently, the CDC recommends that children receive a two or three-dose primary series with an additional booster dose.[27] The countries of the world who have included the Hib vaccine in their immunization schedules typically begin the series at the age of two or three months with subsequent doses administered at four or eight week intervals.[28] Routine vaccination in these nations has led to a dramatic decrease in the incidence of invasive diseases caused by H. influenzae type b such as epiglottitis, meningitis and pneumonia.[28] It has been reported that epiglottitis cases have decreased by 95% since the 1980s following the introduction of the first Hib vaccine.[8]
The
Management
The most important part of treatment involves securing the airway.
Intravenous antibiotics such as
Necrotizing epiglottitis is treated similarly to uncomplicated epiglottitis, but usually requires intubation in addition to standard IV antibiotic therapy.[23] If the tissue damage continues to spread and necrotizing fasciitis of the neck is suspected, patients are taken to the operating room for emergency debridement.[23]
Prognosis
With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent.[3] Elsewhere, it has been reported that only one percent of adults diagnosed with epiglottitis die from the disease.[11] Some people may develop pneumonia, lymphadenopathy, or septic arthritis.[30]
Between 1998 and 2006, there were an average of 36 deaths per year in the United States attributed to epiglottitis, giving a case-fatality rate of 0.89% during that time period.[31]
Patients who recover from necrotizing epiglottitis often regain their ability to swallow foods and liquids despite the tissue damage.[23]
Epidemiology
While, historically, young children were mostly affected, it is now more common among older children and adults.
Notable cases
Bill Bixby's 6-year-old son Christopher died of the condition in 1981.[32]
Jeannie Mai spent some time in an ICU with epiglottitis.[33]
George Washington is thought to have died of epiglottitis.[37] The treatments given to Washington, such as severe bloodletting, an enema, vinegar, sage, molasses, butter, blistering his throat with Spanish fly, requiring him to swallow mercurous chloride and antimony potassium tartrate, and applying wheat poultices to various parts of the body, are no longer used.[38]
Jin announced in a 2022 video that he had been diagnosed with epiglottitis.[39]
Wes Moore's father died of epiglottitis when Moore was four years old.[40]
References
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- ^ a b c Damian Crowther. "management of epiglottitis - General Practice Notebook". gpnotebook.co.uk. Dept. of Genetics, Downing Street, Cambridge UK. Archived from the original on 8 September 2017. Retrieved 2 June 2017.
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- ^ "Haemophilus influenzae type b (Hib)". www.who.int. Retrieved 2022-11-08.
- ^ CDC (2022-02-17). "Immunization Schedules for 18 & Younger". Centers for Disease Control and Prevention. Retrieved 2022-11-08.
- ^ PMID 18582836.
- ^ OCLC 1135758317.
- ^ "Epiglottitis". The Lecturio Medical Concept Library. 22 June 2020. Retrieved 20 July 2021.
- ^ S2CID 6571093.
- ^ "The 6-year-old son of 'Incredible Hulk' television series star". United Press International. 1981-03-03. Retrieved 2018-05-01.
- ^ Atad C (2020-11-02). "Jeannie Mai Forced Off 'Dancing With The Stars' After Being Hospitalized For Rare Condition". ET Canada. Archived from the original on November 2, 2020. Retrieved 2020-11-03.
- ^ "Comedian Sarah Silverman 'lucky to be alive' after surgery". apnews.com. 2016-07-07. Archived from the original on 11 August 2017. Retrieved 2 June 2017.
- ^ "Sarah Silverman Says She Almost Died Last Week, Recounts Terrifying ICU Story". etonline.com. 6 July 2016. Archived from the original on 2 June 2017. Retrieved 2 June 2017.
- ^ Cavassuto M (7 July 2016). "Sarah Silverman Says 'Freak Case' of Rare Condition Almost Killed Her". variety.com. Archived from the original on 11 August 2017. Retrieved 2 June 2017.
- ISBN 978-0-931917-35-6.
- ^ "December 14, 1799: The excruciating final hours of President George Washington". PBS NewsHour. 2014-12-14. Retrieved 31 December 2017.
- ^ [EPISODE] 진 (Jin) 'The Astronaut' Jacket Shoot Sketch - BTS (방탄소년단), retrieved 2022-11-17
- ^ Cheng A (October 7, 2020). "The Other Wes Moore Book Summary, by Wes Moore". Allen Cheng. Archived from the original on October 20, 2022. Retrieved December 28, 2022.