[Effective antibacterial therapy in otorhinolaryngology: bacteriological rationale]

The article presents current views on etiopathogenesis of the diseases associated with contamination with microorganisms; reviews inflammatory ENT diseases in terms of current literature on clinical microbiology of these diseases; characterizes microorganisms more or less specific for each relevant nosological entity; analyses basic groups of antibacterial drugs with formulation of bacteriologically grounded principles of initial antibacterial therapy of ENT inflammation.

Paediatric acute epiglottitis re-visited

INTRODUCTION

Paediatric acute epiglottitis is rare in Asia. The National University Hospital in Singapore has seen only two cases of paediatric acute epiglottitis in the last 10 years. The topic is re-visited here to remind physicians of its acutely dramatic progression.

CLINICAL PICTURE

Both boys presented with a viral prodrome which progressed within hours to life-threatening upper airway obstruction. Examination revealed an inflamed epiglottitis.

TREATMENT

They were successfully intubated and treated with intravenous antibiotics.

OUTCOME

Both recovered uneventfully.

CONCLUSION

Paediatric acute epiglottitis has declined markedly in the West with widespread vaccination against HiB. In contrast, the incidence of invasive HiB disease in Asia has always been low despite limited vaccination. Clinicians must remain vigilant of the possibility of acute epiglottitis in a child with "flu".

Acute epiglottitis caused by Haemophilus influenzae type b: a case report

Acute epiglottitis is an inflammatory, edematous disease of the epiglottis and adjacent structures, usually caused by Haemophilus influenzae type b. It is a life-threatening condition, occurring mainly in childhood. There have never been any reports of this condition in Taiwan. We report a case of 4-year-old boy who presented with characteristics of systemic illness combined with respiratory distress on arrival at the emergency room. His mouth was open and his neck was hyperextended. The diagnosis of epiglottitis was established on the basis of physical examination, lateral neck x-ray, and the finding of an enlarged, swollen, erythematous epiglottis on flexible fiberoptic laryngoscopy. Urine latex agglutination test for H. influenzae type b was positive and a blood culture grew H. influenzae type b. He was treated with cefotaxime and did not require intubation.

Acute epiglottis in adults

Acute epiglottitis can be a serious life-threatening disease because of its potential for sudden upper airway obstruction. It is a well-recognised entity in children but it is uncommon in adults and therefore is often misdiagnosed. In this retrospective study we present twelve cases of acute epiglottitis in adults. The diagnosis was made by visualisation of the epiglottis using fibreoptic laryngoscopy. The illness was managed using a standardised management protocol (see Appendix). The most frequent symptoms were odynophagia (100%), inability to swallow secretions (83%), sore throat (67%), dyspnoea (58%) and hoarseness (50%). Body temperature was elevated (>37.2 degrees C) in 75% and 50% of the patients had tachycardia (>100 bpm). The supposedly typical sign of stridor was found in only 42% of the cases. A routine oropharyngeal examination does not exclude epiglottitis, 44% of our patients had a normal oropharynx and the diagnosis could only be made following fibreoptic laryngoscopy. Nasotracheal intubation was necessary in four patients. A 40-year-old man with sore throat, hoarseness, cough and odynophagia was initially seen by a physician. With the suspected diagnosis of an infection - induced exacerbation of bronchial asthma, he was treated with antibiotics, paracetamol und corticosteroids. On admission six hours later the patient was in coma. The diagnosis was not made until conventional oral endotracheal intubation (without a tracheotomy set placed at the bedside) was attempted. Unfortunately the intubation failed and the patient died. Medical management of epiglottitis in adults includes an antibiotics, NSAIDs and possibly inhalation with adrenaline. The maintenance of an adequate open airway is the main concern in adults as well as in children. Although most adults have no signs of airway obstruction, the clinical threshold for insertion of an airway should remain low, as it is the only way of preventing death. A high index of suspicion is needed to recognise this rare disease correctly and patients must be admitted to a hospital with intensive care facilities, where the diagnosis can be confirmed and intubation performed if necessary and thus reduce the mortality rate.

Identifying acute epiglottitis in adults. High degree of awareness, close monitoring are key

Epiglottitis can be a rapidly fatal condition in adults. Important clues that should raise clinical suspicion include the tripod sign, fever, stridor, sore throat, odynophagia, shortness of breath, and drooling. These features must be differentiated from those associated with common viral infections. The most helpful diagnostic studies are radiography of the neck and direct laryngoscopy. The patient's airway should be monitored during evaluation to avoid obstruction. Successful management requires teamwork between the primary care physician and personnel skilled in intubation as well as timely consultation with an otolaryngologist. Laryngoscopy and intubation always should be performed by the most skilled personnel because repeated attempts may increase periepiglottal swelling and the risk of airway obstruction. Racemic epinephrine should be avoided because of the rebound effect. Awareness of the possibility of epiglottitis in adults and close monitoring of the airway are the keys to management of this potentially life-threatening condition.

Update on pneumococcal infections of the respiratory tract

Respiratory illnesses are the leading reason for seeking medical care here in the United States. Streptococcus pneumoniae is the most common bacterial pathogen causing acute otitis media (AOM), sinusitis, and community-acquired pneumonia in both the pediatric and adult populations. The continued development of antibiotic resistance to an increasing number of different antibiotic classes by this organism has made the treatment of some of these infections more difficult. Recently, a heptavalent pneumococcal conjugate vaccine was approved for infants and toddlers, beginning at 2 months of age. Widespread implementation of this vaccine in the childhood population may have a significant impact on the amount of systemic disease seen with this organism.

Acute epiglottitis in adults: the Royal Melbourne Hospital experience

BACKGROUND

To examine the common presentations and management of acute epiglottitis in adults.

METHOD

Retrospective clinical study of 17 consecutive adult patients who presented to the Royal Melbourne Hospital between January 1988 and December 2000 was undertaken.

RESULTS

The mean patient age was 47 years (range 20-87 years) and the male-to-female ratio was 1.8 : 1.0. Peak incidence occurred in September during early spring. All patients presented with sore throat and dysphagia; however, respiratory distress was only noted in 65%. The most common signs were temperature and tachycardia. Four patients (23%) required endotracheal intubation, which was performed electively in three and as an emergency in one. Three of 14 blood cultures were positive, two yielded Haemophilus influenzae type b and one yielded Streptococcus mitis. One of the four throat cultures was positive for Haemophilus influenzae type b. Twelve patients underwent awake flexible laryngoscopy under topical anaesthetic as part of their initial assessment, and there were no complications associated with this procedure. There was no mortality.

CONCLUSIONS

The diagnosis of acute epiglottitis in the adult population is difficult as respiratory distress may be absent. Patients who have a significant sore throat with no obvious aetiology should have direct visualization of their larynx by flexible laryngoscopy. Lateral X-ray of neck is of limited value. Once diagnosed, these patients should be hospitalized and monitored as airway obstruction may develop rapidly.

Acute epiglottitis: a presentation of haemophagocytic lymphohistiocytosis

The incidence of acute epiglottitis in children has declined with the introduction of the Haemophilus influenzae b vaccine in 1992. We report a case of acute epiglottitis in a child secondary to an immunocompromised state. We suggest that when acute epiglottitis is diagnosed in a child we should ensure there is no underlying predisposing condition.

[Epiglottitis--a pediatric disease?]

Epiglottitis, commonly described as a paediatric disease, also occurs in adults. Early diagnosis and immediate treatment are crucial because of the rapid and possibly lethal course of upper airway obstruction due to swelling. Initial treatment consists in securing the upper airway and in antibiotic treatment. Streptococci and, especially in children, Haemophilus influenzae b are the most common bacteria. Our study focused on clinical and epidemiological changes since children started to be vaccinated against Haemophilus influenzae b in Switzerland (1992). We reviewed patient histories of 31 adults and 88 children who were hospitalised with epiglottitis at the University Hospital of Berne between 1989 and 1999. Our findings show that the incidence of epiglottitis in children, a clinically, epidemiologically and bacteriologically homogeneous disease, has dramatically decreased. Epiglottitis in adults presents as a more heterogeneous disease without change since the beginning of the vaccination programme. Due to the variety of germs it is impossible to recommend vaccination for adults against Haemophilus influenzae b.

[Acute epiglottitis in the adult. Retrospective study of 14 cases]

Acute epiglottitis instead of been a well recognised disease in children, is a rare condition in adult patients. Failure to diagnose epiglottitis early, in adults, undoubtedly contributes to its continuing mortality. We report our experience with acute epiglottitis in grown-up people with a retrospective series of 14 patients seen in our Department from 1993 to 1997. We comment about clinical features and therapeutic management of these patients.

Acute epiglottitis as a cause of airway obstruction in an adult patient

Epiglottitis in adults is a dangerous infectious disease with a rising incidence and potential fatal complications as illustrated in this case report. Like in children, skilled and aggressive airway protection with appropriate antibiotic therapy have been effective in reducing mortality.

Clinical aspects on antibiotic resistance: upper respiratory tract infections

In view of the increased resistance to antibiotics in several upper airway pathogens, the clinical rationale for use of antimicrobial therapy in various upper respiratory tract infections is discussed. The diagnostic skill and the clinical significance of various bacteria are taken into account and strategies for treatment of the different infections, with focus on acute otitis media, are discussed.

Post-varicella epiglottitis and necrotizing fasciitis

Varicella is a nearly ubiquitous acquired childhood disease. Infectious complications of varicella can be life- or limb-threatening. These complications appear 3 to 4 days after the appearance of varicella exanthem and are heralded by fever, pain, and erythema of the overlying skin. Airway complications of varicella are rare, rapidly evolving, and, unfortunately, difficult to visualize. We report a child who presented with a unique combination of varicella-induced airway complications-acute epiglottitis and subsequent necrotizing fasciitis of the head and neck. varicella, epiglottitis, necrotizing fasciitis, group A beta-hemolytic streptococcus, nasopharyngoscopy.

[Acute epiglottitis in children: current criteria for the diagnosis and treatment]

Acute epiglottitis is still a potentially lethal pathology, particularly in early childhood. The present study involves seven cases of acute epiglottitis in children under 4 years of age. The authors describe the diagnostic and therapeutic protocols used in these pediatric patients placing particular emphasis on the use of endoscopy and the need for prompt hospitalization in an intensive care unit to best integrate the diagnostic approach with therapeutic treatment.

Paediatric epiglottitis: the influence of the Haemophilus influenzae b vaccine, a ten-year review in the Sheffield region

Cases of acute epiglottitis in children have become very uncommon in recent years. This study set out to find whether the introduction of the Haemophilus influenzae b (Hib) vaccine in the UK in October 1992 has influenced the incidence of acute epiglottitis in the Sheffield region, and whether the pathogenesis has altered. A 10-year retrospective case note review was undertaken. A total of 30 children were treated for acute epiglottitis in Sheffield Children's Hospital over that time period. A sharp decline in the number of cases was found after the vaccine was introduced. Most children presenting with the disease after October 1992 had not been vaccinated. In addition, the pathogens isolated in those children who had received the vaccine were all Streptococci. This is the first study in the UK to examine the influence of the Hib vaccine on acute paediatric epiglottitis.