Unique case presentations of acute epiglottic swelling and a protocol for acute airway compromise

Acute epiglottitis is a well-described life-threatening disease. Since the generalized use of the Haemophilus influenzae type B (HIB) vaccine, presentations of this disorder have decreased dramatically in children. Presentations of this and other acute epiglottic swelling can vary remarkably and may easily be misdiagnosed by physicians who have little or no experience with the acutely obstructed airway. Early suspicion and a proper evaluation is mandatory to prevent a life-threatening crisis. Six patients are presented with unusual presentations of acute epiglottic swelling from differing etiologies; these include the following: case 1, recurrent epiglottitis; case 2, chronic epiglottitis; case 3, traumatic epiglottitis; case 4, caustic ingestion; and cases 5 and 6, simultaneous infection of family members. Because the incidence of acute epiglottitis is decreasing, it has become rare at most institutions. To help primary care and emergency room physicians, a formal written protocol should be available at medical facilities that might be faced with patients presenting with acute airway obstruction. An "acute airway obstruction protocol" used successfully for the last decade is offered. Use of such a written document might be life-saving for patients with impending upper airway obstruction. The otolaryngologist is a key member of the recommended multidisciplinary team.

CT in adult supraglottitis

We describe the CT appearance of supraglottitis and its complications in three adults. The most common CT findings were thickening of the epiglottis, aryepiglottic folds, false and true vocal cords, obliteration of the preepiglottic fa, thickening of the platysma muscle, and reticulation of the subcutaneous fat. Multiple loculated fluid-density collections consistent with abscesses were seen in one patient. Although the diagnosis of supraglottitis is generally made on the basis of the patient's history and by direct endoscopy, CT may be used to confirm the diagnosis when an adequate laryngoscopic examination cannot be performed. CT is also useful in evaluating the complications of this disorder.

Group A beta-hemolytic streptococcal epiglottitis as a complication of varicella infection

A rare complication of varicella in an otherwise normal host is described: epiglottitis caused by group A beta-hemolytic streptococci (GABHS). The resurgence of invasive disease secondary to GABHS is discussed. The rarity of GABHS bacteremia and epiglottitis in the context of varicella is emphasized.

Epiglottitis: a 9-year case review

A retrospective chart review of all cases of suspected epiglottitis from 1985 to 1993 at Arkansas Children's Hospital identified 29 patients treated for epiglottitis during this 9-year period. Review of the immunization status of these patients showed 72% without Hib vaccination, 11% who had initiated the Hib series, and 17% with unknown immunization status. The incidence of epiglottitis declined over the duration of the study with 0.61/1,000 admissions in 1985, 0.27 in 1986, 1.42 in 1987, 0.9 in 1988, 0.39 in 1989, 0.0 in 1990, 0.35 in 1991, 0.0 in 1992, and 0.0 in 1993. Comparing the years before available conjugate vaccine--1985 to 1988--with the years after conjugate vaccine--1989 to 1993--shows a significant change in the incidence of epiglottitis. With increasing populations of susceptible children receiving Hib immunization, Hib epiglottitis may become a vanishing entity.

[Review of epiglottitis]

Seven cases of acute epiglottitis in children (mean age 38 months) are reported. The major clinical features are described. The review of the literature on current diagnosis and treatment underlined the value of early orotracheal or nasotracheal intubation when this serious condition is suspected.

Differing antibody responses to Haemophilus influenzae type b after meningitis or epiglottitis

Two common forms of invasive disease due to Haemophilus influenzae type b (Hib) are epiglottitis and meningitis. It is not known why some children develop epiglottitis and others meningitis. To examine the hypothesis that epiglottitis occurs in children who may have been previously exposed to Hib, and who would therefore exhibit a more vigorous antibody response in convalescence, we measured levels of antibody to Hib capsule in 92 children. Geometric mean convalescent-phase IgG, IgA, IgM and total antibody levels were significantly higher in 45 children with epiglottitis than in 47 with meningitis, even after adjustment for age differences (mean total antibody, 95% confidence intervals: meningitis 0.38, 0.34-0.43; epiglottitis: 2.25, 2.0-2.54 micrograms/ml). However, contrary to previous reports, a poor antibody response was only observed in a minority of children with meningitis; the antibody response of the majority was indistinguishable from that observed in children with epiglottitis.

Epiglottitis and Haemophilus influenzae immunization: the Pittsburgh experience--a five-year review

OBJECTIVE

Current trends in the clinical presentation and management of children with epiglottitis at Children's Hospital of Pittsburgh were reviewed for the years 1988 to 1993.

METHODOLOGY

The medical records of all patients diagnosed as having epiglottitis between July 1988 and June 1993 at the Children's Hospital of Pittsburgh were reviewed. An additional telephone survey was conducted among the primary care physicians of those patients to collect information regarding administration of Haemophilus influenzae type b (HIB) vaccines.

RESULTS

During the study period 28 children (age range, 11 months to 11 years, 10 months) were admitted with the diagnosis of epiglottitis. Cases declined remarkably in 1991. Fever, sore throat, and stridor were the usual symptoms. HIB was the most common cause of epiglottitis accounting for 21 cases. Candida albicans was recovered from the surface culture of the epiglottis in two patients. At least 11 children experienced vaccine failure: nine with polysaccharide vaccine and two with the conjugate vaccine for HIB.

CONCLUSION

Cases of epiglottitis have declined dramatically since licensure of HIB conjugate vaccines for use in early infancy. At least 52% of the reported cases represent vaccine failures with the purified polysaccharide vaccine.

Acute epiglottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland

OBJECTIVE

To determine the incidence and characteristics of acute epiglottitis among children (< or = 19 years of age) and adults (> or = 20 years of age) before and after widespread conjugate Haemophilus influenzae type b vaccination for infants.

DESIGN

A retrospective population-based survey over a 27-year period from 1967 through 1993 in 35 communities in a northern province of Finland with a population of approximately 300,000.

SETTING

An academic tertiary referral center.

MAIN OUTCOME MEASURES

All acute epiglottitis cases in the area identified from the hospital discharge register and the regional autopsy register.

RESULTS

The average incidence rate for children was 1.8 cases per 100,000 individuals per year (95% confidence interval [CI], 1.3 to 2.5). As no vaccine failures emerged, the incidence rate for children aged 0 to 4 years declined sharply once the vaccination started in 1986 from 7.6 (95% CI, 5.3 to 10.4) to 0 (95% CI, 0 to 3.3) cases per 100,000 individuals per year. By contrast, a fourfold increase in adult acute epiglottitis (incidence rate ratio, 4.6; 95% CI, 2.7 to 7.9) was detected after vaccination of the children, the average incidence rate for the whole period being 1.0 cases per 100,000 individuals per year (95% CI, 0.8 to 1.3). No marked change in the adult patient profile was found during this increase, however.

CONCLUSION

Acute epiglottitis practically vanished among young children in this population after conjugate H influenzae vaccination, but adult cases increased, the patient profile remaining the same.

[Pediatric surveillance of invasive infections caused by Haemophilus influenzae type b in children in the period following introduction of vaccination]

OBJECTIVE

Evaluation of the effect of vaccination against Haemophilus influenzae type b (Hib) on the occurrence of invasive Hib infections in children since its introduction into the national immunization programme in April 1993.

DESIGN

Observational study.

SETTING

Nationwide investigation.

METHOD

Data collected through active surveillance of invasive Hib infections by paediatricians for the period from October 1993 to September 1994 (11 months) were compared with data from the meningitis surveillance by the Netherlands Reference Laboratory for Bacterial Meningitis.

RESULTS

A total of 139 paediatric reports of invasive disease by H. influenzae concerned 57 cases of only meningitis, 35 of meningitis with sepsis, 2 of meningitis with arthritis, one of meningitis with arthritis and osteomyelitis, 34 of epiglottitis including one case with sepsis, 8 of only sepsis and 2 of only arthritis. All proven infections by Hib occurred in children who had not or incompletely been vaccinated. One child with sepsis had had three vaccinations and became ill five months later; the isolated bacterial strain was not serotyped. Typing was performed in only 80% of the isolates, of which 98% were of type b. Appropriate culturing and typing was often omitted in case of epiglottitis.

CONCLUSION

The effect of vaccination against Hib became apparent in a small number of cases of invasive Hib disease reported by paediatricians; the peak incidence of meningitis no longer occurred in children under one year of age but in children aged one year. The paediatric surveillance described offers possibilities for monitoring Hib epidemiology.

Invasive Haemophilus influenzae disease: epidemiology and clinical spectrum before large-scale H. influenzae type b vaccination

In a prospective study between January 1987 and December 1992, 103 patients with invasive Haemophilus influenzae (Hi) infection were identified in a well-defined population before large-scale Haemophilus influenzae type b (Hib) vaccination was introduced. The incidence (case/100,000/year) of invasive Hi infection was 5.9 for the whole population, 55 for children 0-4 years old and as high as 2.8 for adults. Hib was the predominant cause of the infection (83 cases) in children but, in adults, 13/39 (30%) cases were caused by non-typable Hi and 6/39 (19%) by Hi serotype f. Three patients (3%) died and 6 (5.8%) suffered a permanent sequel from the infection. All patients with such a sequel had invasive Hib infection. No significant difference between patients 0-6 years old and matched controls regarding the frequency of subnormal serum levels of immunoglobulins was found.

Acute epiglottitis in the adult caused by Neisseria meningitidis

Acute epiglottitis is being increasingly encountered in the adult population. While it has many similarities to its pediatric counterpart, the presentation and associated pathogens are distinct. In addition, although the recent literature has suggested that acute epiglottitis in the adult follows a benign course this is not always the case. Here we describe a case of acute, fulminant epiglottitis in an immunocompetent host, caused by Neisseria meningitidis.

Toxic shock syndrome related to simultaneous Staphylococcus aureus epiglottic abscess and group A streptococcal pharyngitis with bacteremia

A case of toxic shock syndrome (TSS) is reported in which both a TSST-1-producing Staphylococcus aureus strain and a group A beta-hemolytic streptococcal strain (GABHS) were involved. The S. aureus group I strain was isolated from an epiglottic abscess, and the GABHS strain from tonsils and blood cultures. Acute intubation was needed because of obstruction of the airways by swollen and hyperemic mucous membranes in the oro- and hypopharynx together with external edema around the neck. Intravenous therapy with penicillin G was instituted initially on account of GABHS cellulitis and bacteremia. The patient's condition deteriorated during this treatment, and improvement did not occur until drainage and intravenous dicloxacillin therapy was instituted. It is not possible in this case to draw any conclusions as to which of the two organisms caused the TSS or if they were both involved.

Haemophilus influenzae type B epiglottitis after immunization with HbOC conjugate vaccine

INTRODUCTION

US Food and Drug Administration (USFDA) has licensed four Haemophilus influenzae type B (Hib) vaccines for use in children. Haemophilus influenzae type B is by far the most common pathogen in childhood epiglottitis and it is hoped that with the introduction of the Hib vaccine that a corresponding decrease in epiglottitis cases will be appreciated.

MATERIALS AND METHODS

A retrospective study of all children admitted with the diagnosis of epiglottitis for the 11-year period of 1982 to 1992 was conducted in order to determine the incidence of epiglottitis and Hib vaccine failure. Fifty-nine cases were included in the study by documentation of an inflamed epiglottis. The case of Hib epiglottitis in a 4-year-old child immunized with HbOC conjugate vaccine at 18 months of age is detailed.

RESULTS

A statistically significant decrease was found in the incidence of epiglottitis since introduction of the vaccines; however, the overall trend in decrease for the 11-year period was not statistically significant. Vaccination status was difficult to accurately document with only two cases of vaccine failure identified.

CONCLUSION

The incidence of Haemophilus influenzae type B epiglottitis at our regional Children's hospital has decreased since the introduction of the Hib vaccine. Reasons for vaccine failure are postulated.

Changing patterns in pediatric supraglottitis: a multi-institutional review, 1980 to 1992

Supraglottitis is a rapidly progressive, life-threatening airway emergency in pediatric patients typically caused by Haemophilus influenzae type B (HIB). With distribution of the first efficacious vaccine for HIB in April 1985, changing disease patterns have begun to emerge; however, certain characteristics have remarkably persisted. The authors reviewed 252 pediatric patients with acute supraglottitis spanning the prevaccination and postvaccination years 1980 to 1992 at three major regional pediatric hospitals in Massachusetts, Ohio, and California, as well as at two community hospitals in Massachusetts. Findings include a decline in disease prevalence in all geographic areas with demographic, etiologic, and management evolution all seen. Children who had been immunized yet developed supraglottitis have been examined as predictive of future trends.