Adult epiglottitis: Trends and predictors of mortality in over 30 thousand cases from 2007 to 2014

Epiglottitis Strikes Twice: A Case of Adult Recurrent Epiglottitis

Epiglottitis is an uncommon condition in adults, and recurrent episodes are rare. We report a 58-year-old male who had a second episode of epiglottitis nine years after his first. Our patient's immunologic profile obtained during his hospitalization revealed a significantly low absolute cluster of differentiation 4+ (CD4+) T lymphocyte count of 77 cells/mcL and a low immunoglobulin G (IgG) level of 635 mg/dL. Our patient was successfully managed with broad-spectrum antibiotics and corticosteroids. Given the known ability of short-term corticosteroids and acute inflammation's effect on lymphocyte populations, the significance of these laboratory values remains unclear due to our patient's unwillingness to undergo further diagnostic testing following discharge from our facility. We have considered multiple underlying etiologies for our patient's predisposition to developing this rare, recurrent, infectious manifestation; however, the exact cause is yet to be fully elucidated.

Airway management of adult epiglottitis: a systematic review and meta-analysis

Background

Adult epiglottitis is a life-threatening airway emergency where airway protection is the immediate priority. Despite its importance, the optimal approach to airway management remains unclear. We performed a systematic review of the airway management for adult epiglottitis, including meta-analysis of trends over time.

Methods

We systematically searched PubMed, Ovid MEDLINE®, and Embase® for adult epiglottitis studies that described the airway management between 1980 and 2020. The primary outcome was the prevalence of airway intervention. Secondary outcomes were prevalence of tracheal intubation, tracheostomy, and failed intubation. A random-effects model meta-analysis was performed with subgroups defined by decade of study publication. Cases that described the specific method of airway intervention and severity of epiglottitis were included in a separate technique summary.

Results

Fifty-six studies with 10 630 patients were included in the meta-analysis. The overall rate of airway intervention was 15.6% (95% confidence interval [CI] 12.9-18.8%) but the rate decreased from 20% to 10% between 1980 and 2020. The overall rate of tracheal intubation was 10.2% (95% CI 7.1-13.6%) and that of failed intubation was 4.2% (95% CI 1.4-8.0%). The airway technique summary included 128 cases, of which 75 (58.6%) were performed awake and 53 (41.4%) involved general anaesthesia. We identified 32 cases of primary technique failure.

Conclusion

The rate of airway intervention for adult epiglottitis has decreased over four decades to a current level of 10%. Tracheal intubation is a high-risk scenario with a 1 in 25 failure rate. Specific technique selection is most likely influenced by contextual factors including the severity of epiglottitis.

Using Transfer Learning of Convolutional Neural Network on Neck Radiographs to Identify Acute Epiglottitis

Acute epiglottitis (AE) is a life-threatening condition and needs to be recognized timely. Diagnosis of AE with a lateral neck radiograph yields poor reliability and sensitivity. Convolutional neural networks (CNN) are powerful tools to assist the analysis of medical images. This study aimed to develop an artificial intelligence model using CNN-based transfer learning to identify AE in lateral neck radiographs. All cases in this study are from two hospitals, a medical center, and a local teaching hospital in Taiwan. In this retrospective study, we collected 251 lateral neck radiographs of patients with AE and 936 individuals without AE. Neck radiographs obtained from patients without and with AE were used as the input for model transfer learning in a pre-trained CNN including Inception V3, Densenet201, Resnet101, VGG19, and Inception V2 to select the optimal model. We used five-fold cross-validation to estimate the performance of the selected model. The confusion matrix of the final model was analyzed. We found that Inception V3 yielded the best results as the optimal model among all pre-train models. Based on the average value of the fivefold cross-validation, the confusion metrics were obtained: accuracy = 0.92, precision = 0.94, recall = 0.90, and area under the curve (AUC) = 0.96. Using the Inception V3-based model can provide an excellent performance to identify AE based on radiographic images. We suggest using the CNN-based model which can offer a non-invasive, accurate, and fast diagnostic method for AE in the future.

Association Between Systemic Corticosteroid Use and Mortality in Patients with Epiglottitis

OBJECTIVES

To clarify whether treatment with systemic corticosteroids at a certain dose was associated with better outcomes in patients with epiglottitis requiring airway management (tracheotomy or airway intubation).

METHODS

This was a retrospective cohort study on patients hospitalized for epiglottitis requiring airway management from a nationwide inpatient database (between July 2010 and March 2019). Patients treated with systemic corticosteroids equivalent to methylprednisolone ≥40 mg/d within 2 days of admission and patients who were not treated with corticosteroids within 2 days of admission were compared after inverse probability of treatment weighting using covariate balancing propensity score. The primary outcome was all-cause 30-day in-hospital mortality, and secondary outcomes included all-cause 7-day in-hospital mortality, length of hospital stay, and total medical cost.

RESULTS

There were 1986 and 1771 patients in the corticosteroid and control groups, respectively. A total of 72 of 3757 (1.9%) patients died within 30 days of admission, including 17 of 1986 (0.9%) patients in the corticosteroid group and 55 of 1771 (3.1%) in the control group (weighted odds ratio, 0.28 [95% confidence interval, 0.11-0.70]; weighted risk difference, -2.2% [-3.2% to -1.3%]). Treatment with corticosteroids was associated with lower total medical costs (weighted median, $6,187 vs. $6,587; weighted difference, $-1,123 [-2,238 to -8]) but not all-cause 7-day in-hospital mortality (weighted odds ratio, 0.63 [0.22-1.82]; weighted risk difference, -0.3% [-0.9 to 0.2]) and length of hospital stay (weighted median, 13 vs. 13 days; weighted difference, -0.2 days [-2.1 to 1.8]).

CONCLUSIONS

Systemic corticosteroids may be beneficial to patients with epiglottitis requiring airway management.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:344-349, 2023.

A Case of Adult Epiglottitis in a Patient With Uncontrolled Diabetes and Occupational Risks

Epiglottitis is inflammation of the epiglottis with or without the involvement of supraglottic structures including the hypopharynx. Timely diagnosis is crucial as the treatment of epiglottitis is tailored to the degree of airway obstruction. Most patients improve with conservative measures, while some require an emergent airway intervention. We report a case of a 39-year-old Caucasian male with a history of uncontrolled diabetes mellitus and smoking who presented to the emergency department (ED) with a sore throat, dry cough, odynophagia, and difficulty swallowing. He was afebrile, tachycardic, tachypneic, hypertensive, and saturating at 99% on room air. His physical examination was remarkable for drooling, muffled voice, pharyngeal swelling, and erythema. Laboratory tests were significant for leukocytosis, hyperglycemia, and hemoglobin A1c (HbA1c) of 14.3% with a negative infectious workup. Lateral neck X-ray and emergent direct fiberoptic laryngoscopy revealed findings of epiglottitis with airway patency. The patient did not require intubation and was started on intravenous dexamethasone, vancomycin, ampicillin-sulbactam, and humidified air with suctioning of secretions and quickly recovered. In addition to known risk factors for developing epiglottitis such as uncontrolled diabetes and smoking, our patient was exposed to metal shavings at his new job, an occupational hazard that might have contributed to his clinical presentation. Our case highlights the importance of a prompt diagnosis and risk factor identification in the management of epiglottitis in adults.

Acute infectious supraglottitis in adult population: epidemiology, management, outcomes and predictors of airway intervention

Purpose

The purpose is to analyze the incidence of acute infectious supraglottitis in our center between 2010 and 2020, define the characteristics and trends of those patients and identify factors associated with the need of airway intervention.

Methods

A retrospective single-center observational study of a cohort of patients diagnosed with acute infectious supraglottitis between January 2010 and December 2020. Patients were stratified according to airway management.

Results

Eighty eight patients were included: 59 men (67%) and 29 women (33%). A significant upward trend of 9% in the annual incidence rate of supraglottitis was seen during 2010–2020, with an important increase in cases during 2019. Muffled voice (41%) and respiratory distress (38%) were the most common presenting symptoms; and the median duration of symptoms before hospital admission was 2 days [IQR 1; 3]. Airway intervention was performed in fifteen patients (17%). Nine patients (10%) were intubated and six required tracheotomy (7%). Comparing the patients who required airway intervention with those who received a conservative treatment, younger patients (p < 0.01) were more likely to need airway intervention. In logistic regression analysis, we found that epiglottic abscess (p = 0.015), hypersalivation (p = 0.027) and smoking (p = 0.036) were independent factors with a significant association with airway intervention.

Conclusion

There was an important increase in cases and its severity in 2019, but due to COVID-19 pandemic, it was not possible to define if it was an isolate event or an upward trend. Epiglottic abscess, hypersalivation and smoking could be possible risk factors for airway intervention.

Angioedema Masqueraders

Angioedema is a common reason for referral to immunology and allergy specialists. Not all cases are in fact angioedema. There are many conditions that may mimic its appearance, resulting in misdiagnosis. This may happen when a clinician is unfamiliar with conditions resembling angioedema or when there is a low index of clinical suspicion. In this article, we explore a list of differential diagnoses based on body parts, including the lips, the limbs, periorbital tissues, the face, epiglottis and uvula, as well as the genitalia, that may pose as a masquerader even to an experienced eye.