High risk and low prevalence diseases: Adult epiglottitis

Investigation of a cluster of acute epiglottitis in Vendée, western France, October - December 2022

OBJECTIVES

In our investigation of an episode of clustered acute epiglottitis occurring in Vendée, western France, between October and December 2022, we described the reported cases and confirmed its unusual character at several geographic levels.

METHODS

The investigation relied on three data sources: hospitalization and emergency department reports; national reference centre data; and data from the French syndromic surveillance system.

RESULTS

The six patients were male, with an average age of 42 years [32-66]; all were hospitalized in an ICU, and one of them died. Documented risk factors for epiglottitis (active smoking, regular alcohol consumption, overweight) were present in the majority of cases. No causal pathogen was identified. Syndromic surveillance data confirmed increased acute epiglottitis at the local, regional and national levels.

CONCLUSION

We not only characterized the episode of serious clustered acute epiglottitis in Vendée, but also observed a nationwide increase in this pathology occurring concomitantly with increased circulation in France of streptococcus A.

Rising Incidence of Acute Epiglottitis in Eastern China: An Eight-Year Retrospective Study and Its Association with the 24 Solar Terms

Purpose

This study aimed to investigate the clinical characteristics of acute epiglottitis (AE) patients in East China and examine the correlation between the incidence of AE and the 24 solar terms (24 STs).

Methods

A retrospective, observational study was conducted on patients diagnosed with AE between January 2014 and December 2021 at a single-center medical institution in East China. The clinical characteristics of patients with AE and their correlation with the 24 STs were investigated.

Results

A total of 287 patients with AE were included in this study, among which there were 179 males (62.37%) and 108 females (37.63%), with a mean age of 47.79 ± 13.83 years (range 16-87 years). Of these patients, 100 (34.84%) had at least one comorbidity and the most common comorbidities were hypertension, smoking and type 2 diabetes. The duration of hospitalization was 3 days (IQR, 1-16 days). All patients, except for one who required tracheal intubation, were cured with intravenous antibiotic administration and the combined use of corticosteroids. The incidence of AE showed significant fluctuations between the 24 STs and the highest number of cases occurred during the Summer solstice (24 cases, 8.36%).

Conclusion

The incidence of AE was seen to increase annually in this study. The main features of AE are sore throat, dysphagia, odynophagia and fever, which may be accompanied by inflammation in surrounding areas. A clear correlation exists between the incidence of AE and the fluctuations within the 24 STs, notably with the peak incidence observed during the Summer solstice, which approximately corresponds to June 21 to July 7 in the Gregorian calendar.

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.

A Case of Brodifacoum-Induced Epiglottitis

This case report presents a 33-year-old woman who presented to the emergency department with abdominal pain and gingival and vaginal bleeding. She admitted to using synthetic cannabinoids, and contamination with brodifacoum was suspected, for which qualitative testing was positive. The patient was discharged with an improved international normalized ratio (INR) seven days later with oral vitamin K. Fourteen days after discharge, she re-presented with widespread ecchymosis, leg swelling, and intermittent gingival and vaginal bleeding. Her INR was again elevated. She was controlled with oral vitamin K therapy, stabilized, and discharged three days later. Twenty-eight days following the second discharge, the patient re-presented with oral swelling, right eye ecchymosis, and vaginal bleeding after abstaining from vitamin K therapy for two weeks. A bedside nasopharyngolaryngoscopy showed the base of the tongue, epiglottis, aryepiglottic (AE) folds, arytenoids, and false vocal folds were all edematous with ecchymosis. Due to the diffuse epiglottic and supraglottic edema, the patient was intubated to avoid further decompensation. After receiving IV and oral vitamin K, she was extubated two days later. Her INR fully normalized, and she was then discharged on day 4. Our case of epiglottitis could demonstrate thermal injury associated with smoking synthetic cannabinoids, but given diffuse ecchymosis and severe coagulopathy, hematoma associated with brodifacoum poisoning was considered the most likely etiology. The patient's coagulopathy was rapidly reversed, empiric antibiotic coverage was provided, and she rapidly improved. Brodifacoum exposure has been known to cause increased bleeding, as seen in this case. However, it should also be considered that exposure can lead to epiglottitis. If a similar patient is presented in the future, it is important to consider that coagulopathy may be caused by the adulteration of drugs of abuse, specifically brodifacoum with synthetic cannabinoids.

Infection and sudden lethal upper airway occlusion - An overview

A multitude of conditions may cause acute and unexpected upper airway compromise in both children and adults. These include mechanical blockage of the airways either from internal obstructions due to inhaled food or foreign objects, or from external compression. In addition, kinking of the airway in cases of positional asphyxia may compromise aeration. Infections represent another cause of airway narrowing with the potential for occlusion. The case of a 64-year-old man with acute laryngo-epiglottitis is used to demonstrate that death may occur from infections in previously structurally-normal airways. Infections may compromise respiration due to acute airway occlusion from intraluminal material/mucus, mural abscesses or from acutely inflamed and oedematous mucosa with adherent tenacious mucopurulent secretions. External compression from nearby abscesses may also critically narrow air passages.

MRI of acute neck infections: evidence summary and pictorial review

Infection of the deep neck spaces is a life-threatening acute illness that requires prompt diagnosis and treatment. Magnetic resonance imaging (MRI) offers unsurpassed soft tissue discrimination and is therefore well suited for imaging neck infections. Recently, the feasibility, diagnostic accuracy, and clinical significance of this method have been documented in patients with acute neck infections. This review article summarizes the scientific evidence, provides a practical guide to image acquisition and interpretation, reviews the most common imaging findings, and discusses some difficult diagnoses and pitfalls in acute neck infections, to help both radiologists and clinicians in managing these critically ill patients.