Adult epiglottitis

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.

Upper Respiratory Tract Infections in the Critically I11

A review of severe upper respiratory tract infections that present in the critically ill (supraglottitis [epi glottitis], deep neck infections, and sinusitis) is pre sented with attention to pathogenesis, pathophysiology, diagnosis, differential diagnosis, and treatment. Supra glottitis is increasingly diagnosed in adults and, as with children, early recognition is crucial to limit mortality. To aid in diagnosis and treatment, a management al gorithm is used. Deep cervical infections, usually exten sions of upper airway infections, can spread along fascial planes with fatal results. Knowledge of the interconnec tions between anatomical spaces is a prerequisite to diagnosis and treatment. Sinusitis will present in the critically ill as orbital or intracranial complications or as a nosocomial infection. Discussions of acute and chronic community-acquired sinusitis in general, noso comial sinusitis, and sphenoid sinusitis as a separate en tity highlight differences in clinical presentation and bacteriology that are important to diagnosis and treat ment.

Adult acute epiglottitis: Experiences in a Taiwanese setting

OBJECTIVE: Acute epiglottitis is a potentially disastrous disease seen occasionally in otolaryngology emergency service. This study reports our experiences in managing adult patients with acute epiglottitis in a Taiwanese setting.

STUDY DESIGN: Admission medical records from 46 adult patients with acute epiglottitis over a period of 8 years in a tertiary referral otolaryngology service were retrospectively reviewed.

RESULTS: No mortality was reported; 4 (8.7%) patients were supported by artificial airway. A total of 16 (34.8%) patients had comorbid conditions; hypertension and diabetes mellitus were the most common systemic diseases. Patients who needed artificial airway support tended to have more systemic comorbidities ( P = 0.001) and a higher level of hyperglycemia ( P = 0.004) than those who did not need airway support. The incidences of drooling, stridor/dyspnea, and muffled voice were significantly higher in the airway-supported group ( P < 0.05). Stridor/dyspnea is a reliable clinical predictor of airway compromise (odds ratio 2.94; P = 0.0277).

CONCLUSION: Dyspnea is a warning sign of impending airway collapse during an episode of acute epiglottitis. Adult patients with more systemic comorbidities might bear higher risk of airway compromise; the role of diabetes mellitus can't be overlooked. (Otolaryngol Head Neck Surg 2005;132:689-693.)

Routine computerised tomography in patients with acute supraglottitis for the diagnosis of epiglottic abscess: is it necessary?--a prospective, multicentre study

OBJECTIVES

To evaluate the predictive factor of epiglottic abscess and to investigate whether routine computerised tomography (CT) in patients with acute supraglottitis are necessary.

DESIGN

A prospective and multicentre study.

SETTINGS

Tertiary care referral medical centre.

PARTICIPANTS

A total of 202 patients with suspected acute supraglottitis were enrolled. All patients underwent CT to confirm the presence of abscess.

MAIN OUTCOME MEASURES

The patients' characteristics, symptoms at presentation, laryngoscopic findings of epiglottic swelling and arytenoid swelling by scope classification and initial laboratory finding were analysed.

RESULTS

Of 202 patients, 158 (78%) had acute supraglottitis and 44 (22%) had epiglottic abscess. There was no significant difference in age between the acute supraglottitis group and the epiglottic abscess group. Men were significantly more frequent in the epiglottic abscess group than females (P = 0.042). When comparing the symptom at presentation, the patients with epiglottic abscess complained of voice change more frequently (P = 0.003). Moderate or severe epiglottic swelling in scope classification was significantly associated with epiglottic abscess (P < 0.001). In logistic regression analysis, voice change [OR = 2.64, 95% CI = 1.29-5.40, P = 0.008] and moderate or severe epiglottic swelling in laryngoscopic findings [OR = 3.94, 95% CI = 1.63-9.53, P = 0.002] were independent predictive factors for epiglottic abscess. The positive predictive values of voice change and moderate or severe epiglottic swelling were 33% and 30%, respectively. The negative predictive values of voice change and moderate or severe epiglottic swelling were 15% and 9%, respectively.

CONCLUSIONS

Routine CT might be suggested for diagnosis of epiglottic abscess in the patients with acute supraglottitis, because of the poor predictive values of symptoms and signs.

Aspergillus epiglottitis in a non-immunocompromised patient

The authors present a case that highlights an atypical example of a fungal epiglottis in an otherwise well adult patient with no medical history of fungal infection or an immunocompromised state. As current medical literature presents this fungus as only manifesting in the immunocompromised, the authors suggest, by this case report, that fungal pathogens be considered as a potential cause of epiglottitis in non-immunocompromised patients.

Efficacy of spinal needle aspiration for epiglottic abscess in 90 patients with acute epiglottitis

CONCLUSION

Patients with epiglottic abscesses showed more severe symptoms than those with acute epiglottitis and were at increased risk of airway compromise. All 11 patients with epiglottic abscesses underwent spinal needle aspiration; all were cured without severe complications. These findings indicate that spinal needle aspiration is both safe and effective in patients with epiglottic abscesses.

OBJECTIVES

Acute epiglottitis is a disease that may become serious or even fatal because of sudden upper airway obstruction. An epiglottic abscess may result from a coalescent epiglottic infection due to acute epiglottitis or secondary infection of an epiglottic mucocele. There have been few reports comparing acute epiglottitis with epiglottic abscess. We therefore assessed the clinical characteristics of each condition, as well as the efficacy of spinal needle aspiration and drainage of epiglottic abscesses.

PATIENTS AND METHODS

We retrospectively reviewed the records of 90 hospitalized patients diagnosed with acute epiglottitis and epiglottic abscess by flexible nasopharyngolaryngoscopy between March 2006 and February 2008. All patients were treated with medication; in addition, those with epiglottic abscess underwent spinal needle aspiration.

RESULTS

Of 90 patients, 79 had acute epiglottitis and 11 had epiglottic abscesses. Acute epiglottitis was most common in May (16.5%) and epiglottic abscesses were most common in June (27.3%). The most common symptoms were sore throat (91.1%), dysphagia (38.9%), voice change (33.3%), and dyspnea (16.7%). All patients were treated with antibiotics and steroids. The mean length of hospitalization was 5 days. No patient required a tracheostomy or orotracheal intubation.

Epiglottic abscess in an HIV-positive patient

Coalescence of infection of the epiglottis, or epiglottic abscess, is a rare manifestation of epiglottitis. We report the case of a 49-year-old Hispanic man with HIV (CD4 count 243 [16.2%]), HIV viral load 175,689 copies per milliliter, antiretroviral-naive) contracted from his wife who presented to the emergency department with a 3-week history of sore throat, odynophagia, left temporal headache, left neck pain, and occasional blood-streaked sputum. This case represents the first reported case of epiglottic abscess in an HIV-positive individual. Epiglottic abscess formation is associated with potentially rapid airway compromise and carries a high mortality rate. The diagnosis of epiglottic abscess is often difficult. In HIV-infected individuals, a variety of infectious and oncologic sources of respiratory compromise should be considered in addition to epiglottic abscesses. Prompt diagnosis and treatment of this condition is crucial for ensuring optimal outcomes in this rare but often lethal infection.

Adult epiglottitis in a Canadian setting

The objective of this study was to determine stable estimates of the incidence, case fatality, and epidemiologic features of adult epiglottitis, and risk factors for intubation. The authors designed a retrospective cohort combined with a nested case-control study, followed by detailed analysis of cases from two tertiary care institutions. Among 813 cases, the incidence was 2.02 cases/10(5) population per year. Ten recorded deaths constituted a case fatality rate of 1.2% (95% confidence interval [CI]: 0.5% to 1.9%). The eight fully documented deaths indicated no sudden episodes of catastrophic upper airway obstructions without previous dyspnea. A detailed review of 51 cases revealed that 18% of patients underwent expeditious intubation. Patients managed without initially requiring intubation did not need emergency airway interventions. Only the presence of dyspnea (noted in 29% of patients) at the time of admission (P < 0.001) predicted the need for intubation. A low case fatality rate in a conservatively managed cohort and the absence of sudden upper airway catastrophes in patients without dyspnea suggest that prophylactic intubation and intensive care unit monitoring is not warranted in all patients. An early complaint of dyspnea may safely discriminate between patients requiring invasive airway management and close observation.

Epiglottitis in adults

Acute epiglottitis has become a disease of adults, probably as a result of immunization of children against Haemophilus influenzae. This article is a review of the literature on epiglottitis, including signs and symptoms, investigation, differential diagnosis, and treatment in the emergency department. The microbiology is discussed and the importance of prophylaxis in exposed persons is stressed.

Acute epiglottitis in a gravid 19-year-old

We report a case of adult onset epiglottitis needing emergent tracheal intubation in a parturient at 11 weeks gestational age.

Acute epiglottitis. An 18-year experience in Rhode Island

OBJECTIVE

To assess the incidence, clinical characteristics, management, and outcome of epiglottitis in a defined population over an 18-year period.

DESIGN

Case series.

SETTING

The state of Rhode Island, 1975 through 1992.

PATIENTS OR OTHER PARTICIPANTS

Cases who met predetermined criteria for acute epiglottitis identified from hospital discharges and the State Medical Examiner's log of prehospitalization deaths.

MAIN OUTCOME MEASURES

Incidence by year and age, clinical presentation, results of diagnostic evaluations, management, and outcome.

RESULTS

Four hundred seven cases were identified, 134 in children and 273 in adults. Incidence in children dropped from 38 cases in the first 3 years of the study to 1 case in the last 3 years (p < 0.001). Adult cases increased from 17 in the first 3 years to 69 in the last 3 years (p < 0.001). Seventy-nine percent of adults and 32% of children were treated without an artificial airway. Factors associated with airway obstruction included symptomatic respiratory difficulty, stridor, drooling, shorter duration of symptoms, enlarged epiglottis on radiograph, and Haemophilus influenzae bacteremia (p < 0.001 for each). Twelve patients died (3 children and 9 adults), with all cases of fatal respiratory obstruction occurring within 12 h of presentation.

CONCLUSIONS

There have been significant changes in the clinical epidemiology of epiglottitis, which now occurs almost exclusively in adults, often with less severe symptoms and a lower incidence of H influenzae infection. While careful observation is indicated for all patients, the data suggest that those with certain clinical characteristics can be treated safely without an immediate artificial airway.

Epiglottic abscess

BACKGROUND

Epiglottitis is more commonly seen in children less than 6 years of age, although this entity has also been well described among adults. A coalescence of infection of the epiglottis, or epiglottic abscess, has been infrequently reported in series of epiglottitis. Risk factors for epiglottic abscess include adult age at onset, diabetes, and the presence of a foreign body.

METHODS

Case study.

RESULTS

We present a case of a woman with a 4-day history of febrile illness, odynophagia, and an altered voice. Clinical examination and computed tomography (CT) demonstrated an epiglottic abscess. The patient underwent direct laryngoscopy, intubation, drainage of abscess, and intravenous antibiotics.

CONCLUSIONS

The diagnosis of epiglottic abscess should be considered in adult patients initially seen with odynophagia and dysphonia. Principles of treatment include airway management, antibiotics, and surgical drainage.

Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management

A 64-year-old man with acute epiglottitis, monitored in an ICU without an artificial airway, suffered sudden fatal respiratory arrest 36 h after admission despite rapid emergency interventions. This case demonstrates the importance of adequate airway protection in adult epiglottitis even within an ICU setting. A protocol for airway management for such patients is presented.

Adult respiratory distress syndrome associated with adult epiglottitis

Adult respiratory distress syndrome (ARDS) is an increased permeability pulmonary edema syndrome known to be associated with a variety of direct and indirect pulmonary insults. ARDS occurred in a 37-year-old woman during an episode of epiglottitis. The patient was treated with endotracheal intubation and mechanical ventilation and recovered, to be discharged from the hospital 1 week after presentation. There are only two cases of ARDS reported in this setting, and in each case, pulmonary edema followed cardiac arrest and the patients had a fatal outcome.

Acute epiglottitis in the adult: is intubation mandatory?

Acute epiglottitis (AE) in the adult results in inflammation of the supraglottic structures and carries the potential for complete airway obstruction. There is disagreement in the medical literature as to the appropriate management of the airway in the adult with AE. Some authors advocate intubation in all patients while others propose more selective intervention, intubating the trachea only in those patients presenting with airway compromise. We reviewed our institutional experience with 21 patients over the last seven years admitted with a proven diagnosis of AE. Six patients presented with respiratory distress, three in severe distress with symptoms and signs of upper airway obstruction. The three patients in severe distress were taken to the operating room, in two the tracheas were intubated and one underwent tracheostomy after failed intubation. All other patients were monitored but their tracheas were not intubated. The majority of the patients were monitored for 24 hr in the ICU before transfer to wards. No patient initially monitored required tracheal intubation for progression of disease. There were no deaths. Recommendations for the care of the airway in the adult with AE based on our experience and a review of approximately 1000 cases reported in the last ten years are presented. It is our opinion that adults presenting without respiratory symptoms may be safely monitored in an intensive care setting given that provision is made for tracheal intubation or tracheostomy should respiratory distress become evident.

Acute infectious epiglottitis in children and adults: annual incidence and mortality

The incidence and mortality of acute epiglottitis were retrospectively analysed covering a 12-year period, 1975-1987. The diagnosis was made by the laryngoscopic findings in 95% of patients. Based on 902 hospitalized patients, a mean annual incidence of 4.9 cases per 100,000 children and adults was found. Although adult patients predominated (60%), the incidence was far higher in children, 13.8 per 100,000 compared with 3.9 per 100,000 in adults. Two peaks in incidence were identified, one for the youngest children, and the second for young adults (15-29 years). Over the years the incidence varied little in adults, but decreased significantly in children over the last 6 years studied. The data presented indicate acute epiglottitis to be a more frequent disorder than previously believed but with less risk of a fatal outcome. The mortality rate was below 1% in children and adults and the annual incidence of death from acute epiglottitis was estimated at 0.5 cases per million. The primary admission of these patients to ENT units seems to be the single factor having the most powerful impact on mortality.

Recurrent adult acute epiglottitis: the role of lingual tonsillectomy

Acute epiglottitis is a life-threatening infection of the supraglottic airway that can occur at any age. Although it is traditionally described as a childhood infection, recent reports describe an increased recognition of this problem in adults. When appropriate and timely therapy is instituted, this condition is generally self-limited. Recurrent acute epiglottitis is exceedingly uncommon, and its treatment rarely is addressed. We encountered and treated a case of recurrent acute epiglottitis in an adult. After the third recurrence, careful consideration was given to possible pathophysiologic mechanisms and potential therapeutic options. Further recurrence was prevented effectively by performing a lingual tonsillectomy. Although this is an unusual condition, the cause of recurrent acute epiglottitis may be related to chronic lingual tonsillitis. Lingual tonsillectomy in these cases may help prevent further recurrent episodes.

Adult epiglottitis

Adult epiglottitis (or "supraglottitis") is an uncommon but increasingly recognized entity. Though prior studies emphasized the fulminant nature of the disease, recent evidence suggests that epiglottitis in adults may follow a relatively less severe clinical course, especially if Hemophilus influenza is not isolated. The records of 28 patients with adult epiglottitis were retrospectively analyzed to characterize the presenting features and clinical course of the disease. The diagnosis was established by laryngoscopy, lateral cervical radiographs, or both. Laryngoscopy did not precipitate airway obstruction in any patient. The majority of patients experienced a relatively benign clinical course and improved with medical management that consisted of ICU admission, intravenous antibiotics, hydration, inhaled mist, and corticosteroids. Only two patients (7%) required airway support with orotracheal intubation because of respiratory difficulty. There were no instances of respiratory arrest or airway obstruction. No tracheostomies were performed, and there were no deaths. It was concluded that adult epiglottitis can follow a less severe course than classically described.

Etiology of acute infectious epiglottitis in adults: septic vs. local infection

Adult patients with acute epiglottitis hospitalized between 1975 and 1988 were retrospectively analysed. 79 of 138 patients had a valid diagnosis and had delivered at least one blood culture and were considered eligible for further evaluation. Cultures from the upper airways, including epiglottis, were available in 43 of the patients as a consequence of prospective measures. 27% of the patients had bacteremia, which may however be an overestimation. Haemophilus influenzae was the predominating finding, but Streptococcus pneumoniae was isolated from 3 severely ill patients, indicating the existence of pneumococcal epiglottitis at a rate of less than 5%. From the non-bacteremic patients with a localized disease, either H. influenzae or beta-hemolytic streptococci were isolated from the epiglottis in one third of the cases. The distribution of pathogens in upper airways indicates that beta-hemolytic streptococci may have an etiological role in acute infectious epiglottitis. Except for H. influenzae, species with the potential ability of beta-lactamase production have no significance in the disease.

Acute epiglottitis in adults (the Singapore experience)

Acute epiglottitis in adults is a potentially fatal but self-limiting disease of increasing incidence world-wide. Forty-two patients, seen consecutively over a four year period at the ENT Department, Singapore General Hospital were reviewed retrospectively. A strong male predominance with a peak age incidence in the sixth decade was noted. A severe sore throat and dysphagia with disproportionate signs of oropharyngeal inflammation was the main presenting picture. Only three patients had stridor on presentation. Vigilant monitoring of the airway with empirical high-dose intravenous ampicillin, cloxacillin and steroids resulted in a dramatic clinical improvement in most patients and none developed stridor after admission. The yield from throat swabs and blood cultures were low. Two patients developed complications, a Ludwigs angina and an epiglottic abscess. Recurrent epiglottitis was a problem in one patient. There was low morbidity and no mortality on the management regime outlined.

Epiglottitis at the extremes of age

Epiglottitis may occur at any age. The typical presentation in the young child and young adult is well known, but the presentation in patients at the extremes of age has not been characterized. At our locale, from 1974 to 1984, 19 children 24 months of age or less and, from 1979 to 1984, 9 adults 50 years of age or greater with epiglottitis were seen in the emergency department. In the infantile group, rapidly progressive interference with swallowing, vocalization, and respiration was encountered in less than half the patients. Symptoms were often prolonged before parents sought attention for their child. No preference was shown for maintenance of the upright position while at rest, as recumbency did not promote stridor or initiate respiratory distress. Respiratory complaints were common and included cough, tachypnea, and retractions. Drooling or retention of pharyngeal secretions was uncommon. The adult population had a history of symptoms that spanned several days. Extreme sore throat, pooling of oral secretions, muffled voice, and elevated temperature were uncommon. Dysphagia and mild respiratory complaints were frequent. Upper airway obstruction did occur. At both extremes of age, exceptions to the classic clinical pattern of epiglottitis occurred with significant frequency. Despite this, diagnosis and management in the emergency department were appropriate in most cases.

Adult epiglottitis

Adult epiglottitis is a disease that is well known to otolaryngologists, but is less commonly encountered in general medical practice. It is being recognized with increasing frequency, and in many respects is different from paediatric epiglottitis. Three patients with adult epiglottitis are described, with an emphasis on the variation in clinical presentation and the difficulty in diagnosis. The appropriate examinations and the management of the disease are discussed.

Acute epiglottitis in adults: bacteriology and therapeutic principles

Acute epiglottitis is seldom encountered in adults, but the condition is probably more frequent than reported in the literature. Nineteen cases of adult epiglottitis were analysed retrospectively. In 53% of the patients, the symptoms were present for less than 24 h prior to hospitalization. Sore throat and dysphagia were invariably present. Three patients presented with stridor and 2 with complete airway obstruction. Throat cultures from 5 patients grew beta-haemolytic streptococci and from 2 Haemophilus influenzae type B was grown. Two tracheotomies and 1 nasotracheal intubation were performed. One death occurred. It is emphasized that any adult with an acute sore throat and dysphagia should undergo indirect laryngoscopy and that blood cultures should always be part of the routine bacteriological investigation. Cooperation and understanding among otolaryngologists and anaesthesiologists is of paramount importance in the management of acute adult epiglottitis, as nasotracheal intubation and cricothyroidotomy appear to be the methods of choice in securing an airway. Ampicillin and chloramphenicol are recommended in the medical treatment.