The incidence of epiglottic cysts in a cohort of adults with acute epiglottitis

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.

Rare cause of voice muffling: pyogenic vallecular cyst

A vallecular cyst is a benign laryngeal cyst that rarely causes symptoms in adults. We report a rare case of an infected vallecular cyst in a man who is in his 60s with diabetes mellitus. The patient presented to us with acute onset of voice muffling and respiratory distress. He showed signs of sepsis and upper airway obstruction. He had spikes of high-grade fever with an elevated total white cell count (predominantly neutrophil count) and C reactive protein level. Plain cervical X-ray revealed a large, smooth, lobulated mass in the vallecular area. Direct laryngoscopic findings supported the diagnosis of an infected vallecular cyst with suppuration, which originated from the vallecula fossa. The cyst was drained and excised completely, and the pus culture revealed the presence of Klebsiella pneumoniae The patient responded well to the administration of intravenous cefuroxime for 2 weeks according to the sensitivity and culture test. He was discharged after the completion of the course of antibiotics, having recovered fully. This case illustrates the versatility of a plain cervical X-ray in giving clues about this rare, unexpected pathology.

Clinical and Microbiological Factors Associated With Abscess Formation in Adult Acute Epiglottitis

OBJECTIVES

To evaluate clinical and microbiological findings that are correlated with abscess formation in adult acute epiglottitis (AE).

METHODS

We reviewed 140 cases of adult AE. Demographic, clinical, imaging, and microbiological findings are analyzed for all patients with AE in comparison to those with epiglottic abscess (EA).

RESULTS

A total of 113 patients presented with AE and 27 presented or progressed to EA (19.3%). Age, sex, seasonality, smoking, body mass index (BMI), and comorbidities were statistically insignificant between the 2 groups. Muffled voice (P < .013), respiratory distress (P < .001), and pre-existence of epiglottic cyst (P < .001) are symptoms and signs connected with abscess formation. A total of 120 patients were treated conservatively. Surgical treatment was performed on 20 patients with EA. About 72 out of 80 cultures revealed monomicrobial infection. Mixed flora was isolated in 8 patients with EA. Streptococcus was isolated in 51 out of 80 positive cultures (64%). Haemophilus Influenza (Hib) was not isolated in any sample. EA and mixed flora relates to a higher rate of airway intervention (P < .001).

CONCLUSION

A high level of suspicion for abscess formation is required if clinical examination reveals dyspnea, muffled voice, or an epiglottic cyst in adult with AE. The existence of EA doubles the duration of hospitalization. EA is typically found on the lingual surface of the epiglottis. Supraglottic or deep neck space expansion should be treated surgically. EA is associated with a mixed flora and a higher rate of airway obstruction. Streptococcus is discovered to be the most common pathogen.

Ultrasound guided transcervical drainage of tongue base abscess

IMPORTANCE

Infected vallecular cysts should first be treated conservatively and if airway is compromised surgical treatment is considered.

OBJECTIVE

The aim of this study was to determine the feasibility and safety of transcervical aspiration of an infected vallecular cyst.

DESIGN

A retrospective review of a novel technique that has been used for drainage of vallecular cyst abscesses for 5 years (2012 to 2017).

SETTING

Galilee Medical Center affiliated to Azrieli Faculty of Medicine.

PARTICIPANTS

Consecutive patients who underwent ultrasound guided percutaneous vallecular cyst drainage.

MAIN OUTCOME & MEASURES

Medical records were reviewed to identify patient characteristics, symptoms, and outcomes.

RESULTS

During 2012-2017, seven patients underwent transcutaneous ultrasound-guided drainage of a tongue-base abscess as an in-hospital office procedure. In all patients the technique described above was feasible. About a month after the procedure, patients underwent surgical marsupialization of the cyst under general anesthesia.

CONCLUSIONS AND RELEVANCE

Ultrasound guided transcutaneous needle drainage of a base of tongue abscess is possible as it may achieve palliation and obtain material for culture. In this first-described series we show this technique's feasibility. Physicians should be familiar with this technique as it can easily be done under ultrasound guidance in the clinic using local anesthesia, and culture may be obtained, airway obstruction relieved, and recovery facilitated.

Gold laser removal of a large ductal cyst on the laryngeal surface of the epiglottis

Laryngeal cysts are rare lesions of the larynx that are often described on incidental discovery. We report an unusual presentation of a large ductal cyst located on the laryngeal surface of the epiglottis. The patient presented with a low tone voice while displaying bilateral normal appearing vocal cords with normal mobility. Computed tomography scans and flexible laryngoscopy showed a round supraglottic mass approximately 2 cm in diameter on the right lateral laryngeal surface of the epiglottis. The mass was removed surgically during microsuspension laryngoscopy with excision of the mucocele utilizing a gold laser. Postoperatively, the patient's voice returned to baseline with no complications.

Calculated parenteral initial treatment of bacterial infections: Infections in the ear, nose, throat and mouth and jaw area

This is the sixth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the antibacterial treatment of more severe infections of the ear, the nose, the throat and the maxillofacial region, including odontogenic and salivary gland infections.

Videolaryngoscope-assisted coblation of epiglottic cysts

PURPOSE

This study aims to investigate the safety and effectiveness of videolaryngoscope-assisted coblation of epiglottic cysts (VACECs) under general anesthesia.

METHODS

Twenty-eight consecutive patients with epiglottic cysts (ECs), underwent VACECs in this prospective clinical series from January 2015 to March 2019. The pre-operative electronic flexible laryngoscopic or 70° rigid laryngeal endoscopic examination was carried out to assess the location and size of ECs. There was a periodical follow-up survey for all patients.

RESULTS

A total 28 of patients were enrolled, including 12 men and 16 women, with an average age of 55 (range 24-78). The patient's medical history ranged from half a month to 2 years. The size of the cyst arranged from 0.8 to 1.5 cm. All patients were cured without pharyngeal or systemic complications. No tooth loss occurred in five patients (17.9%) with loose anterior teeth. Specimen pathology confirmed the diagnosis in all patients. No recurrence was found after more than half a year's follow-up.

CONCLUSIONS

VACECs brings together the advantages of videolaryngoscope and coblation. It is a simple, safe and feasible procedure for patients with ECs and is worthy of clinical application.

Neisseria flavescens Infection in Atypical Multiple Vallecular Cysts

A 53 year-old female patient presented with symptoms of intermittent odynophagia and halitosis persisting for 2 months. Physical examination revealed bilateral lingual tonsillar cysts and multiple vallecular cysts with clear fluid. Laboratory studies were unremarkable. The patient underwent surgery, during which uncapping of the multiple vallecular cysts was performed, and multiple microbiological samples and biopsies were taken. After surgery, the patient had complete resolution of all her symptoms. Pathological results demonstrated lymphoepithelial cysts. Microbiological tests demonstrated an infection by Neisseria flavescens, which is a non-pathogenic commensal of the oropharynx, and has never been described as causing agent of infected vallecular cysts.

A systematic review and meta-analysis of predictors of airway intervention in adult epiglottitis

OBJECTIVE

Epiglottitis is typically considered a pediatric disease; however, there is growing evidence that the incidence of adult epiglottitis has changed since the introduction of the Haemophilus influenzae vaccine. The literature is composed of multiple small series with differing findings. To date, there has been no attempt to collaborate evidence on predictors of airway intervention in this disease.

METHODS

The population of interest was adults with a diagnosis of epiglottitis. The primary outcome in this review was incidence of airway intervention. A comprehensive literature search was conducted of the MEDLINE and Embase databases, and a separate random-effects model meta-analysis was undertaken for all outcome data. Moderator tests for comparison between prevaccine and postvaccine estimates were made, and absolute risk difference (RD) and relative risk (RR) calculations were made for all predictors of airway intervention.

RESULTS

Thirty studies and a total of 10,148 patients were finally included for meta-analysis. A significant decrease in airway intervention was seen post vaccine introduction introduction from 18.8% to 10.9% (P = 0.01). The presence of an abscess (RD 0.27, P = 0.04; RR 2.45, P < 0.001), stridor (RD 0.64, P < 0.001; RR 7.15, P < 0.001), or a history of diabetes mellitus (RD 0.11, P = 0.02; RR 2.15, P = 0.01) were associated with need for airway intervention.

CONCLUSION

In the postvaccine era, clinicians should expect to have to secure airways in 10.9% of cases. The presence of an epiglottic abscess, stridor, or a history of diabetes mellitus are the most reliable clinical features associated with need for airway intervention.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:465-473, 2020.

Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study

Objective

Studies have revealed that 3.5%–26.6% of patients with epiglottitis have comorbid diabetes mellitus (DM). However, whether preexisting DM is a risk factor for acute epiglottitis remains unclear. In this study, our aim was to explore the relationship between preexisting DM and acute epiglottitis in different age and sex groups by using population-based data in Taiwan.

Methods

We analyzed data between January 2000 and December 2013 obtained from the Taiwan National Health Insurance Research Database. The case group consisted of 2,393 patients with acute epiglottitis. The control group comprised 9,572 individuals without epiglottitis, frequency matched by sex, age, urbanization level, and income. Underlying DM was retrospectively assessed in the cases and controls. Univariate and multivariate logistic regression analyses were used to investigate the associations between underlying DM and acute epiglottitis.

Results

Of the 2,393 patients, 180 (7.5%) had preexisting DM, whereas only 530 (5.5%) of the 9,572 controls had preexisting DM. Multivariate logistic regression analyses indicated that preexisting DM was significantly associated with acute epiglottitis (adjusted odds ratio [aOR] = 1.42, 95% confidence interval [CI] = 1.15–1.75, P = 0.004). Subgroup analysis showed that the association between DM and epiglottitis remained significant for men (aOR = 1.57, 95% CI: 1.19–2.08, p = 0.002) but not for women. Age-stratified analysis revealed a significant association between DM and acute epiglottitis in patients aged 35–64 years. Use of anti-diabetic agents was not significantly associated with the development of acute epiglottitis among diabetic patients, including oral hypoglycemic agents (OHA) alone (aOR = 0.88, 95% CI = 0.53–1.46, p = 0.616), and OHA combined with insulin/ insulin alone (aOR = 1.30, 95% CI = 0.76–2.22, p = 0.339). The association between presence of diabetes complications and the occurrence of acute epiglottitis was also not significant among diabetic patients in this study setting (aOR = 0.86, 95% CI = 0.59–1.26, p = 0.439).

Conclusions

The results of our large-scale population-based case–control study indicate that preexisting DM is one of the possible factors associated with the development of acute epiglottitis. Physicians should pay attention to the symptoms and signs of acute epiglottitis in DM patients, particularly in men aged 35–64 years.

Laryngeal Cysts in Adults: Simplifying Classification and Management

Objective

Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx.

Data Sources

PubMed/Medline.

Review Methods

A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance.

Conclusion

Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up.

Implications for Practice

A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

Efficacy of Spinal Needle Aspiration in Patients with Epiglottic Abscess

Objective/Hypothesis

To evaluate the efficacy of spinal needle aspiration for symptom improvement in awake patients with epiglottic abscess (EA).

Study Design

Prospective randomized controlled study.

Setting

Tertiary center.

Subjects and Methods

Twenty-two patients who were diagnosed with EA were randomly allocated to group A (needle aspiration and antibiotics) or group B (antibiotics only). Patients’ characteristics, laryngoscopic findings of epiglottic swelling and arytenoid swelling by scope classification, and initial laboratory findings were analyzed. Needle aspiration was done under local anesthesia in awake patients using an 18-gauge spinal needle and indirect laryngoscope. Changes in the following symptoms during hospital stay were assessed: sore throat, hoarseness, dyspnea, odynophagia, and dysphagia.

Results

Eleven patients were treated with needle aspiration and antibiotics, and 11 patients were treated with antibiotics only. There was no statistically significant difference between the 2 groups regarding age, sex, white blood cell count, C-reactive protein, presenting clinical symptoms, abscess size, and scope classification at time of diagnosis. Patients in both groups had significant improvement in all clinical symptoms. While there were no between-group differences in improvement for any of the symptoms, the length of hospitalization was significantly lower in group A (4.0 ± 1.9 days) than in group B (5.7 ± 1.2 days) ( P = .037).

Conclusion

We did not find any significant additional benefit of needle aspiration for the treatment of EA, with the exception that needle aspiration reduced the length of hospitalization. Further proof with a large-scale study is needed.

Laryngeal Ultrasound for Assessment of Supraglottic Laryngitis with Abscess

Here we report a rare case, for this era, of supraglottic laryngitis with abscess formation after antibiotics use. Laryngeal ultrasound for abscess detection and follow-up has advantages over neck computed tomography. This modality can assess vocal cord movement noninvasively with the benefits of cost effectiveness, easy availability, freedom from radiation, and high resolution-factors that are superior to other modalities. Although laryngeal abscesses are rare, clinicians should be aware of their myriad presentations. Acute supraglottitis with abscess formation may cause potentially fatal obstruction of the airway. Early recognition and intervention to prevent morbidity and mortality is thus very important.

How to cite this article

Chiu PH, Shih CW, Tsai YJ, Chiang RPY. Laryngeal Ultrasound for Assessment of Supraglottic Laryngitis with Abscess. Int J Phonosurg Laryngol 2013;3(1): 24-27.