Acute epiglottitis. An 18-year experience in Rhode Island

Epiglottitis in Patients With Preexisting Autoimmune Diseases: A Nationwide Case-Control Study in Taiwan

OBJECTIVES

The role of autoimmune diseases on the risk for acute epiglottitis remains uncertain. This study aimed to delineate the association between epiglottitis and autoimmune diseases using population database.

METHODS

A population-based retrospective study was conducted to analyze claims data from Taiwan National Health Insurance Research Database collected over January, 2000, to December, 2013.

RESULTS

In total, 2339 patients with epiglottitis were matched with 9356 controls without epiglottitis by sex, age, socioeconomic status, and urbanization level. The correlation between autoimmune diseases and epiglottitis was analyzed by multivariate logistic regression. Compared with controls, patients with epiglottitis were much more likely to have preexisting Sjögren syndrome (adjusted odds ratio [aOR]: 2.37; 95% CI: 1.14-4.91; P = .021). In addition, polyautoimmunity was associated with increased risk of epiglottitis (aOR: 2.08; 95% CI: 1.14-3.80; P = .018), particularly in those aged >50 years (aOR: 2.61; 95% CI: 1.21-5.66; P = .015).

CONCLUSIONS

Among autoimmune diseases, we verify the association between epiglottitis and Sjögren syndrome in Taiwan. Furthermore, we present the novel discovery that patients with epiglottitis have an increased risk of polyautoimmunity, particularly those aged >50 years.

Vaping-induced acute epiglottitis: a case report

BACKGROUND

E-cigarette use, or vaping, is an alternative nicotine delivery system that is becoming increasingly prevalent in adolescents and young adults. There is currently a lack of comprehensive research on the adverse effects of vaping on the upper airway. Acute epiglottitis is a potentially life-threatening condition that can lead to airway obstruction. It is commonly caused by bacterial infections such as streptococci, staphylococcus, and Moraxella. Adult patients with acute epiglottitis mainly present with odynophagia, dysphagia, and respiratory difficulties. The diagnosis of epiglottitis is made by direct laryngoscopy, and the mainstay of treatment is antibiotics. Bozella et al. (2020) reported a case of subacute non-infectious epiglottitis associated with e-cigarette use in a pediatric patient (Pediatrics 145(3), 2020). Here we present a case of acute epiglottitis in a healthy young adult after vaping, with a negative infectious workup. To our knowledge, there has been no such reported case of epiglottitis associated with e-cigarette use in an adult patient.

CASE DESCRIPTION

A previously healthy 29-year-old male with daily e-cigarette use presented to the emergency department with a severe sore throat, dysphagia, mild hoarseness, and shortness of breath, especially when lying supine. A lateral neck soft tissue radiograph revealed a thickened epiglottis with a thumb sign. Direct bedside laryngoscopy showed a swollen epiglottis, partially obstructing the supraglottic region confirming the diagnosis of acute epiglottitis. Throat and nasal swabs were negative for streptococcus and COVID-19 infection, respectively. The patient's condition improved significantly after receiving intravenous Dexamethasone and antibiotics for 2 days. Repeat laryngoscopy showed the resolution of epiglottis swelling, and subjective symptoms had resolved entirely 2 weeks following the start of the treatment.

CONCLUSIONS

Although bacterial infections usually cause acute epiglottitis, this case presents the second report of this condition associated with vaping with negative microbiological investigations. Therefore, we recommend that physicians consider non-infectious causes such as vaping in their differential diagnosis for patients with acute and subacute epiglottitis. More research is warranted on the utility of antibiotics in treating vaping-induced epiglottitis.

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.

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.

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.

The management of acute supraglottitis patients at the intensive care unit

INTRODUCTION

Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis.

METHODS

A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam.

RESULTS

Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively.

CONCLUSION

Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.

Predictors of airway intervention in acute supraglottitis (AS), a recent 7- year experience

AIMS

Acute supraglottitis (AS) can be a life threatening infection that may lead to sudden airway obstruction. Thankfully, paediatric instances have decreased with public health vaccination programmes. Owing to the nature of the location of pathology, this time sensitive emergency requires astute clinical acumen and awareness of early warning signs. This study aimed to i) determine if the incidence of AS has changed over time; ii) investigate geographical and seasonal variation of infection; iii) identify features of presentation which may predict airway intervention; iv) assess efficacy of treatment and make recommendations for management.

MATERIALS AND METHOD

All adult patients admitted to a tertiary hospital with the diagnosis of acute supraglottitis between 2013 and 2021 were included. Diagnosis was confirmed with flexible nasendoscopy and consultant review. Demographics, management and outcomes were recorded. Statistical analysis was performed by calculating means and standard deviation for descriptive purposes. Fischer's exact test and two tailed t-test for categorical and continuous variables respectively. Results were deemed significant if P values of less than or equal to 0.05 were calculated.

RESULTS

Forty-three adults were identified. Five patients (11.6%) required airway intervention. Stridor, respiratory distress and CRP of >100 mg/L were noted to be significant predictive factors for airway intervention. Intubated patients had a significantly longer hospital stay. Regions with a higher population density were noted to have a higher incidence but this did not prove to be significant.

CONCLUSION

This is the largest study of AS in Ireland to date. There is a trend towards increasing incidence of acute supraglottitis in adults. Factors such as stridor, respiratory distress and elevated CRP should alert the clinician to the possible need for airway intervention. Acute supraglottitis is more common in higher density populated regions.

Short-Term Exposure to Air Pollution and Epiglottitis: A Nested Case-Control Study

OBJECTIVES/HYPOTHESIS

This study investigated the impacts of air pollution and meteorological factors on the occurrence of epiglottitis.

STUDY DESIGN

A nested case-control study.

METHODS

Participants ≥40 years old in the Korean National Health Insurance Service-Health Screening Cohort were analyzed. A total of 2,615 epiglottitis patients and 10,460 matched control participants were analyzed. The odds ratios (ORs) for epiglottitis associated with meteorological and air pollution factors, including sulfur dioxide (SO₂ , ppb), nitrogen dioxide (NO₂ , ppb), ozone (O₃ , ppb), and carbon monoxide (CO, ppm), after 3, 7, 15, and 30 days of exposure were analyzed using conditional logistic regression adjusted for total cholesterol, blood pressure, fasting blood glucose, obesity, smoking, alcohol consumption, prior upper respiratory infection, tonsillectomy, immunocompromise, autoimmune disease, and the Charlson comorbidity index.

RESULTS

The daily temperature range and NO₂ exposure after 3 days were associated with increased rates of epiglottitis (OR = 1.03, 95% confidence interval [CI] = 1.02-1.05 for temperature range and OR = 1.78, 95% CI = 1.14-2.77 for NO₂ , respectively). These results were generally consistent at 7, 15, and 30 days.

CONCLUSIONS

The temperature range and NO₂ exposure for 3, 7, 15, and 30 days were positively related to the occurrence of adult epiglottitis.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Intubation decision criteria in adult epiglottitis

OBJECTIVES

To identify contributive criteria in decision-making for intubation in acute epiglottitis, based on clinical and endoscopic data in adult patients, and to study clinical and biological characteristics and management.

MATERIALS AND METHODS

Diagnosis was established by flexible endoscopy showing epiglottic edema in association with general signs of sepsis in 28 patients consulting into two French hospitals between 2005 and 2016. Retrospective univariate and multivariate analysis between patients managed by intubation (Group I) or surveillance (Group S) was performed on clinical and endoscopic data.

RESULTS

Ten patients were intubated (36%). On univariate analysis, 4 variables were suggestively associated with intubation. On multivariate analysis, associations remained suggestive for dyspnea (OR=50.6; 95% CI=[2.7; 940.1]) and supraglottic edema extension (OR=42.2; 95% CI=[2.2; 799.5]). The area under the curve identifying intubated patients on these 2 criteria was 90.8%, testifying to high discrimination.

CONCLUSION

Intubation must always be considered in epiglottitis. Dyspnea and supraglottic extension of the edema seem to be the two main criteria to be considered in airway control decision-making.

Disseminated Herpes Simplex Infection Presenting as Acute Supraglottitis in an Adult

Supraglottitis is a life-threatening, predominantly bacterial disease that is rarely caused by viral etiologies. Herpes Simplex Virus (HSV) supraglottitis has been infrequently reported, but its presentation can mimic that of bacterial supraglottitis or pharyngitis which may lead to delayed diagnosis and increased morbidity. We present a case of supraglottitis in an immunocompetent man initially thought to have bacterial epiglottitis. After receiving a tracheostomy due to impending airway compromise and failing to improve on antibiotic therapy, biopsy of the upper airway tissue revealed infection with HSV type 2. The patient improved after multiple weeks of systemic antivirals. HSV supraglottitis remains an unusual but important diagnostic consideration in patients with dysphonia, dysphagia, ulcerative supraglottal lesions, and acute supraglottic inflammation unresponsive to antibiotics.

End-stage renal disease as a risk factor for epiglottitis: a population-based cohort study in Taiwan

OBJECTIVES

Patients with uremia are prone to infection; however, end-stage renal disease (ESRD) as a risk factor for acute epiglottitis warrants study. We investigated the risk of severe epiglottitis requiring hospitalisation in patients with ESRD.

SETTING

We conducted a retrospective matched cohort study by using the claims data of Taiwan's National Health Insurance Research Database.

PARTICIPANTS

We identified an ESRD cohort with 87 908 patients newly diagnosed in 2000-2013 and underwent dialysis. The non-ESRD cohort comprised patients who had not received a diagnosis of ESRD, and they were matches to the ESRD cohort (1:1) by sex, age, residence urbanisation level, monthly income, and diabetes and hypertension status.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cumulative incidence of epiglottitis at the end of 2013 was analysed with Kaplan-Meier methods and log-rank tests. The HR of epiglottitis was calculated using the Cox proportional hazards model after adjustment for confounding factors.

RESULTS

The overall epiglottitis incidence rate was 94% greater in the ESRD cohort than in the non-ESRD cohort (10.3 vs 5.3 cases per 100 000 person-years, p=0.002), with an adjusted HR of 1.89 (95% CI: 1.23 to 2.91, p=0.004). In the log-rank analysis, compared with the non-ESRD group, the epiglottitis cumulative incidence was significantly higher in the ESRD group (p=0.003). Epiglottitis did not exhibit an association with higher rates of airway interventions, intensive care unit admissions or longer hospitalisation in patients with ESRD than in controls.

CONCLUSIONS

This nationwide matched cohort study indicated that ESRD patients should be monitored for the risk of severe epiglottitis requiring hospitalisation.

Use of Indirect Laryngeal Biopsy Forceps to Treat Epiglottic Abscess

OBJECTIVES

To evaluate the efficacy of indirect laryngeal biopsy forceps in the treatment of epiglottic abscess (EA).

METHODS

Twenty patients were diagnosed with EA in our department and were randomly divided into group A (indirect laryngeal biopsy forceps combined antibiotics) and group B (antibiotics only). Demographics, the degree of epiglottic and arytenoid swelling, and inflammatory cells were collected for analysis. The drainage of EA was performed under local anesthesia in conscious patients with indirect laryngeal biopsy forceps and 70° direct laryngoscopes. The length of symptomatic relief and length of hospitalization were assessed.

RESULTS

Ten patients were treated with indirect laryngeal biopsy forceps under the view of the 70° direct laryngoscopes combined with intravenous antibiotics, whereas the other 10 patients were treated with antibiotics only. The differences between the 2 groups had no statistical significance in age, gender, white blood cell count, neutrophils count, and the percent of neutrophils, abscess size, and scope classification at the time of diagnosis. The length of hospitalization and length of symptomatic relief was significantly lower in patients treated with indirect laryngeal biopsy forceps combined antibiotics than those treated with antibiotics only.

CONCLUSIONS

Indirect laryngeal biopsy forceps are safe and effective method to treat EA, which shorten the hospitalization and has the advantages of cost savings and convenience.

A Lot to Choke on: Case of Adult Epiglottitis with Concurrent Peritonsillar Abscess in a Patient with a Sore Throat

BACKGROUND

In the winter months, one often sees a large increase in the volume of patients presenting to emergency departments with acute pharyngitis. While most cases of acute pharyngitis are benign, a rare minority can be life threatening.

CASE REPORT

We report a case of epiglottis with a concomitant peritonsillar abscess (PTA) in an adult who presented to the emergency department with a sore throat. Computed tomography (CT) scan showed epiglottitis with a developing left PTA. The patient was treated with broad-spectrum antibiotics, high-dose steroids, and underwent multiple laryngoscopies with eventual resolution of his epiglottic swelling. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case serves to highlight the importance of physical examination and CT imaging in identifying patients with pharyngitis who can benefit from additional interventions and monitoring. It is also an unusual example of the presence of two likely related upper respiratory pathologies presenting in the same patient.

Review of epiglottitis in the post Haemophilus influenzae type-b vaccine era

BACKGROUND

This study reviewed the demographics, presentation, management, complications and outcomes of acute epiglottitis post Haemophilus influenzae type-b vaccine introduction in Australia.

METHODS

Retrospective review of acute epiglottitis at four Victorian tertiary centres from 2011 to 2016 was conducted. Patient characteristics, presentation, investigations, management, complications and outcomes were recorded. Subgroup analysis aiming to identify risk factors for patients requiring acute airway management was performed.

RESULTS

Eighty-seven adult and six paediatric cases were identified. The most frequent clinical findings in adults were sore throat (88.5%), dysphagia (71.3%), odynophagia (57.5%), dysphonia (56.3%) and fever (55.2%); 75.9% required intensive care unit admission. Airway compromise requiring intubation occurred in 27.6%, with 12.5% of these patients undergoing emergency surgical airways. Stridor, hypoxia, shortness of breath, odynophagia and lymphadenopathy were statistically more frequent amongst cases requiring airway intervention (P < 0.05). Cultures revealed mixed results with no aetiological pattern. H. influenzae type-b was never cultured. Amongst paediatric cases, fever, tachycardia and stridor were frequently observed and all were admitted to intensive care unit. Two of six required intubation and one underwent surgical intervention. There were no deaths, but one patient suffered a hypoxic brain injury.

CONCLUSION

Modern epiglottitis is not the disease previously encountered by clinicians. With changing demographics and varying organisms, management is adapting to reflect this. Complications are rare, and symptomatology at presentation aids earlier recognition of patients who may require airway protection.

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.

Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics

BACKGROUND

Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider.

OBJECTIVE

This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease.

DISCUSSION

GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions.

CONCLUSIONS

GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.

Clinical evaluation of intravenous ampicillin as empirical antimicrobial treatment of acute epiglottitis

INTRODUCTION

The significant pathogens in acute epiglottitis (AE) are poorly defined in the post Haemophilus influenza type b-vaccine era. Furthermore, there is a lack of clinical evaluations of antibiotic regimens in patients with AE. We aimed to evaluate the effectiveness of empiric intravenous ampicillin in the treatment of patients with AE.

MATERIALS & METHODS

All patients admitted with AE to the Ear-Nose-Throat Department, Aarhus University Hospital, Denmark, from 2001 to 2015 were included.

RESULTS

In total, 103 (51 males) patients were included in the study. The median duration of hospitalization was four days. There was no statistical significant difference between patients initially treated with intravenous ampicillin (n = 83) or other antibiotics (n = 20) (p = .26). The antibiotic regimen was altered during admission in 11% of patients, without significant difference between antibiotic groups (ampicillin 10% vs non-ampicillin 15%, p = .44). Complications potentially related to insufficient antibiotic treatment were observed in four (5%) patients initially treated with ampicillin, but in none of the patients initially treated with antibiotics other than ampicillin (p = 1.00). Throat swab cultures and blood cultures frequently yielded negative results.

CONCLUSIONS

Intravenous ampicillin is efficient as empiric antibiotic therapy for AE patients, leading to a quick recovery and low complication rates.

Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission

Objectives

(1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification.

Methods

A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007.

Results

The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care.

Conclusion

A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.

Pasteurella multocida Epiglottitis

Epiglottitis is an uncommon but life-threatening disease. While the most common infectious causes are the typical respiratory pathogens, Pasteurella multocida is a rare causative organism. We present a case of P. multocida epiglottitis diagnosed by blood culture. The patient required intubation but was successfully treated medically. P. multocida is a rare cause of epiglottitis; this is the ninth reported case in the literature. Most diagnoses are made from blood culture and patients usually have an exposure to animals.

Pregame Sore Throat, Postgame Intensive Care Unit

A collegiate football athlete presented, on game day, with an acute onset of sore throat. He was afebrile, speaking in full sentences, without signs of respiratory distress. His examination was negative for lymphadenopathy or tonsillar enlargement or exudate. Twelve hours after initial presentation, he developed acute epiglottitis. He underwent urgent fiberoptic intubation and was empirically treated with broad-spectrum antibiotics and corticosteroids. Currently, there are no published reports of acute epiglottitis in athletes. Consequently, there is no evidence to guide return to play decisions. Return to play, following acute epiglottitis, should include resolution of symptoms and a graded return to play, taking into consideration the level of deconditioning the athlete experienced from hospitalization.

Laryngeal Infections

The following chapter is a review of the most common viral and bacterial etiologies of pediatric laryngeal infections. The chapter reviews the diagnostic approach to laryngeal infections, focusing on key points of the history and physical exam, including concerning signs and symptoms suggestive of airway distress. Viral and bacterial laryngitis, croup, epiglottis, recurrent respiratory papillomatosis, as well as some less common causes of bacterial infections are discussed in detail with each etiology’s epidemiology, clinical features, associated diagnostic evaluation, and management reviewed.

Upper Airway Obstruction in Children

Children with upper airway obstruction are both unique and variable in their presentation and management, often posing a challenge to the pediatrician. Several anatomical and physiologic peculiarities make a child vulnerable to develop an obstruction of upper airways. The characteristic finding in upper airway obstruction is stridor-inspiratory, biphasic or expiratory. The etiologies vary widely throughout the age groups and according to the mode of presentation. The approach starts with suspicion, mandates careful clinical evaluation of the degree of obstruction and many a times emergency measures precede any investigation or even precise diagnosis. Maintaining an open and stable airway is of the utmost importance, often requiring a team approach of emergency physician, pediatrician, otorhinolaryngologist and pediatric pulmonologist. The commonest condition presenting with upper airway obstruction in pediatric population is viral croup. Croup is a clinical diagnosis in a febrile child, with barking cough and stridor preceded by upper respiratory infection. It is treated with systemic or inhaled steroids and nebulized epinephrine. Epiglottitis and bacterial tracheitis are acute bacterial infections of upper airways, presenting as true airway emergencies. Though the mainstay of therapy is IV antibiotics, the prime concern is maintenance of airway, which frequently requires endotracheal intubation. Rigid bronchoscopy is the procedure of choice for airway foreign bodies, a common cause of upper airway obstruction in children below 3 y of age. Airway malacias are the commonest cause of chronic stridor and are mostly managed conservatively.

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.

Viral croup: diagnosis and a treatment algorithm

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.

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.

Epiglottic abscess as a complication of acute epiglottitis

OBJECTIVE

An epiglottic abscess is considered a life-threatening medical situation that can cause death by obstruction the upper airways. We describe a 58-year-old man who presented to our hospital with sore throat, dysphagia and dysphonia.

MATERIALS AND METHODS

A fiberoptic laryngoscope (FOL) demonstrated beefy red edematous epiglottis with edema extending from the base of the tongue to the aryepiglottic folds and arytenoids. CT scan showed multiple air bubbles inside the swollen epiglottis, in keeping with the diagnosis of necrotizing epiglottic abscess.

RESULTS

Under local anesthesia we performed puncture of the abscess at the tip of the epiglottis. He was dismissed 5days from his admission to the hospital after an improvement was noticed in his epiglottis.

CONCLUSION

Treatment consists of airway management if needed under anesthesia and draining of the abscess. An IV antibiotics plus corticosteroids should be administrated the moment a suspicion of epiglottitis is present.

Head and neck emergencies: bacterial meningitis, encephalitis, brain abscess, upper airway obstruction, and jugular septic thrombophlebitis

Head and neck infectious disease emergencies can be rapidly fatal without prompt recognition and treatment. Empiric intravenous (IV) antibiotics should be initiated immediately in any patient with suspected bacterial meningitis, and IV acyclovir in any patient with suspected encephalitis. Surgical intervention is often necessary for brain abscesses, epiglottitis, and Ludwig's angina. A high index of suspicion is often needed to diagnose epiglottitis, Ludwig's angina, and Lemierre's syndrome. Brain infections can have high morbidity among survivors. In this article, the causes, diagnostic tests, treatment, and prognosis are reviewed for some of the more common head and neck infectious disease emergencies.

A rare case of acute epiglottitis due to Staphylococcus aureus in an adult

Epiglottitis has been mainly associated with childhood infection with Haemophilis influenzae type B but cases of adult epiglottitis are increasing. We report here a case of adult epiglottitis and present evidence that it was caused by Staphylococcus aureus. A 48-year old patient with clinical symptoms of epiglottitis grew Staphylococcus aureus in pure culture from an epiglottal swab. Staphylococcus aureus should be considered as a potential pathogen in adult epiglottitis.