7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 1/9

Search the site ...

Epiglottitis

December 18, 2016 by Josh Farkas

(https://emcrit.org/ibcc/epiglottitis/attachment/epiglothead/)

CONTENTS

Signs & symptoms (#signs_&_symptoms)

Differential diagnosis (#differential_diagnosis)

Diagnosis (#diagnosis)

ManagementMedical Management (#medical_management)

Epiglottic abscess (#epiglottic_abscess)

Airway managementIndications for intubation (#indications_for_intubation)

Intubation procedure (#intubation_procedure)

Extubation procedure (#extubation_procedure)

Podcast (#podcast)

Questions & discussion (#questions_&_discussion)

Pitfalls (#pitfalls)

PDF of this chapter (https://emcrit.org/wp-content/uploads/2017/01/hyperthermia.pdf)  (or create customized PDF (https://emcrit.org/ibcc/about-guide/#pdf) )

signs & symptoms(back to contents) (#top)

symptoms

Sore throat (92%)(31173373 (https://pubmed.ncbi.nlm.nih.gov/31173373/) )Swallowing problems

Odynophagia (82%)Dysphagia (80%)Drooling (18%)

TOC ABOUT THE IBCC TWEET US IBCC PODCAST

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 2/9

Voice change (43%)Hoarseness (26%)Mu�ed voice (30%)

Respiratory dysfunctionStridor (8%)Dyspnea (33%)Inability to lie �at, sitting upright in “sni�ng” or “tripod” position

signs

Pharyngitis is reported in 38% of patients.(31173373 (https://pubmed.ncbi.nlm.nih.gov/31173373/) )Classic presentation of epiglottitis is sore throat with unremarkable throat exam.However, epiglottitis can involve pharynx and uvula – so erythema seen on throat exam doesn't exclude epiglottitis. (27031010(https://pubmed.ncbi.nlm.nih.gov/27031010/) )

Anterior neck tenderness may occur.

di�erential diagnosis(back to contents) (#top)

Peritonsillar or retropharyngeal abscessDeep neck space infection (e.g., Ludwig's angina)Foreign bodyEpiglottitis plus simultaneous pneumonia or pharyngitis (the presence of epiglottitis doesn't protect against infection elsewhere.)Streptococcal pharyngitisCaustic ingestion

diagnosis(back to contents) (#top)

Cleveland Clinic MD@CleClinicMD

A patient presents with both the uncommon infection uvulitis and epiglottitis cle.clinic/2oJgcXq

6�25 PM · May 16, 2017

28 26 people are Tweeting about this

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 3/9

(https://i1.wp.com/emcrit.org/wp-content/uploads/2016/12/epiglottitis.png)

lateral neck x-ray

FindingsSwollen epiglottis may be seen as a “thumb sign” (normally, epiglottis pro�le should look like a �nger).Obliteration of the vallecula (“vallecula sign”) may be seen (�gure above, white arrow).

Performance?~88% sensitive, so a negative X-ray doesn't exclude epiglottitis. (27247205 (https://pubmed.ncbi.nlm.nih.gov/27247205/) )

neck CT scan

Aside from epiglottitis, CT scan may detect an epiglottic abscess.CT scan is a useful global survey tool for serious neck infection or other anatomic lesions.Transportation to the scanner may be appropriate for a reasonably stable patient, who isn't at risk of immediate airway loss.

bedside nasolaryngoscopy

NEJM@NEJM

Image of the Week: Epiglottitis nej.md/2Hsavc3

4�30 PM · Sep 3, 2019

571 241 people are Tweeting about this

Eric Levi@DrEricLevi

Flexible nasoendoscopy or nasal endoscopy is a simple diagnostic procedure performed routinely by Ear Nose & Throat Surgeons as part of a routine examination. Here Eric performs it on himself It s̓ easy as! #meded

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 5/9

Meropenem, piperacillin-tazobactam, or �uoroquinolones could be considered for patients who truly have allergy to ampicillin and third-generation cephalosporins – depending on the scenario (this scenario is exceedingly rare, however; see the chapter on allergies tobeta-lactam antibiotics (https://emcrit.org/ibcc/penicillin/) ).

steroid

Intermediate dose steroid is generally used (e.g., 125 mg methylprednisolone IV once, then lower doses daily for a few days).(30207030(https://pubmed.ncbi.nlm.nih.gov/30207030/) )  A 2-3 day course might be reasonable.There is no solid data on this, nor is there likely to be any in the near future (given the rarity of epiglottitis).  However, steroid has beendemonstrated to be bene�cial for pharyngitis – which involves a similar anatomy and range of pathogens.(28931508(https://pubmed.ncbi.nlm.nih.gov/28931508/) )

epiglottic abscess(back to contents) (#top)

diagnosis

May be identi�ed on CT scan of the neck or nasolaryngoscopy.

management implications

There is no de�nitive evidence regarding how to manage epiglottic abscess.One tiny RCT found that abscess drainage under local anesthesia in awake patients reduced the hospital length of stay.(25931293(https://pubmed.ncbi.nlm.nih.gov/25931293/) )  Likewise, another small series reported that pre-emptive abscess drainage without intubationwas feasible.(18728917 (https://pubmed.ncbi.nlm.nih.gov/18728917/) )

In retrospective studies, abscess was associated with 27% likelihood of requiring airway intervention. (31173373(https://pubmed.ncbi.nlm.nih.gov/31173373/) )Bottom line?

Don't assume that an abscess necessarily mandates drainage or intubation (many patients may respond to medical therapy alone).Consult ENT surgery regarding optimal management.

indications for intubation(back to contents) (#top)

(https://i0.wp.com/emcrit.org/wp-content/uploads/2016/12/epiglot2.gif)

general concepts regarding airway management in epiglottitis 

(#1)  85-90% of adults with epiglottitis don't require intubation.(31173373 (https://pubmed.ncbi.nlm.nih.gov/31173373/) )  Adults might do betterthan children for two reasons:

With aging, the epiglottis may get smaller and more rigid; meanwhile the larynx may grow larger.  Overall, this makes epiglottitis lesslikely to obstruct the adult airway, compared to the pediatric airway.(30613442 (https://pubmed.ncbi.nlm.nih.gov/30613442/) )

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 4/9

Flexible �beroptic exam allows visualization of the larynx at the bedside.This may be preferable for a tenuous patient, since it doesn't require transportation out of the department.In addition to diagnosing epiglottitis, nasolaryngoscopy should provide additional information about the airway (How much airwaycompromise is there?  How di�cult or easy would it be to intubate the patient?).

blood cultures

Positive in ~25% of cases.May assist in narrowing antibiotics.

medical management(back to contents) (#top)

antibiotics

Pathogens in adult epiglottitis (31173373 (https://pubmed.ncbi.nlm.nih.gov/31173373/) )#1 = Streptococcal species (~30%) – may include pneumococcus or group A streptococci.#2 = Haemophilus (~5% in post-vaccine era).#3 = Staphylococcus (~5%).Gram-negatives can occur in immunocompromised patients. (29564363 (https://pubmed.ncbi.nlm.nih.gov/29564363/) )(Unfortunately, it's often unclear whether cultures obtained from pharyngeal swab represent truly invasive infection, or bystanderorganisms.)

Antibiotic choiceThird-generation cephalosporin is generally the front-line choice (e.g., ceftriaxone 1-2 gram IV Q24 hrs x7 days).Ampicillin-sulbactam is also a good choice.

Here, Eric performs it on himself. It s̓ easy as! #meded #ENTsurgery

2�03 17.2K views

6�57 AM · Jun 23, 2020

479 193 people are Tweeting about this

EpiglottitisEpiglottitis

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 6/9

Adults may be less prone to development of laryngospasm.(#2)  With steroid and antibiotic, most patients will gradually improve.  So when in doubt, meticulous observation with aggressive preparationmay be reasonable.

If there is any concern regarding the airway, patients should be monitored in a setting where there is immediate ability to manage theairway.

(#3)  Laryngospasm ??Some patients with epiglottitis could theoretically develop laryngospasm, leading to rapid airway loss.(3042183(https://pubmed.ncbi.nlm.nih.gov/3042183/) )This seems to be extremely rare in adults, with hardly any cases reported.  As such, it's doubtful whether the existence of this entityshould affect airway management in adults with epiglottitis.

possible indications for intubation

(1) True airway compromiseSigni�cant dyspnea, tachypneaStridorTripoding, inability to lie �at

(2) Clinical course (e.g., rapidly progressive symptoms, progressive deterioration despite medical therapy)

not necessarily indications for intubation

(1) Voice change(2) GI dysfunction – odynophagia, dysphagia, or di�culty handling secretions are not associated with the need for intubation. (27031010(https://pubmed.ncbi.nlm.nih.gov/27031010/) )  However, some sources do recommend intubation for patients with di�culty handling secretions.

role of �exible nasolaryngoscopy to determine need for intubation?

>50% obstruction of the laryngeal lumen is suggested as an indication for intubation.  However, this seems to be arbitrary and not based onany particular evidence.

intubation procedure(back to contents) (#top)

intubation is fraught with hazard

Airway manipulation may worsen swelling.Epiglottic edema will often preclude the use of a laryngeal mask airway.In severe epiglottitis, orotracheal intubation may simply be impossible.

scenario #1:  the crashing epiglottitis patient (extremely rare!)

DescriptionPatient is at immediate risk of losing their airway.Patient is stridorous, sitting bolt upright, and struggling for breath.Patient may be unable to lie down.

Potential management:  Ketamine-dissociated cricothyrotomyPlace the patient on 100% FiO2 using one of the following:

i) High-�ow nasal cannula at 100% FiO2 and 60 liters �ow.ii) BiPAP mask.iii) 100% Non-rebreather facemask set to �ush rate (crank the �ow rate well past the 15 liters/min mark).iv) 100% non-rebreather facemask set to 15 liters/minute plus a nasal cannula underneath it running at 15 liters/minute.

Provide a dissociative dose of IV ketamine (e.g., 1.5-2 mg/kg) slowly, over ~120 seconds.  This should fully dissociate the patient,without impairing the respiratory drive.  Patients with a history of alcoholism may require more ketamine to fully dissociate.Perform a scalpel-�nger-bougie cricothyrotomy (more on this here (https://emcrit.org/emcrit/surgical-airway/) ).  The patient should continuebreathing throughout the entire procedure, so you should be able to take your time a bit with this.  However, if asphyxiation occurs, the

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 7/9

procedure should be achievable very rapidly.

scenario #2:  the non-crashing anaphylaxis patient

DescriptionThe patient requires intubation, but isn't actively crashing.There is time to call for help and additional equipment.

Suggested management:  The awake double setup:Obtain an experienced intubator and someone competent at scalpel-�nger-bougie cricothyrotomy (Note:  it doesn't matter whether thisperson is a surgeon; what matters is skill in this speci�c procedure).Perform awake �beroptic intubation.  These patients often have tongue swelling, so the best approach is often nasotracheal intubation(for taller patients, consider obtaining an extra-long ETT for nasotracheal intubation).During the intubation procedure, the second operator should be prepared to perform cricothyrotomy if the airway is lost.

extubation procedure(back to contents) (#top)

It often takes 2-3 days for swelling to improve.  However, some patients are intubated pre-emptively, so they may be extubated earlier.The decision to extubate may be assisted by visualizing the epiglottis as follows:

Deeply sedate the patient (e.g., with high-dose propofol).  Paralysis may be needed in some patients as well (e.g., 10 mg vecuroniumbolus).Very gently insert a hyperangulated video laryngoscope (e.g., Glidescope or CMAC D-blade) until you see the epiglottis.This isn't perfect, but it may give you some concept of how in�amed the epiglottis is.  For example, the image below shows a normal-appearing epiglottis.This is especially useful for patients who were intubated at an outside hospital, who often didn't actually require intubation to beginwith.

(https://i1.wp.com/emcrit.org/wp-content/uploads/2016/12/FullSizeRender.gif)

podcast(back to contents) (#top)

(https://i1.wp.com/emcrit.org/wp-content/uploads/2016/11/apps.40518.14127333176902609.7be7b901-15fe-4c27-863c-7c0dbfc26c5c.5c278f58-912b-4af9-

88f8-a65fff2da477.jpg)

Follow us on iTunes (https://itunes.apple.com/ca/podcast/the-internet-book-of-critical-care-podcast/id1435679111)

questions & discussion(back to contents) (#top)

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 8/9

To keep this page small and fast, questions & discussion about this post can be found on another page here (https://emcrit.org/pulmcrit/epiglottitis/) .

(https://i0.wp.com/emcrit.org/wp-content/uploads/2016/11/pitfalls2.gif)

Missed diagnosis:  consider this especially in a patient complaining of sore throat whose throat actually looks OK.Consider early IV steroid to reduce in�ammation.Most patients won't require intubation.  When in doubt, watchful waiting is generally best, as patients will tend to improve with medicaltherapy.🛑 DO NOT USE RAPID SEQUENCE INTUBATION IN AN EPIGLOTTITIS PATIENT.Don't try to secure the airway of an epiglottitis patient unless there is someone present who is ready, willing, and able to perform a scalpel-�nger-bougie cricothyrotomy.  No matter how skilled you or your anesthesiologist may be, many of these patients will be impossible tointubate from the top end.

Going further

Epiglottitis (https://rebelem.com/rebel-core-cast-11-0-epiglottitis/) (RebelEM, Anand Swaminathan)Epiglottitis (https://coreem.net/core/epiglottitis/) (CoreEM, Matt Rogers)Epiglottitis (https://wikem.org/wiki/Epiglottitis) (WikEM)Epiglottitis (https://radiopaedia.org/articles/epiglottitis) (Radiopaedia, by Derek Smith and Gagandeep Singh)

References

03042183  Baxter FJ, Dunn GL. Acute epiglottitis in adults. Can J Anaesth. 1988;35(4):428-435. doi:10.1007/BF03010869  [PubMed(https://pubmed.ncbi.nlm.nih.gov/3042183/) ]18728917  Kim SG, Lee JH, Park DJ, et al. E�cacy of spinal needle aspiration for epiglottic abscess in 90 patients with acuteepiglottitis. Acta Otolaryngol. 2009;129(7):760-767. doi:10.1080/00016480802369302  [PubMed (https://pubmed.ncbi.nlm.nih.gov/18728917/) ]25931293  Lee YC, Lee JW, Park GC, Eun YG. E�cacy of Spinal Needle Aspiration in Patients with Epiglottic Abscess: A Prospective,Randomized, Controlled Study. Otolaryngol Head Neck Surg. 2015;153(1):48-53. doi:10.1177/0194599815583475  [PubMed(https://pubmed.ncbi.nlm.nih.gov/25931293/) ]27031010  Lichtor JL, Roche Rodriguez M, Aaronson NL, Spock T, Goodman TR, Baum ED. Epiglottitis: It Hasn't Gone Away. Anesthesiology.2016;124(6):1404-1407. doi:10.1097/ALN.0000000000001125  [PubMed (https://pubmed.ncbi.nlm.nih.gov/27031010/) ]27247205  Takata M, Fujikawa T, Goto R. Thumb sign: acute epiglottitis. BMJ Case Rep. 2016;2016:bcr2016214742. Published 2016 May 31.doi:10.1136/bcr-2016-214742  [PubMed (https://pubmed.ncbi.nlm.nih.gov/27247205/) ]28931508  Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review andmeta-analysis of randomised trials. BMJ. 2017;358:j3887. Published 2017 Sep 20. doi:10.1136/bmj.j3887  [PubMed(https://pubmed.ncbi.nlm.nih.gov/28931508/) ]29564363  Chen C, Natarajan M, Bianchi D, Aue G, Powers JH. Acute Epiglottitis in the Immunocompromised Host: Case Report and Reviewof the Literature. Open Forum Infect Dis. 2018;5(3):ofy038. Published 2018 Feb 17. doi:10.1093/o�d/ofy038  [PubMed(https://pubmed.ncbi.nlm.nih.gov/29564363/) ]30207030  Baird SM, Marsh PA, Padiglione A, et al. Review of epiglottitis in the post Haemophilus in�uenzae type-b vaccine era. ANZ J Surg.2018;88(11):1135-1140. doi:10.1111/ans.14787  [PubMed (https://pubmed.ncbi.nlm.nih.gov/30207030/) ]30613442  Ramlatchan SR, Kramer N, Ganti L. Back to Basics: A Case of Adult Epiglottitis. Cureus. 2018;10(10):e3475. Published 2018 Oct22. doi:10.7759/cureus.3475  [PubMed (https://pubmed.ncbi.nlm.nih.gov/30613442/) ]31173373  Sideris A, Holmes TR, Cumming B, Havas T. A systematic review and meta-analysis of predictors of airway intervention in adultepiglottitis. Laryngoscope. 2020;130(2):465-473. doi:10.1002/lary.28076  [PubMed (https://pubmed.ncbi.nlm.nih.gov/31173373/) ]

7/1/2020 Epiglottitis - EMCrit Project

https://emcrit.org/ibcc/epiglottitis/ 9/9

The Internet Book of Critical Care is an online textbook written by Josh Farkas (@PulmCrit), an associate professor ofPulmonary and Critical Care Medicine at the University of Vermont.

EMCrit is a trademark of Metasin LLC. Copyright 2009-. This site represents our opinions only. See our full disclaimer, our privacy policy, commenting policy and here for credits

and attribution.