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Epiglottitis
ALTERNATIVE NAMES: Supraglottitis.
DEFINITION: Inflammation of the epiglottis.
WHAT IS GOING ON IN MY BODY? The epiglottis is a normal structure in the larynx. It is shaped like an upside down teardrop. The point of the teardrop is where it attaches in the larynx just above where the vocal cords come together. The normal function of the epiglottis is as a cover that folds over the voice box during the act of swallowing. As the voice box elevates during swallowing, the back of the tongue moves backward. This forces the epiglottis down over the opening of the voice box. With the epiglottis over the voice box, there is closure of the vocal cords. The swallowed material then passes through the throat into the esophagus, with completion of the act of swallowing. The epiglottis, therefore, is an important structure which helps to prevent swallowed material from entering into the larynx or tracheal airways. Inflammation of the epiglottis (epiglottitis) can occur by several mechanisms. There can be viral, allergic, bacterial, chemical, or thermal causes of epiglottitis. When it is inflamed, the loose mucous membrane covering can quickly fill up with fluid. Since it sits above the opening to the voice box, as the epiglottis and surrounding tissues fill up with fluid, they become more and more swollen and start to limit the amount of air that enters into the lower airway. It can, therefore, be a cause of rapid and severe life-threatening airway obstruction.
WHAT ARE THE SIGNS AND SYMPTOMS? In an acute infectious process, be it viral or bacterial, fever, severe sore throat, and drooling are common. Patients with epiglottitis are usually children, although adults can be affected. They tend to have very noisy breathing on inspiration, making a high-pitched sound (stridor). The harder the individual tries to breathe, the louder the stridor becomes and the more difficult it is to move air past the swollen epiglottis into the lower airway. Individuals with acute epiglottitis tend to lean forward and hold very still in order to minimize the amount of upper airway obstruction that occurs. The sequence of symptoms can occur very rapidly, and epiglottitis is a true medical emergency. In those individuals with chemical, allergic, or thermal causes, there is often a very recent history of exposure to intensely hot steam, allergens, or noxious chemicals respectively. There will usually not be symptoms of acute infection, such as pain, fever, sore throat, or drooling, but the airway obstructive symptoms, such as stridor, leaning forward, and more difficult breathing with increased respiratory effort will be present.
WHAT ARE THE CAUSES AND RISKS? Any viral upper respiratory infectious process can give rise to an acute epiglottitis. The most feared form of epiglottitis occurs with Hemophilus influenza infection. Hemophilus influenza is a family of bacteria consisting of numerous types. The most serious type of Hemophilus influenza infection occurs from type B. Other less aggressive forms of Hemophilus are normal residents in the upper respiratory tract and are frequent causes of acute ear and sinus infections. In the Hemophilus influenza type B infection, the bacteria are often found in the bloodstream, and therefore, it is not uncommon for an individual with epiglottitis to also be at risk simultaneously for meningitis. Other bacteria are known to cause acute epiglottitis. Staph aureus is a more frequent cause in adults. Children are much more likely to be affected than adults only because the airway of a child is much smaller, and thus, it takes less swelling to lead to complete airway obstruction. For those individuals working around high-pressure steam or noxious chemicals, release of those agents can put that individual at risk for acute infectious epiglottitis.
HOW TO PREVENT THE DISEASE: One of the most promising medical advances to come along in many years has been Hemophilus influenza type B vaccine (HIB) which is now routinely given to children. With the advent of HIB vaccination, there has been a noticeable decline in epiglottitis and meningitis in vaccinated individuals. Preventing other viral illnesses or other bacterial causes of acute epiglottitis does not exist at this time.
HOW IS IT DIAGNOSED? The most important diagnostic method is to have a very high index of suspicion that the patient is suffering from epiglottitis. It would be safe to presume that an individual with severe sore throat, high fever, and inspiratory stridor has epiglottitis until proven otherwise. It is diagnosed by carefully examining the patient. Vital signs are taken to document fever and observing the type of noise occurring during respiration. When it is in the respiratory phase is important. Noticing the drooling, patient leaning forward, and breathing slowly and shallowly are often important diagnostic clues. In adults it is acceptable to perform a throat and mouth examination but not in children. The concern with children is that a throat examination might cause an acute upper airway obstruction – X-rays of the neck looking for a swollen epiglottis can be useful to try to exclude other causes of respiratory obstruction, such as croup. In an adult, mirror examination of the top part of the larynx or using a flexible telescope placed through the nose can identify the swollen epiglottis.
WHAT ARE THE LONG-TERM EFFECTS: The long-term effects from a viral or bacterial infection which resolves are non-existent. Certainly the concern with steam or a chemical injury would be scarring of structures above or at the level of the vocal cords with subsequent chronic hoarseness or airway obstruction.
AM I PUTTING OTHERS AT RISK? As viral infections are transmittable, being around others might make them susceptible to the same virus. The same could occur with Hemophilus influenza type B infections.
WHAT ARE THE TREATMENTS? Because of the potential for acute airway obstruction that can occur in children, any time epiglottitis is considered, the greatest concern is controlling that child's airway. Often hospitals have epiglottitis teams consisting of anesthesiologists, ENT specialists, pediatricians, and other support services, who come together to care for an individual suspected of having epiglottitis. The safest way to treat these individuals is to not stimulate them by aggressive examination, drawing blood, or placing IVs while they are awake. Under the care of the epiglottitis team, they should be brought to the operating room, where the anesthesiologist will administer an inhalant anesthetic under positive pressure, which helps to hold the swollen upper airway open. As the child is going through the stages of anesthesia, the other members of the operating team, including the ENT specialist, are readying instruments to be able to examine the airway or perform a tracheotomy. When the patient is at a deep enough stage of anesthesia, the anesthesiologist and ENT specialist will usually examine the airway and place a breathing tube into the larynx to thus bypass the swollen epiglottis. If the airway cannot be established, the ENT specialist performs a tracheotomy. Once the airway is secure, then the IV is placed and blood drawn. The child is then sedated, taken to the Intensive Care area, placed on a ventilator, and treated aggressively with antibiotics and steroids. It usually takes 48 to 72 hours to reduce the upper airway swelling enough that the breathing tube can be safely removed. The child is kept sedated and restrained during this time period to prevent accidental removal of the breathing tube, which could be fatal. Adults usually do not need to be intubated, but must be observed in an intensive care setting. If airway obstruction develops, they are taken to the operating room to receive the airway.
WHAT ARE THE SIDE EFFECTS TO THE TREATMENTS? Other than allergic reaction to medications or scarring if a tracheotomy is performed, there are really no side effects of treatment.
WHAT HAPPENS AFTER TREATMENT? Once the upper airway swelling has resolved, and the child is extubated and sent to a normal pediatric floor and then discharged, usually they are on oral antibiotics and a tapering dose of steroids.
HOW DO I MONITOR THE DISEASE? As this is a true medical emergency, monitoring this illness at home only invites disaster. If there is a suspicion of epiglottitis, the patient should be brought to the nearest emergency room and the emergency room staff notified.
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