OverviewEpiglottitis is a medical emergency that may result in death if not treated quickly. Epiglottitis is inflammation of the epiglottis - the flap that sits at the base of the tongue, which keeps food from going into the trachea (windpipe). Due to its place in the airway, swelling of this structure can interfere with breathing and constitutes a medical emergency. The infection can cause the epiglottis to either obstruct or completely close off the windpipe. When it gets infected and inflamed, it can obstruct, or close off, the windpipe, which may be fatal unless promptly treated.
Respiratory infection, environmental exposure, or trauma may result in inflammation and infection of other structures around the throat. This infection and inflammation may spread to involve the epiglottis as well as other upper airway structures. Epiglottitis usually begins as an inflammation and swelling between the base of the tongue and the epiglottis. This may cause the throat structures to push the epiglottis backward. With continued inflammation and swelling of the epiglottis, complete blockage of the airway may occur, leading to suffocation and death. Autopsies of people with epiglottitis have shown distortion of the epiglottis and its associated structures including the formation of abscesses (pockets of infection). For unknown reasons, adults with epiglottic involvement are more likely than children to develop epiglottic abscesses.
Epiglottitis Causes
Conditions that cause epiglottitis include infectious, chemical, and traumatic agents. Infectious is the most common. H influenzae type b was once the most common cause prior to vaccination. Currently, other organisms such as bacteria, viruses, and fungi are the causes, especially among adults.
When epiglottitis strikes, it usually occurs quickly but may range from just a few hours to a few days. The most common symptoms include sore throat, muffling or changes in the voice, difficulty speaking, fever, difficulty swallowing, fast heart rate, and difficulties in breathing.
Fever is usually high but may be low at 37.8°C (100.1°F) in adults or even slightly lower at 37.2°C (99°F) in cases of thermal epiglottitis.
Currently, immediate hospitalization is required whenever the diagnosis of epiglottitis is suspected. The person is in danger of sudden and unpredictable closing of the airway. So doctors must establish a secure way for the person to breathe. Antibiotics may be given.
Continue taking all antibiotics until the full course is completed. Keep all follow-up appointments with your doctor. In the event that a breathing tube had to be placed through the neck, follow-up with the surgeon to have the tube removed and make sure the site is healing well. Most people improve significantly before leaving the hospital, so taking the antibiotics and returning to the hospital if there are any problems are the most important parts of follow-up.
Prevention
Prevention of epiglottitis can be achieved with proper vaccination schedules against H influenza type b (Hib). Therefore it is important that your doctor make the appropriate recommendations for vaccination against Hib for children (see the children's immunization schedule). Adult vaccination is not routinely recommended, except for people with immune problems such as sickle cell anemia, splenectomy, cancers, or other diseases affecting the immune system.
When there is a member of a family with an unvaccinated child under age 4 years who is exposed to a person with H influenza epiglottitis, preventive medication (rifampin, Rifadin) should be given to all household contacts to make sure that both the person with the illness and the rest of the household have the bacteria completely eradicated from their bodies. This prevents formation of a "carrier state" in which a person has the bacteria in the body but is not actively sick. Carriers can still spread the infection to other family members in this state.
Epiglottitis Causes
Conditions that cause epiglottitis include infectious, chemical, and traumatic agents. Infectious is the most common. H influenzae type b was once the most common cause prior to vaccination. Currently, other organisms such as bacteria, viruses, and fungi are the causes, especially among adults.
- Various organisms. For examples: Streptococcus pneumoniae, Haemophilus parainfluenzae, varicella-zoster, herpes simplex virus type 1, and Staphylococcus aureus, among others.
- Heat damage injured. Heat damage that results in epiglottitis is also known as thermal epiglottitis. Thermal epiglottitis occurs from drinking hot liquids, eating solid foods, or using illicit drugs such as inhalation of metal pieces from crack cocaine pipes or the tip of marijuana cigarettes. In these cases the epiglottitis from thermal injury is similar to the illness caused by infection.
- Unusual causes of epiglottitis include brown recluse spider bites to the ear, which may result in swelling or eating buffalo fish, which may cause an allergiclike reaction and swelling. Blunt trauma or something blocking the throat may also lead to epiglottitis.
When epiglottitis strikes, it usually occurs quickly but may range from just a few hours to a few days. The most common symptoms include sore throat, muffling or changes in the voice, difficulty speaking, fever, difficulty swallowing, fast heart rate, and difficulties in breathing.
Fever is usually high but may be low at 37.8°C (100.1°F) in adults or even slightly lower at 37.2°C (99°F) in cases of thermal epiglottitis.
- Signs of respiratory distress, or trouble breathing, are seen with epiglottitis as drooling, leaning forward to breathe, taking rapid shallow breaths, "pulling in" of muscles in the neck or between the ribs with breathing (retractions), high-pitched whistling sound when breathing (stridor), and trouble speaking. Someone with acute epiglottitis usually looks very ill.
- Children may sit in a "sniffing position" with the body leaning forward and the head and nose tilted forward and upward as though they are sniffing a good smelling pie.
- People with epiglottitis may appear restless and breathing with their neck, chest wall, and upper belly muscles. While they may be taking in less air with each breath, they will still manifest the high-pitched whistling sound, called inspiratory stridor.
- Typically, a child who comes to the hospital with epiglottitis has a history of fever, difficulty talking, irritability, and problems swallowing for several hours. The child often sits forward and drools. In infants younger than 1 year, signs and symptoms such as fever, drooling, and upright posturing may all be absent. In this small population group, the infant may have a cough and a history of an upper respiratory infection. Thus it is very difficult to know if an infant has epiglottitis.
- In contrast, adolescents and adults have a more general appearance with sore throat as the main complaint along with fever (50-70%), difficulty breathing (25%), drooling (15%), and stridor (noise with breathing) (10%). Doctors have characterized adult epiglottitis into 3 categories:
- Category 1: Severe respiratory distress with imminent or actual respiratory arrest. People typically report a brief history with a rapid illness that quickly becomes dangerous. Blood cultures, which are tests that check for bacteria in the blood, are often positive for Hib.
- Category 2: Moderate-to-severe clinical symptoms and signs of considerable risk for potential airway blockage. Symptoms and signs usually are of sore throat, inability to swallow, difficulty in lying flat, muffled "hot potato" voice (speaking as if they have a mouthful of hot potato), stridor, and the use of accessory respiratory muscles with breathing.
- Category 3: Mild-to-moderate illness without signs of potential airway blockage. These people often have a history of illness that has been occurring for days with complaints of sore throat and pain upon swallowing.
Currently, immediate hospitalization is required whenever the diagnosis of epiglottitis is suspected. The person is in danger of sudden and unpredictable closing of the airway. So doctors must establish a secure way for the person to breathe. Antibiotics may be given.
- Initial treatment of epiglottitis may consist of making the person as comfortable as possible including placing an ill child in a dimly lit room with the parent holding the child, humidified oxygen, and close monitoring. If there are no signs of respiratory distress, IV fluids may be helpful. It is important to prevent anxiety because it may lead to an acute airway obstruction especially in children.
- People with possible signs of airway obstruction require laryngoscopy in the operating room with proper staff and airway intervention equipment. In very severe cases, the doctor may need to perform a cricothyrotomy (cutting the neck to insert a breathing tube directly into the windpipe).
- IV antibiotics may effectively control inflammation and get rid of the infection from the body. Antibiotics are usually prescribed to treat the most common types of bacteria. Blood cultures are usually obtained with the premise that any organism found growing in the blood can be attributed as the cause of the epiglottitis. However, in many cases, if not the actual majority, blood cultures fail to yield this information.
- Corticosteroids and epinephrine have been used in the past. However, there is no good proof that these medications are helpful in cases of epiglottitis.
Continue taking all antibiotics until the full course is completed. Keep all follow-up appointments with your doctor. In the event that a breathing tube had to be placed through the neck, follow-up with the surgeon to have the tube removed and make sure the site is healing well. Most people improve significantly before leaving the hospital, so taking the antibiotics and returning to the hospital if there are any problems are the most important parts of follow-up.
Prevention
Prevention of epiglottitis can be achieved with proper vaccination schedules against H influenza type b (Hib). Therefore it is important that your doctor make the appropriate recommendations for vaccination against Hib for children (see the children's immunization schedule). Adult vaccination is not routinely recommended, except for people with immune problems such as sickle cell anemia, splenectomy, cancers, or other diseases affecting the immune system.
When there is a member of a family with an unvaccinated child under age 4 years who is exposed to a person with H influenza epiglottitis, preventive medication (rifampin, Rifadin) should be given to all household contacts to make sure that both the person with the illness and the rest of the household have the bacteria completely eradicated from their bodies. This prevents formation of a "carrier state" in which a person has the bacteria in the body but is not actively sick. Carriers can still spread the infection to other family members in this state.
