Adult Epiglottitis Update

Author: Vivian Lau, DO // Editor: Alex Koyfman, MD (@EMHighAK)

General Info/Intro

  • Localized inflammation to epiglottis, base of tongue, lingual tonsils, vallecula, aryepiglottic fold, and arytenoids
  • Incidence rate 1-1.6/100,000, more common than peds cases after Hib vaccine implemented
    • Ratio of peds:adults 0.4:1
  • Mortality rate ~7%
  • Causes:
    • Infectious (bacterial, viral, fungal) most common, thermal (inhalation, caustic), trauma
    • Bugs: Haemophilus, Strep, Staph, HSV, CMV
  • Male predominance 2.5:1
  • Mean age: 30-50yo
  • No seasonal variance

Recap Basics

  • Typically with 1-2 day URI prodrome
  • Complaints: Sore throat/odynophagia (most common), dysphagia, dysphonia, muffled voice, stridor, drooling, +/- fever, tender hyoid region
  • Complications: epiglottic abscess, airway compromise
  • Work-up
    • Direct (flexible laryngoscopy) / indirect visualization
    • Imaging
      • Thumb sign and vallecula sign on lateral soft tissue XR
      • CT soft tissue neck
      • US: alphabet “P” sign
    • Blood cultures
    • Throat cultures (if possible)
    • CBC
  • Treatment
    • IV antibiotics
      • 3rd gen cephalosporins, ampicillins, vancomycin if concerned for MRSA
    • Airway support
      • Orotracheal/nasotracheal intubation, surgical airway
      • needle jet insufflation as temporizing
    • Abscess drainage
    • Humidified oxygen
    • Bronchodilators may be supportive
    • Corticosteroids are controversial
  • Disposition
    • Admit to a monitored bed (typically ICU)
    • ENT consult

Bottom Line/Pearls & Pitfalls

  • IV antibiotics early
  • Be prepared to intubate, early if in severe distress
  • Have a backup airway plan (video laryngoscopy, surgical airway)

Further Reading

Discussion Questions/Future Exploration

  • When to intubate? Patients in severe respiratory distress
  • Corticosteroids and bronchodilators are controversial, no randomized control trials to date

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