Epiglottitis
Jill C. Cash and Kathleen Bradbury-Golas
Definition
A.Epiglottitis is inflammation and swelling of the epiglottis and is a medical emergency.
Incidence
A.Epiglottitis usually occurs in children between ages 2 and 8 years, but it may also occur in adults. The incidence of epiglottitis has decreased since the Haemophilus influenzae vaccine was introduced.
Pathogenesis
A.Epiglottitis is almost always caused by H. influenzae (25%), although Streptococcus pneumoniae and Streptococcus pyogenes have also been implicated.
Predisposing Factors
A.Upper respiratory infection.
B.Trauma to the mucosa in the nasopharynx tissue from a viral infection or from injury from food being swallowed.
C.Hypertension.
D.Diabetes mellitus.
E.Substance abuse.
F.Immune deficiency.
Common Complaints
A.Sudden onset of fever.
B.Sudden onset of dysphagia.
C.Sudden onset of drooling.
D.Sudden onset of muffled voice.
Other Signs and Symptoms
A.Difficulty with breathing and/or respiratory distress.
B.Stridor.
C.Very ill appearance.
D.Sore throat.
E.Change in voice (muffled voice commonly called a hot potato voice,
as if the patient is struggling with a mouthful of hot food).
Subjective Data
A.Determine onset, duration, and course of illness.
B.Has breathing been labored?
C.Is breathing interfering with the patient’s ability to eat or drink?
D.Has the patient had a fever?
E.Has the patient had trouble swallowing or talking?
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Observe overall appearance.
2.Check nail beds and lips for cyanosis.
3.Note drooling or difficulty swallowing.
4.Note breathing pattern and rhythm.
5.Note cough if present.
6.Direct exam of the throat can be attempted if there is no concern about compromising the airway. If airway compromise is of concern, do not examine the throat; airway occlusion may result.
C.Auscultate: Auscultate heart and lungs.
Diagnostic Tests
A.Lateral neck radiograph confirms diagnosis. However, this test may delay establishment of airway.
Differential Diagnoses
A.Epiglottitis.
B.Foreign body aspiration.
C.Retropharyngeal abscess.
Plan
A.General interventions:
1.Immediate transfer to the ED for evaluation and hospitalization.
2.While awaiting transport to hospital, establish patent’s airway, start oxygen, and assemble airway equipment.
3.Insert intravenous (IV) access for fluids and antibiotic administration.
4.If respiratory arrest occurs, you may not be able to see the airway to intubate. An Ambu bag and mask may work temporarily, but nasogastric (NG) tube insertion may be necessary to prevent gastric distension.
5.Prompt recognition and appropriate treatment usually result in rapid resolution of swelling and inflammation.
B.Patient teaching:
1.Educate patient and family that epiglottitis is a medical emergency.
2.If patient has drooling and no cough, diagnosis is most likely epiglottitis.
C.Pharmaceutical therapy in-hospital treatment:
1.IV fluids.
2.Antibiotics; IV antibiotics after physician consultation.
3.Blood and epiglottis cultures obtained prior to starting antibiotics.
4.Drug of choice:
a.First-line antibiotic therapy includes the use of third-generation cephalosporins, which include ceftriaxone (Rocephin), ampicillin/sulbactam (Unasyn).
b.If unable to use these because of allergy, and so on, other alternatives include chloramphenicol, cefuroxime (Ceftin), and clindamycin (Cleocin).
Follow-Up
A.Follow-up care occurs in the hospital.
B.An airway specialist should evaluate the patient in the operating room.
Consultation/Referral
A.If you suspect epiglottitis, consult with the physician/specialist immediately.
B.The patient should be transferred to the ED for treatment and care.
C.Maintain a patent airway while transferring the patient to the ED.
Individual Considerations
A.Geriatrics:
1.Epiglottitis may induce intractable vomiting. Geriatrics are at high risk for aspiration pneumonia and must be monitored closely.
2.Although rare, poor oral healthcare may cause esophageal inflammation and tongue-base abscess that could cause obstruction. Presentation mirrors epiglottitis: pain, neck swelling, drooling, dyspnea, and respiratory compromise. Promote appropriate mouth care to prevent epiglottitis and infections.