Acute Epiglottitis

A 74-year-old nursing home resident was admitted to the hospital with shortness of breath and stridor. Radiographic examination of the neck revealed the “thumb sign” of a swollen epiglottis (Figure, white arrow); the black arrow indicates the normal posterior wall of the pharynx. Acute epiglottitis was diagnosed.

This rapidly progressive cellulitis can cause complete airway obstruction. Narrowing of the supraglottic airway-and subsequent obstruction of the glottis-may result either from swelling of the epiglottis that begins at the tongue base and pushes it posteriorly or from generalized swelling of the epiglottis and supraglottis.

Drs Vallari Shukla and Parag Mehta of New York Methodist Hospital, Brooklyn, report that as many as 25% of patients present with dyspnea, 15% with drooling, and 10% with stridor. Airway occlusion may occur suddenly; if respiratory distress exists, secure the airway immediately. Lateral neck films that show an enlarged epiglottis are helpful, but such films may appear falsely normal.

The diagnosis is made by direct viewing of the epiglottis with a flexible laryngoscope; however, this maneuver may cause a sudden laryngospasm with airway obstruction.

Keep the patient in a sniffing position (bending forward) and give humidified oxygen. Although difficult to obtain in most emergency departments, heliox is ideal for such patients. Intubated patients can usually be extubated in 48 hours.

All patients require antibiotics and must be closely monitored in the ICU. The most common causative organism is Haemophilus influenzae followed by Haemophilus parainfluenzae, Streptococcus pneumoniae, and group A streptococci. Treatment options include cefuroxime, ampicillin/sulbactam, and nafcillin plus ceftriaxone. Clindamycin plus trimethoprim-sulfamethoxazole can be given to patients who are allergic to penicillin.

When an unvaccinated child younger than 4 years lives with a patient who has H influenzae epiglottitis, administer prophylactic rifampin to all members of the household to eradicate carriage of this organism.

This patient was given epinephrine, corticosteroids, and ceftriaxone. The symptoms resolved in a few days.