Epiglottitis in a 48-Year-Old Man

A 48-year-old man was admitted with a sore throat, subjective fever, and cough of 2 days’ duration. Two days before admission, he had dysphagia, began to drool, and felt like he was choking.

An x-ray film of the neck showed soft tissue swelling at the level of the epiglottis and a thumbprint sign (arrow), which confirmed the diagnosis of epiglottitis. The patient was treated empirically with ceftriaxone and cefazolin. After 3 days, the patient’s symptoms abated, and recovery was uneventful.

Epiglottitis (also known as supraglottitis) has been rare since 1991, when the Haemophilus influenzae type B (Hib) vaccine was first recommended for children. Pathogens that most commonly give rise to epiglottitis are thought to include Haemophilus types A and F (and nontypeable strains); Haemophilus parainfluenzae; Streptococcus pneumoniae; Staphylococcus aureus; and group A streptococci.¹

The peak incidence of epiglottitis is during the third year of life; three-quarters of cases arise in children between 1 and 5 years old.^2,3 The incidence of epiglottitis in adults is on the rise. Before the Hib vaccine, 0.22 to 1 per 100,000 adults were affected.^4,5 There have been reports of the rate increasing to 0.88 per 100,000 between 1991 and 1995 to 3.1 per 100,000 between 1996 and 2000.⁶ Epiglottitis in adults has been associated with comorbid conditions, such as hypertension and diabetes mellitus.^5,7,8

Epiglottitis is marked by abrupt onset of a constellation of symptoms, including fever, severe sore throat, dysphagia, and drooling. Physical symptoms combined with leukocytosis (white blood cell count of 20,000/μL or more and an increased percentage of neutrophils and band forms) are highly suggestive of epiglottitis.^9,10 Radiographic visualization of the epiglottis usually confirms the diagnosis. Cultures of blood or epiglottis tissue identify the pathogen responsible for infection. A retrospective study found that the thumb sign was present in 77.5% of radiographs of patients with epiglottitis. In comparison, the vallecula sign was present in radiographs of 1.4% of those with epiglottitis.¹¹

References:

REFERENCES:

1.

Cherry JD. Epiglottitis (supraglottitis). In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds.

Textbook of Pediatric Infectious Diseases.

6th ed. Philadelphia: Saunders; 2009:244.

2.

Faden HS. Treatment of

Haemophilus influenzae

type B epiglottitis.

Pediatrics.

1979;63:402-407.

3.

Cohen SR, Chai J. Epiglottitis. Twenty-year study with tracheotomy.

Ann Otol Rhinol Laryngol.

1978;87(4 pt 1):461-467.

4.

Takala A, Eskola J, van Alphen L. Spectrum of invasive

Haemophilus influenzae

type disease in adults.

Arch Intern Med.

1990;150:2573-2576.

5.

MayoSmith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island.

N Engl J Med.

1986;314:1133-1139.

6.

Berger G, Landau T, Berger S, et al. The rising incidence of adult acute epiglottitis and epiglottic abscess.

Am J Otolaryngol.

2003;24:374-383.

7.

Chang YL, Lo SH, Wang PC, Shu YH. Adult acute epiglottitis: experiences in a Taiwanese setting.

Otolaryngol Head Neck Surg.

2005;132:689-693.

8.

Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis.

Laryngoscope.

1990;100:183-185.

9.

de Diego JI, Prim MP, Hardisson D, et al. Graft-vs-host disease as a cause of enlargement of the epiglottis in an immunocompromised child.

Arch Otolaryngol Head Neck Surg.

2001;127:439-441.

10.

Johnson GK, Sullivan JL, Bishop LA. Acute epiglottitis: review of 55 cases and suggested protocol.

Arch Otolaryngol.

1974;100:333-337.

11.

Ng HL, Sin LM, Li MF, et al. Acute epiglottitis in adults: a retrospective review of 106 patients in Hong Kong.

Emerg Med J.

2008;25:253-255.