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Epiglottitis is a life-threatening emergency if not diagnosed early and managed by a multi-disciplinary approach. Early symptoms and signs are used to diagnose epiglottitis. Imaging can be helpful if clinically safe to perform and supported by close monitoring. Imaging is an adjunct if the airway is patent and with close monitoring. Despite decreasing incidence of epiglottitis in children secondary to vaccination, there is an increasing incidence of epiglottitis and epiglottic abscess formation in adults over the last two decades. Management involves establishing an airway, broad spectrum antibiotics and possible surgical management of complicated epiglottic abscess. We aimed to systematically review the literature to provide a succinct overview on workup and treatment of epiglottitis and its complications.
A systematic search of Medline Ovid, PsychINFO and CINAHL databases was conducted for the period January 1946 to October 2020. Mesh terms used were “epiglottitis” AND “complications”. Article titles and abstracts were independently screened for inclusion by one author.
Epiglottitis is cellulitis and/or infection of the epiglottis and surrounding nearby structures like the arytenoids, aryepiglottic folds and vallecula. It is more correctly called supraglottitis. Complicated epiglottitis usually involves a coalescent abscess containing pus in the supraglottic region in the oropharynx . Other rare and uncommon complications of epiglottitis include descending necrotizing mediastinitis .
Epiglottitis can be infectious, or noninfectious. Infectious causes can be bacterial, viral, or fungal. The most common cause is Haemophilus influenzae type B (HIB), although the incidence of epiglottitis has dropped significantly due to the introduction of the HIB vaccine in many countries [3-7]. In children, HIB is a
common organism, however in adults’ other pathogenic bacteria include Klebsiella pneumoniae, Streptococcus pneumoniae and Staphylococcus aureus . Immunocompromised patients are susceptible to Pseudomonas aeruginosa and Candida. Noninfectious causes are mainly traumatic such as corrosive, thermal or foreign body ingestion [9-11].
Epiglottitis usually affects children under the age of 6, however currently there is an increasing incidence in adults . The introduction of the HIB vaccination in 1985 has resulted in decreased annual incidence in children over the last decades to less than one case per 100, 000 from 59 cases per 100, 000 [6,13]. In adults the incidence has increased from 0.88 (from 1986-1990) to 3.1 (from 1996-2000) per 100, 000 . Concomitantly the number of epiglottic abscesses or complicated epiglottitis has increased with incidence of epiglottitis. The mortality rate in adults has been reported as 7.1% . Moreover, the age of children with epiglottitis has increased from 3 years of age to 6-12 years old post vaccination schedules . In adults the age of presentation of epiglottitis is in the 4th decade of life with a male predilection of 2.5:1 .
The anatomy of the airway and physiological differences
between children and adults may explain the difference in
pathology presentation. In children anatomically, the epiglottis
is located anteriorly and superiorly with an oblique angle to the
trachea. The cartilage of the epiglottis in children is composed
of pliant cartilage compared to the rigid cartilage of the adult.
Thus, in children, oedema and swelling of the epiglottis caused
by bacterial infection leads to an increase in the weight and
mass of the epiglottis causing an oedematous epiglottis to cover
the laryngeal airway on inspiration (ball-valve effect) causing
symptoms. In comparison, a rigid and stiffer epiglottis and
laryngeal cartilages in adults may resist the increase in epiglottic
mass due to infection, however surrounding supraglottic oedema
can manifest in symptoms and an unstable airway. The most
common bacterial organism causing oedema of the epiglottis
is HIB in children and adults leading to symptoms of airway
obstruction. Other organisms such as S. pneumoniae, S. aureus
and beta-hemolytic Streptococcus sp. are important pathogens in
Symptoms initially appear very mild for a period of hours
to days then rapidly worsen to a sudden onset of symptoms. In
children, they usually present with a generalized toxemia of a fever
(temperature above 38.5 degrees Celsius), dysphagia, difficulty
moving the neck downward and stridor (usually inspiratory).
As the infection progresses the child may sit upright leaning
forward in a tripod position with their mouth open, tachypnoea
and drooling as they are unable to swallow their saliva secondary
to difficulty or pain . Sometimes other subtle respiratory
symptoms may include orthopnoea and a muffled voice. Croup
may also present with fevers, stridor and dyspnoea. However,
croup is usually associated with a gradual increase in symptoms
over a couple of days in addition to a cough described as “barking”
usually without the development of drooling . In adults,
supraglottitis usually presents predominately with symptoms
of odynophagia (100%), dysphagia (85%) and dysphonia (74%)
The diagnosis of epiglottitis is primarily a clinical diagnosis.
Avoiding instrumenting the oropharynx during examination will
reduce progression of epiglottic oedema leading to potential
airway disaster. A lateral neck radiograph may show swelling of
the epiglottis due to epiglottic fold oedema called “thumb sign”
(Figure 1) . The radiograph is not necessary, although can
be used to eliminate differential diagnoses (epiglottic abscess,
parapharyngeal abscess, or retropharyngeal abscess). Imaging is
performed in hemodynamically stable and cooperative patients.
Adults may have obliteration of the vallecula known as the
“vallecula sign” from an oedematous epiglottis . Flexible
laryngoscopy is best completed in a safe and controlled setting such
as the operating theatre as there may be a risk of laryngospasm
and imminent airway obstruction. Once a clinical diagnosis of
epiglottitis is made, the patient needs to be transferred to the
operating room for airway examination. In an adult, indirect,
direct, and flexible laryngoscopies are accurate, safe and have not
been demonstrated to exacerbate airway obstruction .
Complicated epiglottitis in the form of an epiglottic abscess
may necessitate further CT scan of the soft tissues of the neck
to investigate for a deep neck space abscess. The patient should
be accompanied by an otolaryngologist or anesthetist to the
radiology department to ensure airway monitoring and prevent
a respiratory crisis. CT findings suggestive of an epiglottic
abscess include a rim enhancing low density collection within
the epiglottis (Figure 2). A complete blood count and differential,
blood and throat cultures can be obtained once the airway is
secured. Usually, blood and throat cultures are negative and
rarely change clinical management. Ultrasonography has been
described as a method to evaluate patients by visualizing an
“alphabet P sign” in longitudinal view through the thyrohyoid
membrane . Although a stable clinical condition is advised
prior to instrumentation of the ultrasound probe alongside the
neck in children with suspected epiglottitis.
Securing the airway is the most important management of an
epiglottitis in both children and adults. This needs to be performed
by an experienced team including an anesthetist, otolaryngologist
and intensivist because intubation may be a potentially difficult procedure (Figure 3) especially in complicated epiglottitis.
Airway intervention is more likely to occur in children compared
to adults . To ensure safe airway intervention this should be
conducted in an operating room under monitoring. In children
once the diagnosis of epiglottitis is confirmed, they need to remain
erect, even sitting on their parents’ laps. This is followed by an
inhalation induction of general anesthesia to ensure spontaneous
ventilation and avoid complications of asleep intubation and
inability to secure the airway . A flexible video laryngoscopy, a
difficult airway trolley and a tracheostomy tray must be set up at
the bedside. Paralytic agents of skeletal muscle should be avoided
to prevent cessation of spontaneous ventilation and increased
risk of a surgical airway. The trachea in children can usually be
anesthetized with a deep inhalation agent. Although the time
necessary for deep anaesthesia may be increased due to airway
obstruction. Capnography monitoring of exhaled gas analysis is
useful in determining the depth of anaesthesia (Figure 4).
Fiberoptic awake nasotracheal intubation is the preferred
method of securing the airway to avoid accidental extubation
which could be disastrous . The type of endotracheal tube
used (cuffed or uncuffed) and size depend on the patient’s age.
However, to prevent subglottic stenosis, there needs to be an air
leak at 20cm H2O. Once intubated an examination for complicated
epiglottitis is made and if there is an epiglottic abscess it is drained
with the pus sent for a culture swab. Once the airway is secured
and any complication of epiglottitis managed, the patient is
transferred to the intensive care unit (ICU) for ongoing antibiotics
(second or third generation cephalosporins). If there is an
immediate hypersensitivity allergy to penicillin, then levofloxacin
or moxifloxacin can be used. Most pediatric intensivists consider
extubation within 24 to 48 hours once the toxemia has resolved.
An air leak needs to be demonstrated once the endotracheal cuff
is deflated to consider readiness of extubating . Moreover,
a second direct laryngoscopy with deep sedation or general
anaesthesia may be needed to assess the extent of epiglottic
oedema or assess for new complicated epiglottitis. Corticosteroids
are administered during the admission reduce pharyngeal and
epiglottic oedema and have been associated with shorter ICU and
overall length of stay .
Adults in contrast may present with supraglottitis with varied
severity and management should be tailored to the presentation.
Mild to moderate cases without symptoms of respiratory
compromise can be managed with medical management with
vigilant airway monitoring. Emergent airway intervention with
intubation or tracheostomy occurs in approximately 11% of cases
. Symptoms of respiratory distress, stridor, tachycardia, and
tachypnoea warrant prompt airway management. Securing the
airway in an adult involves high-flow nasal prong oxygenation,
fiberoptic nasoendoscopic application of topical anaesthesia with
light sedation and subsequent intubation whilst awake .
All non-intubated patients are monitored in a high-vigilance
area with continuous pulse oximetry, parenteral antibiotics as
discussed above and a tracheostomy tray available at the bedside.
Despite a patient being allocated non-surgical management,
communication between the otolaryngology team and anesthetist
are required early in the event of an emergency airway being
required in the form of intubation or a tracheostomy in the
The main limitation of this review is that most of the
literature are case reports due to the infrequent presentation
of complicated epiglottitis. Furthermore, assessing validity and quality is challenging when assessing the data. Future research is
needed when comparing the outcomes of complicated epiglottitis
management in the adult and pediatric populations in tertiary
centers with large patient presentations.
Epiglottitis and complicated epiglottitis require high clinical
suspicion and rapid intervention to avoid life-threatening airway
obstruction. The disease presentation in children and adults
varies with different degrees of respiratory compromise. Airway
management is a priority over investigations and should be
secured in a controlled setting such as the operating room with
experienced anaesthetic and otolaryngology providers.
Joe Jabbour contributed to conception, design, collection
and assembly of data, manuscript writing and final approval of
manuscript. Sarah Lorger, Ranga Sirigiri, Chris Milross and Hayder
Ridha contributed to manuscript writing and final approval of