Introduction:
Acute epiglottitis is a life-threatening severe inflammatory condition of the epiglottis. It causes swelling of the upper respiratory tract and results in respiratory distress. Epiglottis is a small lid or a flap that covers the windpipe (trachea) during swallowing, thus preventing the entry of food into the lungs. It also serves as the base of the tongue. Epiglottitis can be due to several factors, such as direct injury to the throat, bacterial and viral infections, etc. In addition, the epiglottis forms a valve mechanism that closes involuntarily during eating, drinking, etc. This condition was more prevalent in children in the earlier days, but now it is commonly seen in adults, also.
What Causes Acute Epiglottitis?
Epiglottitis is caused primarily due to infection of bacterial, fungal, or viral organisms. Formerly, Haemophilus type B infection was the leading cause of epiglottitis in children that has reduced drastically nowadays due to proper immunizations administered in the children. Other bacterial organisms that cause epiglottitis are:
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Streptococcus pyogenes.
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Streptococcus pneumoniae.
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Staphylococcus aureus.
Other causes responsible for epiglottitis are:
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Trauma.
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Foreign body aspiration.
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Head and neck chemotherapy.
Generally, the virus does not cause epiglottitis, but any viral infection may precipitate bacterial superinfection resulting in epiglottitis.
Who Is at High Risk?
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Children below 12 months of age are highly susceptible to epiglottitis. It is also commonly seen in children between two to six years of age and elders above 85 years.
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Children who are not vaccinated with Haemophilus type B.
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Males are more likely to develop epiglottitis than females, although the reason is still unclear.
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Children with compromised or weak immune systems.
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Adults with diabetes are at higher risk.
What Are the Signs and Symptoms of Acute Epiglottitis?
In the case of acute epiglottitis, the symptoms appear abruptly. It may begin as a mild presentation for a few hours and worsens suddenly to a severe form. During this period, the patient remains uncomfortable. The typical clinical presentations observed during epiglottitis are:
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Abnormal breathing sounds (stridor).
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Mouth breathing.
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Restlessness and anxious behavior.
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Fever with a sudden increase in body temperature.
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Due to oxygen insufficiency and respiratory arrest, there is bluish discoloration of the skin, eyes, and nails.
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Change in the voice.
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Symptoms get better when sitting upright and leaning forward.
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In severe cases, airways are entirely obstructed, resulting in cardiac arrest.
The most typical signs of epiglottitis are the presence of the four D’s. They are:
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Dysphagia.
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Dysphonia.
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Drooling.
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Distress.
What Are the Possible Complications?
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Empyema (collection of pus within the body cavities).
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Pneumothorax.
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Pneumonia.
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Vocal cord granuloma.
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Cervical adenitis.
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Submental infections.
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Generalized toxemia.
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Respiratory failure.
Can Epiglottitis Be Prevented?
Yes, epiglottitis can be prevented. Immunization is an effective way to prevent epiglottitis. Haemophilus type B immunization (Hib immunization) is recommended. It is given in three doses at two, four, and six months. The final dose is given between 12 to 15 months.
Other preventive measures are:
Although the child is given vaccination, proper hygiene measures are recommended.
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Wash the hands frequently with soap and water or use an alcohol hand rub, sanitizer, etc.
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Avoid sharing personal items. Do not recommend sharing food, utensils, or the same cups used by different persons.
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Eat healthy and nutritious food.
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In case of chronic health conditions, get them treated properly.
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Stay away from sick people. If any family member is diagnosed with the infection, then other family members are advised to test and treat it as early as possible.
What Are the Other Similar Conditions?
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Croup.
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Foreign body aspiration.
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Bacterial tracheitis.
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Retropharyngeal abscess.
What Is the Prognosis of Acute Epiglottitis?
The patients do respond well to the treatment. The prognosis of acute epiglottitis is generally good if the diagnosis and treatment are commenced early. If the treatment is delayed, it may compromise the airways resulting in respiratory arrest. The prognosis is good even in intubated patients; they get extubated very soon due to faster recovery. However, a tracheostomy kit should be readily available to meet emergencies and unstable airways.
How Is Epiglottitis Diagnosed?
The diagnosis is made based on the suspicions of the clinicians. Any oral or oropharyngeal examination is not recommended as it may cause respiratory distress. As soon as epiglottitis is suspected, the airway should be immediately stabilized. The oxygen level is monitored continuously. Further diagnostic procedures are conducted only when the child gets an adequate supply of oxygen.
The diagnostic procedures followed are:
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Throat Examination: The throat is examined using a flexible fiber-optic light. It reveals the cause of the condition and the abnormalities seen in the region.
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Chest and Neck X-Ray: The lateral view of the neck shows the presence of swelling of the epiglottis. It is referred to as a thumb’s sign. The chest X-ray helps to rule out pneumonia due to epiglottitis. The X-ray findings also show the narrowing of the larynx and trachea. The X-rays are taken along the bedside in an emergency room to prevent sudden respiratory arrest and not in the regular X-rays.
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Throat Examination: A cotton swab is used to collect the sample in the epiglottis region, and a microscopic examination is done. It reveals the presence of Haemophilus infection.
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Blood Culture: In the case of epiglottitis, severe bacterial septic infection is seen in the bloodstream.
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Computed Tomography: It is recommended in rare circumstances as it may aggravate respiratory distress when the patient is placed in a supine position.
What Is the Treatment for Acute Epiglottitis?
The instantaneous mode of treatment should be securing the airways. An experienced clinician is recommended to intubate the patient with epiglottitis to avoid unnecessary difficulties and delays. A clinician with expertise in performing tracheostomy should also be available during emergency situations. Soon after securing the airways, the patient is transferred to the intensive care unit. The patient should not be placed in the supine position.
Securing the Airways:
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The patient wears an oxygen mask that constantly delivers humidified oxygen to the lungs.
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A breathing tube is placed into the windpipe.
Medications:
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Corticosteroids: It is given to reduce inflammation and edema of the epiglottis and surrounding structures.
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Empirical Antimicrobial Therapy: Empirical therapy is the initial antibiotic regimen started within 24 hours after admission or hospitalization. When the culture test reports are obtained, the exact causative microbial organism is identified, and the regimen is altered accordingly.
Fluid Therapy: Fluids are administered intravenously to keep the patient hydrated.
Tracheostomy: The tracheostomy procedure is performed when all the conservative measures fail. It is a surgical procedure where an incision or opening is made along the neckline, and a trach tube is placed into the windpipe below the vocal cords. So the air enters the lungs directly, bypassing the nose and throat.
Conclusion:
Acute epiglottitis can be a life-threatening condition and fatal if it is not diagnosed and treated early. So when the child reports discomfort, parents should take things seriously and take them to the hospital. Parents and caretakers need not panic about the situation and distress the child since it further complicates breathing, so things should be handled swiftly. Parents are advised to immunize their children with all the recommended vaccinations properly. It helps to prevent several other infectious diseases and not only epiglottitis. Educate the children about hygienic practices and instruct them to follow them regularly. Have a healthy lifestyle and stay away from health conditions.
