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Epiglottitis

Humza Khizer

Overview

Epiglottitis is swelling and inflammation of the epiglottis. It&rsquo;s a potentially life-threatening condition. 
&nbsp;

Epiglottitis is an acute inflammation of the supraglottic tissues surrounding the epiglottis, which covers the windpipe or trachea. The onset of symptoms is often sudden and intense, such that the individual experiences difficulty breathing and swallowing. It may call for immediate medical attention to avoid airway obstruction and death. 
&nbsp;

The incidence of pediatric epiglottitis has been declining due to the Haemophilus influenzae b vaccination. In contrast, the incidence rate of adult epiglottitis has seen a steady increase, especially in the United States where it&rsquo;s jumped from 1 per 100,000 to 4 per 100,000<a href="#accordion">[1]</a>. 
&nbsp;

Epiglottitis is divided into the following categories based on the underlying causes of the disease<a href="#accordion">[2][8]</a>: 
&nbsp;

<h5>1. Infectious Epiglottitis</h5>

The swelling is typically brought on by bacteria, but viruses can also cause it. The most common organism causing epiglottitis in adults is Haemophilus influenzae, H parainfluenzae, Streptococcus pneumoniae, and group A streptococci respectively.&nbsp;

In rare instances, herpes simplex virus, infectious mononucleosis, Aspergillus, Candida, and other bacteria, including mycobacteria, S. aureus, E. coli, Klebsiella pneumoniae, Bacteroides melaninogenicus, Fusobacterium necrophorum, Neisseria meningitidis, Enterobacter cloacae, and Pasteurella multocida can cause epiglottitis. 
&nbsp;

<h5>2. Noninfectious Epiglottitis</h5>

Aside from pathogenic organisms, this includes all other factors that contribute to the development of epiglottitis, such as chemical burns, thermal injuries, head and neck chemotherapy, and ingestion of foreign bodies. 
&nbsp;

Signs and Symptoms

It occurs when the tissue that makes up the epiglottis becomes infected and starts to swell. Continued inflammation can lead to a complete blockage of the airway, which can cause suffocation and death. 
&nbsp;

Epiglottitis symptoms can appear in children within hours whereas adults may experience symptoms over a period of days. Among the symptoms are:

<ul>
	<li>Fever</li>
	<li>Sore throat</li>
	<li>An unusual, high-pitched sound called stridor while breathing in</li>
	<li>Difficulty breathing, especially while lying</li>
	<li>Difficulty swallowing </li>
	<li>Drooling and struggling with managing excess saliva production in the mouth</li>
	<li>Muffled voice</li>
	<li>Prefer to sit upright with the face tilted slightly and the neck extended in a &ldquo;sniffing position&rdquo; to breathe 
	&nbsp;</li>
</ul>

Health care professionals often associate the 4 Ds as the most common epiglottitis symptoms:

<ol>
	<li>Dysphagia: This is a medical term meaning a patient experiences difficulty swallowing.</li>
	<li>Dysphonia: Hoarseness or an abnormal voice is called dysphonia.</li>
	<li>Drooling: This term indicates the involuntary flow of saliva out of the mouth.</li>
	<li>Distress:This is a medical term meaning a patient experiences difficulty breathing or lack of oxygen. 
	&nbsp;</li>
</ol>

Causes

An infection or an injury can cause epiglottitis. 
&nbsp;

<h5>Infection</h5>

People with weak immune systems are more likely to develop an infection.

Bacteria enter the system when a person breathes, making bacterial infection the most common cause of epiglottitis. The most common bacterial strain found responsible for this condition is Haemophilus influenzae type B (Hib) that&rsquo;s contagious and a person can easily pass it to others while sneezing, coughing, or blowing their nose.

Other bacteria include Strep A, B, or C, and Strep pneumoniae, which is a common cause of bacterial pneumonia.

Viruses, like chickenpox and shingles, can cause epiglottitis, too. Incidentally, other viruses that cause respiratory infections can also lead to epiglottitis.

Moreover, fungi such as the one that causes yeast infection or diaper rash can cause inflammation of the epiglottitis as well. 
&nbsp;

<h5>Other</h5>

Epiglottitis can be caused by:

<ul>
	<li>Swallowing a foreign object</li>
	<li>Smoking </li>
	<li>Experiencing throat injury, like a gunshot wound or stabbing</li>
	<li>Inhaling chemicals </li>
	<li>Burning throat due to heat (e.g., steam) 
	&nbsp;</li>
</ul>

Diagnosis

The doctor conducts a physical exam and asks the patient about their symptoms. They may also request the following tests to help diagnose epiglottitis: 
&nbsp;

<ul>
	<li>Laryngoscopy: During this test, the healthcare provider examines the throat with a small camera attached to the end of a flexible tube.</li>
	<li>Culture Tests: A swab is taken from the throat and sent to a lab to test for bacteria or viruses.</li>
	<li>Blood Tests: These are to determine the number of white blood cells in blood or the presence of bacteria or viruses.</li>
	<li>Imaging Tests: An X-ray or CT scan is used to determine the extent of swelling and whether an object is blocking the airway. 
	&nbsp;</li>
</ul>

NOTE: Epiglottitis frequently shares symptoms with other conditions, such as croup. As a result, accurate diagnosis and treatment are critical. 
&nbsp;

Treatment

<h5>Prehospital Care</h5>

A person diagnosed with epiglottitis needs to go to the hospital immediately where a medical team can ensure that the patient&rsquo;s airway is secure while monitoring the oxygen levels with an oximetry device. They&rsquo;ll start with an oxygen mask or a breathing tube if the oxygen levels become too low. 
&nbsp;

At the same time, the doctor may also start with either one or all of the following treatments:

<ul>
	<li>Antibiotics to treat a suspected or known bacterial infection</li>
	<li>IV fluids for hydration as well as nutrition until the person can swallow again</li>
	<li>Anti-inflammatory medication to reduce swelling 
	&nbsp;</li>
</ul>

In case it&rsquo;s a severe condition, the doctor may advise tracheostomy which is a surgical procedure to place a breathing tube directly into the windpipe, bypassing the epiglottis. This is to prevent respiratory failure.

As a last resort, the doctor will opt for cricothyroidotomy wherein a needle is surgically inserted into the trachea just below Adam&#39;s apple. 
&nbsp;

<h5>Unstable Patients</h5>

A patient in critical condition requires immediate airway management. Respiratory distress, stridor, inability to swallow, drooling, and deterioration within 8-12 hours are all signs and symptoms of a need for intubation.

According to a study, adults with epiglottitis who have an abscess, stridor, or a history of diabetes are more likely to require airway intervention<a href="#accordion">[6]</a>.

Needle-jet insufflation (also called percutaneous transtracheal jet ventilation [PTJV]) can produce high intratracheal pressure to lift and open the glottis, which allows better identification of the glottis aperture. 
&nbsp;

<h5>Stable Patients</h5>

Patients with no signs of airway compromise, respiratory difficulty, stridor, or drooling, and who have only mild swelling on laryngoscopy do not need immediate airway intervention by close monitoring in the ICU. However, it&rsquo;s important to observe them for air leaks around the endotracheal tube.

Laryngoscopy is a recommended option before extubation. 
&nbsp;

<h5>Medication</h5>

The doctor can start the antibiotic therapy once the blood and epiglottic cultures have been obtained. Third-generation cephalosporins are preferred as first-line agents due to the increasing resistance to ampicillin.

Further, the patient may be given analgesic-antipyretics to help them deal with the lethargy, malaise, and fever that accompanies epiglottitis. 
&nbsp;

NOTE: The use of corticosteroids is still debatable despite anecdotal evidence supporting its use in the past. 
&nbsp;

Many complications can arise from epiglottitis, including: 
&nbsp;

<ul>
	<li>Breathing Difficulty: The epiglottis is a small, movable &quot;lid&quot; that sits just above the larynx and keeps food and drink from entering the windpipe. The swelling of the epiglottis means it can completely block the airway. This can result in difficulty breathing or respiratory failure, leading to a fatal drop in the level of oxygen in the blood. 
	&nbsp;</li>
	<li>Spreading Of Infection: The bacteria that cause epiglottitis can sometimes spread to other parts of the body and cause infections, like <a href="https://merisehat.pk/disease/pneumonia">pneumonia</a>, <a href="https://merisehat.pk/disease/bacterial-meningitis">meningitis</a>, and bloodstream infections. 
	&nbsp;</li>
</ul>

Epiglottitis can strike anyone at any time. However, several risk factors to look out for include: 
&nbsp;

<h5>Age</h5>

While the disease most commonly affects children aged 2-6 years and adults over 85, children under the age of 12 months are more likely to develop epiglottitis. This is because these children have not yet completed the Hib vaccine series. Also, children who live in countries where vaccines are unavailable or difficult to obtain, or those whose parents refuse to vaccinate them are at a higher risk.&nbsp; 
&nbsp;

<h5>Sex</h5>

Males are more likely than females to develop epiglottitis. 
&nbsp;

<h5>Environment</h5>

Densely populated environments, such as schools or childcare centers, can increase the individual&rsquo;s exposure to various respiratory infections, including those that lead to epiglottitis. 
&nbsp;

<h5>Weak Immune System</h5>

The condition can develop more easily given the immune system is compromised by illness (e.g., diabetes) or medicines. Additionally, not getting vaccinated on time or skipping vaccinations can increase the risk of epiglottitis. 
&nbsp;

<h5>Hib Vaccine</h5>

Getting the Hib vaccine protects against Hib-caused epiglottitis. Children in the United States typically receive the vaccine in 3 or 4 doses:

<ul>
	<li>At 2 months</li>
	<li>At 4 months</li>
	<li>At 6 months, if the child is receiving the four-dose vaccine</li>
	<li>At 12-15 months 
	&nbsp;</li>
</ul>

Given that children over 5 and adults are less likely to develop Hib infection, they are not usually given the vaccine. However, the Centers for Disease Control and Prevention recommends the vaccine for older children and adults with weakened immune systems due to the following:

<ul>
	<li><a href="https://merisehat.pk/disease/sickle-cell-anemia">Sickle cell disease</a></li>
	<li><a href="https://merisehat.pk/disease/hiv-61">HIV</a>/<a href="https://merisehat.pk/disease/aids">AIDS</a></li>
	<li>Spleen removal</li>
	<li>Chemotherapy</li>
	<li>Medicine being used to prevent organ or bone marrow transplant rejection 
	&nbsp;</li>
</ul>

<h5>Vaccine Adverse Effects</h5>

<ul>
	<li>An allergic reaction can occur and necessitate immediate medical attention. Even though it&rsquo;s uncommon, it can cause difficulty breathing, wheezing, hives, weakness, a rapid heartbeat, or dizziness within minutes or hours after the shot. 
	&nbsp;</li>
	<li>Mild side effects are also possible, such as redness, warmth, swelling, pain at the injection site, or fever. 
	&nbsp;</li>
</ul>

<h5>Other</h5>

Besides vaccination, the following precautions can help prevent the condition:

<ul>
	<li>NOT sharing personal items</li>
	<li>Washing hands frequently</li>
	<li>Using an alcohol-based hand sanitizer if soap and water are not available<a href="#accordion">[10]</a>. 
	&nbsp;</li>
</ul>
<quillbot-extension-portal></quillbot-extension-portal>

In individuals with multiple system atrophy (MSA) and a floppy epiglottis (FE), continuous positive airway pressure (CPAP) may worsen obstructive sleep apnea (OSA) because it encourages the epiglottis&#39; downward displacement into the laryngeal inlet. A recent case study explored a treatment for OSA by using an oral appliance (OA)<a href="#accordion">[7]</a>. 
&nbsp;

Patients with OSA who also have MSA and FE may benefit from OA therapy utilizing a two-piece mandibular advancement device. 
&nbsp;

Key Points

<ul>
	<li>Epiglottitis can result in airway blockage and difficulty in breathing.</li>
	<li>The most frequent cause of epiglottitis, Haemophilus influenza, is a harmful bacterium. The infection must be treated with antibiotics.</li>
	<li>Physical examination and a neck x-ray that reveals the inflamed epiglottis is used to diagnose the condition. 
	&nbsp;</li>
</ul>
<quillbot-extension-portal></quillbot-extension-portal>

[1] Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: adult epiglottitis. Am J Emerg Med. 2022;

[2] Amos LB. Cough. Nelson Pediatr Symptom-Based Diagnosis. 2018;15.

[3] Ossoff RH, Wolff AP, Ballenger JJ. Acute epiglottitis in adults: experience with fifteen cases. Laryngoscope. 1980;90(7 Pt 1):1155–61.

[4] Lichtor JL, Roche Rodriguez M, Aaronson NL, Spock T, Goodman TR, Baum ED. Epiglottitis: it hasn’t gone away. Anesthesiology. 2016;124(6):1404–7.

[5] Tebruegge M, Connell T, Kong K, Marks M, Curtis N. Necrotizing epiglottitis in an infant: an unusual first presentation of human immunodeficiency virus infection. Pediatr Infect Dis J. 2009;28(2):164–6.

[6] Sideris A, Holmes TR, Cumming B, Havas T. A systematic review and meta-analysis of predictors of airway intervention in adult epiglottitis. Laryngoscope. 2020;130(2):465–73.

[7] Mikami T, Kobayashi T, Hasebe D, Ohshima Y, Takahashi T, Shimohata T. Oral appliance therapy for obstructive sleep apnea in multiple system atrophy with floppy epiglottis: a case series of three patients. Sleep Breath. 2022;1–7.