Acute supraglottis

'Acute epiglottitis' is a misnomer and 'acute supraglottitis' (Fig. 20.6) should be used instead. Anatomically, there is no boundary to separate the epiglottis from the rest of the supraglottis. Therefore, the whole supraglottis will inevitably be involved by an inflammatory or infective process. In the past, the condition is typically caused by H. influenzae type b

Figure 20.6. Acute supraglottitis. (Note: The whole supraglottitis is swollen sparing only the vocal cord.)

(Hib) and affect almost exclusively paediatric patients. However with universal vaccination against Hib in developed countries, supraglottitis-affecting adults have increasingly been reported in the recent literature. In children, the condition usually presents with airway obstruction. Adult patients usually present with sudden severe sore throat. Respiratory distress may occasionally be the presenting symptoms. Children suspected to have the condition should be taken to the operation theatre immediately for direct laryngoscopy under general anaesthesia. Both the anaesthetist and the surgeon should be experienced to deal with the paediatric airway. If the diagnosis is confirmed, endotracheal intubation should be performed and the patient be observed in the intensive care unit. In adult patients without respiratory distress, the diagnosis should be confirmed by mirror examination or flexible laryngoscopy. Carefully performed, these examinations will not precipitate airway obstruction. It is safer to have a correct diagnosis by a gentle examination. In adult patients with respiratory distress, they should be treated as in the case of children. Adult patients with supraglottitis and stable airway should be observed in intensive care unit where facilities and expertise for endotracheal intubation is readily available. Tracheostomy is not needed in most cases as prolonged intubation is unlikely. The pathogens associated with the condition are more variable nowadays including various streptococcal species, anaerobes as well as Hib. The choice of antibiotics should be guided by the prevalence of pathogens and varies from place to place. In general, a second-generation cephalosporin is recommended as the initial treatment.

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