TABLE 2353 Signs and Symptoms of Epiglottitis

Physical examination of a patient with epiglottitis may reveal an appearance of apprehension, drooling, and difficulty lying supine. Stridor and protrusion of the tongue are frequently noted. The stridor associated with epiglottitis is primarily inspiratory and is softer and lower pitched than in children with croup. 11 Fever is initially absent in 30 to 50 percent of cases and may develop later.11 Patients often position themselves sitting up, leaning forward, mouth open, head extended, and panting. Thick oral pharyngeal secretions are commonly present, with little or no cough. Movement of the upper trachea or thyroid cartilage is often quite painful and is a marker for supraglottic infection.

Diagnosis is made by history, clinical examination, radiographs, and laryngoscopy. Lateral cervical soft tissue radiographs demonstrate obliteration of the vallecula, swelling of the aryepiglottic folds, edema of the prevertebral and retropharyngeal soft tissues, and ballooning of the hypopharynx ( Fig, 235-1i).12 The edematous epiglottis appears enlarged and thumb-shaped. Blood and surface cultures of the epiglottis are useful to confirm the presence of Hib but should be postponed until an artificial airway has been established.

FIG. 235-1. Lateral radiograph demonstrating thumbprinting of the epiglottis and ballooning of the parapharyngeal space consistent with epiglottitis.

Patients should be treated with extreme care because of the possibility of unpredictable sudden airway obstruction. While severe cases of epiglottitis are easily recognized, as many as 36 percent of less severe cases are initially misdiagnosed as pharyngitis. 9 Therefore, clinicians must maintain heightened suspicion for this disease. All patients with suspected epiglottitis require immediate otolaryngologic consultation, and the emergency physician must be prepared to establish a definitive airway at all times. Patients should never be left unattended. Initial treatment consists of supplemental humidified oxygen, intravenous hydration, monitoring, and intravenous antibiotics. Heliox can be given to temporarily decrease airway resistance. In cases of airway obstruction in the emergency department, endotracheal intubation must be attempted, but the physician should be prepared for a very difficult intubation secondary to the swollen, distorted anatomy. In the case of intubation failure, the last resorts for preserving the airway in adult and pediatric patients are cricothyrotomy and needle cricothyrotomy, respectively. Current antibiotic recommendations include cefuroxime, cefotaxime, or ceftriaxone as first-line drugs.10 Alternative antibiotics include ampicillin-sulbactam and trimethoprim-sulfamethoxazole. The use of steroids to decrease inflammation and edema remains controversial, but they are used empirically by many otolaryngologists.

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