Supraglottitis (Case presentation)

Case Presentation (Fever, Odynophagia, Aphonia & Stridor in An Adult(: 

Case Presentation ( Fever, Odynophagia, Aphonia & Stridor in An Adult ( Professor Hossam Thabet, M.D. Otolaryngology-H &N Surgery Alexandria University

Case Presentation: 

Case Presentation A male Filipino patient 46 years old presented to the outpatient clinic at 8 am on June 8, 2005 with fever, throat pain, aphonia, odynophagia, and mild respiratory difficulty. The condition started the night before with sore throat after having dinner.

Case Presentation: 

Case Presentation O/E The patient looked ill and toxic. Temperature was 38 o C, pulse rate was 90/min., BP: 130/90 mmHg. Nose, throat, & ear examination; NAD. Neck examination showed tenderness all over the neck & Rt cervical lymphadenopathy 1X2 cm.

Case Presentation: 

Case Presentation What is your differential diagnosis? What are the other investigations you should ask for?

Case Presentation: 

Case Presentation Radiological Findings: Lateral Neck X-Ray: Swollen epiglottis (thumb print appearance) Thickened AEF Edematous Arytenoids Obliterated preepiglottic space Loss of cervical lordosis Mild increased prevertebral space Chest X-ray: Increase bronchovascular marking with left basal diminished areation & accentuated both hilar shadows

Case Presentation: 

Case Presentation CBC on admission on June 8, 2005 showed leukocytosis with neutrophilia, mild lymphopenia, shift to the left and toxic granulations. WBC:15.4 X10 3 / µ L, HGB: 15.1g/dL, bands:20, neutrophils:71, & lymphocytes:4. CBC on June 9, 2005 shoed WBC: 15.7X10 3 / µ L, HGB: 14.2g/dL, bands:1, neutrophils:86, & lymphocytes:10. CBC on June 11, 2005 shoed WBC: 6.7X10 3 / µ L, HGB: 14.2g/dL, bands:2, neutrophils:58, & lymphocytes:28.

Case Presentation: 

Case Presentation CRP on June 9, 2005 : 86.9 mg/L (N:0-10) CRP on June 11, 2005 : 47.3 mg/L (N:0-10) RBS: 123 mg% (N: up to 160 mg%) EKG : Sinus tachcardia U/S Neck: Rt upper deep cervical lymph node 1.2 X 0.6 cm Epiglottic swab was +ve for E. Coli Sputum culture on 12 June,2005 showed normal flora

Case Presentation: 

Case Presentation Direct laryngoscopy & tracheostomy were performed under GA on June 8, 2005 Incision & drainage of the epiglottic abscess was performed Patient received Maxipieme 2 gm IV/12 h for one week Patient was discharged on June 15, 2005 in good condition

PowerPoint Presentation: 

Preoperative neck X-ray Postoperative neck X-ray

Supraglottitis “Epiglottitis”: 

Supraglottitis “Epiglottitis ” Hossam Thabet,M.D

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Bacterial cellulitis of supraglottis A rapidly progressive & potentially fatal disease that must be recognized immediately. Children 2-7 years old (mean 3.5) Adults around 45 years Haemophilus influenzae type B most common

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Mortality (Children): 10% (no endotracheal intubation) < 1%. (with endotracheal intubation) Mortality (Adults) around 7%.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Incidence 1 in 1000-2000 pediatric admissions 1 in 100,000 adult admissions

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Incidence Historically, it has been a disease of adults. In the last 50 years it has become more common in children, although incidence in children greatly decreased since the introduction of the HIB vaccine in 1985 The ratio of incidence in children to adults was 2.6:1 in 1980 and dropped to 0.4:1 in 1993. Males represent 60% of cases. Male-to-female ratio is approximately 3:1.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) First described in 1878 George Washington probably died of epiglottitis on Saturday December 12, 1799 . (George Washington woke up with a sore throat and died that night.) Portrait of George Washington , by Gilbert Stuart, c. 1795-1800 .

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George Washington lies on his deathbed while others come to say their last good-byes. Life of George Washington: The Christian, color lithograph photographic print by Regnier Stearns.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Microbiology Haemophilus influenzae type B ( HiB ) is the etiologic agent in more than 90% of pediatric epiglottitis cases HiB& group A streptococci are most common causes in adults

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Microbiology RARE now with Hib gone. Pneumococcus, Staph, Strep now more common as cause Other causes; S. pneumoniae ,Group A and group C (ie, beta-hemolytic) streptococci, Staphylococcus aureus,Moraxella catarrhalis ,Haemophilus parainfluenzae, Pseudomonas species ,Candida albicans ,Klebsiella pneumoniae ,Pasteurella multocida

PowerPoint Presentation: 

Specimens of a normal upper airway and one from a child who died of epiglottitis. Photomicrograph of sectioned epiglottis showing severe edema of epiglottitis.

PowerPoint Presentation: 

Haemophilus influenza cocobacillus

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Clinical Picture: Symptoms Acute Onset ( Usually no prodromal URTI) Rapidly progressive sore throat < 1day Toxic appearance & Irritability High fever> 38 o C Classic position (tripod or parking dog) Odynophagia & drooling rather than swallowing Inspiratory stridor & labored breathing Aphonia or muffled voice No cough

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Clinical Picture : Signs Tripod position & the child resists being repositioned Severe pain on gentle palpation over larynx Tender cervical adenopathy Tongue pushed forward ,drooling Cherry-red epiglottis Concomitant pneumonia in 25% of patients.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Clinical Picture Classic position The child may sit with his or her chin hyperextended and body leaning forward (tripod, parking dog or sniffing position) to maximize air entry. The mouth may be open wide, and the tongue may protrude

Epiglottic Abscess: 

Epiglottic Abscess

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Diagnosis If suspected, diagnose by direct laryngoscopy in OR. E ndotracheal intubation is performed in OR under GA using a mask with oxygen & halothane with the patient in a sitting position. Avoid disturbing the child until personnel and equipment are available and ready, as i ncreased anxiety may lead to reflex laryngospasm, acute airway obstruction, & respiratory arrest

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Don ’ t gag child with tongue blade

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Diagnosis Avoid oral examination ( Gagging may cause complete obstruction ) Fiberoptic laryngoscopy can be performed to confirm the diagnoses in an older child or adults who are cooperative & with no airway obstruction. Don’t leave alone during X-ray examination with a nursing aide, parent, or x-ray tech .

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis Visualization of epiglottis - “ cherry red ” Laternal neck x-rays: “ thumb sign ” CBC shows marked leukocytosis with a shift to the left (WBC count > 15,000 left shift ) Epiglottic swab - Positive in 70% of cases Blood culture - Positive in 90% of cases CT &MRI are not recommended for the initial diagnosis of epiglottitis, but may help evaluate for complications such as abscesses

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Lateral radiograph of the neck demonstrates an enlarged epiglottis (red arrow) &thickening of the aryepiglottic folds (yellow arrow). There is also reversal of the normal cervical lordosis and slight dilatation of the hypopharynx Ballooning of the hypopharynx is a finding in children with croup,or epiglottitis, it is a rare radiographic finding in adults.

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis)

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Key Point in Radiological Diagnosis of Epiglottitis Swollen Epiglottis (Thumb print appearance) Thickened edematous AEF Swollen edematous arytenoids Dilated hypopharynx Obliterated vallecula Normal subglottis Loss of cervical lordosis Associated pneumonia in 25 %

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Normal Epiglottitis

Key Findings in Epiglottitis: 

Key Findings in Epiglottitis ‘ Toxic ’ Child X-ray findings ‘ Thumbprint ’ Dilated hypopharynx ‘ Cherry Red ’ Epigottis

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis: Lab. Studies: Laboratory evaluation is nonspecific Samples for laboratory testing should not be obtained until the airway is secured . CBC: marked leukocytosis with left shift (WBC count > 15,000 cells/mm3 with a predominance of bands) Epiglottic swab - Positive in 70% of cases Blood culture - Positive in 90% of cases

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis: Radiography Not necessary for diagnosis . It is needed to confirm the diagnosis & exclude other causes of acute airway obstruction Lateral radiograph should be taken in the erect position only, as supine position may close off airway . Never perform neck radiograph before achieving definitive airway control. The safest procedure is to perform a portable radiograph at the bedside. Patient needs to be accompanied everywhere by a physician experienced in endotracheal intubation

PowerPoint Presentation: 

The normal epiglottis in the image on the right is contrasted with the markedly thickened one on the left. A column of air can still be seen though the epiglottis is swollen.

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis: Radiography Although ballooning of the hypopharynx is a finding in children with croup, and sometimes those with epiglottitis, it is a rare radiographic finding in adults. The ballooning is caused by sucking air through an open mouth against an obstruction. The epiglottis becomes more vertically oriented and develops a convex contour of the anterior and posterior margins. Often, no air column is visible in the shadow of the epiglottis.

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis: Radiography Imaging findings Enlargement of epiglottis “ Larger than your thumb ” Thickening of aryepiglottic folds , True cause of stridor Edema of arytenoids Ballooning of hypopharynx and pyriform sinuses . Reversal of the normal lordotic curve of the cervical spine Chest radiography (CXR) may reveal concomitant pneumonia in up to 25% of patients.

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Diagnosis: Radiography CT & MRI are not recommended for the initial diagnosis of epiglottitis, but may help evaluate for complications such as abscesses CT scan in an adult with acute epiglottitis shows a column of air around the epiglottis (E). The right side is more swollen than the left, and the hypoattenuating area (A) is suggestive of fluid or an early abscess formation

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Management No venipuncture until securing airway Keep the patient in view at all times Maintain adequate airway; ( Nasotracheal intubation) Moist air; oxygen “ O2” IV fluid (unable to swallow) IV antibiotics, after blood culture Extubate when air leak noted - within 48 hours

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Management Antibiotics for 7-10 days Cefuroxime, ceftriaxone, & cefotaxime Ampicillin resistance - up to 30% Chloramphenicol Combination of ampicillin & chloramphenicol . ? Corticosteroids reduce postintubation inflammation

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Management In respiratory arrest, the 1st step is to administer bag-valve-mask ventilation with 100% oxygen . Once the child is oxygenated & ventilated, the airway can be secured with an endotracheal tube, cricothyrotomy, or tracheostomy. Once an airway is established, admit the child to an ICU. Patient should be sedated &/or paralyzed to prevent inadvertent extubations.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Management Estimations of the correct size for an individual child > 1 y may be made by using the formula: ID of the tube = (16 + the age in years) divided by 4 . Thus, a 2-y-old child would probably need a 4.5-mm ID uncuffed tube. An endotracheal tube 0.5-1.0 mm smaller than predicted for the child is usually used.

Epiglottitis (Supraglottitis): 

Epiglottitis (Supraglottitis) Management Ventilation is continued. Visualize the epiglottis daily until the edema resolves, generally within 24-48 hours. Extubated when there is decreased erythema and edema of the epiglottis on direct laryngoscopy after 24-48 h and air leaks around the endotracheal tube

Emergency Airway Equipment: 

Emergency Airway Equipment Oxygen tank with tubing Self-inflating ventilation bags with oxygen reservoir Ventilation masks Oxygen masks Oral airways Nasopharyngeal airways Laryngoscope with extra batteries, lightbulbs, and various blades Stylettes Endotracheal tubes of various sizes Suction catheters and reservoir Tincture of benzoin Scissors Adhesive tape Magill forceps Emergency cricothyrotomy kit (Modified from Chameides, Leon, ed., Textbook of Pediatric Advanced Life Support , American Heart Association and American Academy of Pediatrics, Dallas, TX, 1988, pp. 108)

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Prevention Vaccination to prevent H. influenzae disease was originally begun in 1985 in the US for children 24 months or older, but in October 1990 HiB conjugate vaccines were approved for children 2 months of age & older. Rifampin-20 mg/kg for 4 (not to exceed 600 mg/d). All household contacts if children under 4 Daycare and nursery school contacts Patient before discharge

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Differential Diagnosis Viral croup- barking cough, less abrupt, less toxic Bacterial tracheitis - S. aureus, H. influenzae, Strept., diphtheria Peritonsillar & Parapharyngeal abscess Infectious mononucleosis Aspiration of a foreign body

Characteristics of Viral Croup & Acute Epiglottitis : 

Characteristics of Viral Croup & Acute Epiglottitis Acute Epiglottis Viral Croup Characteristic Looking toxic Well Appearance Tripod Position  Postural preference Abrupt onset Slower onset Onset High fever (>38.5oc) Moderate fever Fever moderate/severe Quit mild/moderate Loud Stridor Minimal or absent Barking, seal-like quality Cough Aphonic, Muffled “ Hot pottato voice ” Hoarse voice Speech Present Abscent Dysphagia Present Abscent Drooling

Characteristics of Viral Croup & Acute Epiglottitis : 

Characteristics of Viral Croup & Acute Epiglottitis Acute Epiglottis Viral Croup Characteristic 2-7 years 3 mo.-5 years Age H. Influenza: type b Viral Organism Rare Common Incidence Swollen Epiglottis ,AEF, & arytenoids Distended hypopharynx ‘ Thumb print sign ” Normal Epiglottis Subglottic narrowing “ Steeple sign ” Neck X-Ray Swollen edematous “ Cherry red appearance Normal Epiglottis Epiglottitis protocol Humidification Racemic epinephrine Treatment

Causes of an Enlarged Epiglottis on X-ray : 

Causes of an Enlarged Epiglottis on X-ray Prominent Normal Epiglottis Omega-Shaped Epiglottis Angioneurotic Edema Stevens-Johnson Syndrome Hemophilia Aryepiglottic Cyst Epiglottic Cyst Foreign Body Trauma including Caustic, Thermal, Irradiation, or Chemical Chronic Epiglottitis Modified from Practical Pediatric Imaging - Diagnostic Radiology of Infants and Children, Kirks, D.R., Little, Brown and Co., Boston, MA., 2nd Edit., p. 562.)

PowerPoint Presentation: 

A 66-year-old patient with acute epiglottitis. The epiglottis (E) is swollen and appears like a thumb, not a petal. The AEF (A) are also swollen and more radiopaque than normal. E A A normal epiglottis in a child. The prevertebral space is wide, and a retropharyngeal abscess is present. Note the petal-like appearance of the epiglottis and the column of air extending up its midline.

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Complications: Airway obstruction, which can lead to respiratory arrest and death from hypoxia. Other complications Aspiration Endotracheal tube dislodgement Extubation Tracheal stenosis Pneumothorax or pneumomediastinum Epiglottic abscess Adenitis Cervical cellulitis Septic shock Pulmonary edema (rare) Cerebral anoxia Death from asphyxia

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Complications: In classic cases involving bacteremia with H influenzae, other structures may have concomitant infectious processes. These may include the following: Meningitis Pneumonia Septicemia Cellulitis Septic arthritis Otitis media Pericarditis (rare)

Epiglottitis (Supraglottitis) : 

Epiglottitis (Supraglottitis) Conclusion Epiglottitis produces a unique and dramatic constellation of signs and symptoms. The key points to remember are: 1. Prepare in advance for the management of the disease. 2. Have a high suspicion for the diagnosis. 3. Do not disturb the child until personnel and equipment are available & ready, as reflex laryngospasm and obstruction may occur rapidly. 4. Treat aggressively with supportive measures, antibiotics, and vaccination. 5. Most children have full recovery if treated promptly and aggressively.

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"To be conscious that you are ignorant of some facts is a great step in knowledge."

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Thank Y ou