The information in this page is intended for patients, parents, and caregivers

 

What is Epiglottitis?

The epiglottis is a leaf shaped cartilage that lies behind the tongue. It helps prevent food from going into the windpipe (trachea) by covering the voice box (larynx) when we swallow (Figure 1A). Epiglottitis is condition where the epiglottis is inflamed and swells (Figure 1B). This is usually because of an infection by a germ (bacteria). People who have epiglottitis will have severe sore throat, pain and difficulty swallowing and high temperature. The epiglottis is located at the top of the voice box (larynx) which is the opening to the wind pipe (trachea). Epiglottitis should therefore be treated promptly to stop the swelling of the epiglottis, this can stop air from reaching the lungs.

Epiglottitis

(This could be devided into 2 images: 1A and 1B. IA will be a normal lateral neck view and laryngeal view [lower left image], and Image 1B will be the exact views but in setting of epiglottitis) What should be labelled on these images should include: Voice box (larynx), Tongue, Epiglottis, wind pipe (Trachea) and in image 1B label “narrowed airway”).

 

Who gets Epiglottitis?

While epiglottitis is rare, it can occur in any age. Epiglottitis amongst children has reduced dramatically since the introduction of the Hib (Haemophilus influenzae) vaccines.

People whose immune system does not work well, for example due to chemotherapy, are at increased risk.

 

What are the causes?

Epiglottitis is largely caused by infection, which is often caused by bacteria although some viruses can in rare cases cause epiglottitis.

Vaccinations have reduced the rate epiglottitis in children. Other causes of epiglottitis include burn (thermal) injury in people with facial burns, ingestion of corrosive chemicals (e.g. acids), or certain autoimmune conditions.

 

Symptoms of epiglottitis

Patients with epiglottitis often have a high temperature (fever), hoarse voice, and very sore throat. They may also not be able to swallow their own saliva and start to drool due to difficulty and pain with swallowing.

If the epiglottis swells significantly, it may cause noisy breathing (stridor) and difficulty breathing. These patients often prefer to sit upright, and lean slightly forward as this position helps open the airway which allows for more air to get through to the lungs. The feeling of airway narrowing can be scary for patents.

This is an emergency and needs to be treated promptly as there is a risk that the airway can close off completely (obstruct). This means not enough air and oxygen will reach the lungs which can lead to collapse and death.

 

How is it diagnosed?

If epiglottitis is suspected in a patient, they should be transferred to a hospital immediately with an ambulance. The diagnosis is often clinical, based on the history and examination findings often with fibreoptic scope visualisation or X-ray evidence to confirm the diagnosis.

In adults with suspected epiglottitis, once in hospital, a flexible nasoendoscopy (Please click here for more information about flexible nasoendoscopy) is used to directly visualise the epiglottis. This will confirm the diagnosis. Alternatively, an X-ray of the neck may show a swollen epiglottis. A swab of the throat may be taken to find out the bacteria responsible which can help with antibiotic choice.

In children, often a neck X-ray will be used to confirm the diagnosis. If there are concerns about a narrowed airway, direct visualisation of the epiglottis will often be done in an operating theatre under anaesthetic in order to avoid causing any distress (which could lead to complete blockage of the airway).

This way, any urgent treatment can also be carried out at the same time.

 

What are the treatment options?

The treatment of epiglottis includes management of the airway and treatment of the underlying infection and swelling.

Patients with epiglottitis should not be asked to lay down. The blood oxygen level and breathing will be monitored closely and they may require additional oxygen. Patients often require prompt treatment with antibiotics (directly into the vein) to counter the bacteria infection, but this process can take some time to work.

While waiting for the antibiotics to work, patients are often given steroids which help reduce the swelling around the airway. This can also be supplemented by breathing in a fine spray of (nebulised) adrenaline. This technique allows delivery of adrenaline directly and quickly to the airway which can help reduce the swelling.

If the swelling is continuing to get worse or the epiglottis is blocking the airway, oxygen will not reach the lungs. In this situation the airway needs to be protected. One option is to introduce a tube into the windpipe (trachea) from the nose or the mouth after a sedating medicine has been given (Figure 2).

These patients often need to be kept asleep in Intensive Care Unit (ICU) and will need help with breathing using ventilator. A procedure often used when intubation is not possible is called a tracheostomy. This is a surgical procedure where a small cut is made through the front of the lower neck directly into the windpipe (trachea). This allows for passage of a breathing tube below the swollen epiglottis for delivery of air and oxygen to the lungs (Please click here for link to “tracheostomy”).

This procedure can sometimes be done under local anaesthetic. Once in place tracheostomy patients can often breath comfortably on their own but in some circumstances may require breathing support from a ventilator.

In children, the management is similar to adults but direct visulisation is often done in the operating theatre under anaesthetic. Once a tube is in place securing the airway of the child, they will be kept asleep in the ICU on ventilator support until swelling starts to improve. This can take few days.

Epiglottitis
Figure 2: Introduction of breathing tube into the windpipe (endotracheal intubation)

 

Complications of epiglottis

The infection can sometimes lead to a collection of pus around the epiglottis (epiglottic abscess) or in other parts of the neck which may require surgical drainage.

Infection can also spread to other parts of the body including the brain, the lungs, or the heart.

If there has been a long period of obstructed breathing with no air entering the lungs, before a secure airway could be put in place, this can lead to brain damage.

If a tracheostomy is required, there may be tracheostomy related complications such as wound problems, speaking problems while the tracheostomy tube is in place.

If a tube is required and the patient is ventilated under sedation in the Intensive Care Unit, there are additional risks such as pneumonia, and deep vein thrombosis.

 

What is the prognosis?

With prompt treatment, most people will recover in few days and leave the hospital often within one week without any long term airway or other problems.

If epiglottitis is not treated quickly, the airway can obstruct completely. This means air and oxygen cannot reach the lungs, and without a breathing tube, person can die or have brain injury due to prolonged lack of oxygen to the brain.

With early diagnosis and treatment breathing tubes may not be required and generally the outlook is very good.

 

Further reading:

https://emedicine.medscape.com/article/763612-overview
https://emedicine.medscape.com/article/963773-overview

 

References:

Guldfred, L., Lyhne, D., & Becker, B. (2008). Acute epiglottitis: Epidemiology, clinical presentation, management and outcome. The Journal of Laryngology & Otology,122(8), 818-823. doi:10.1017/S0022215107000473

Baiu I, Melendez E. Epiglottitis. 2019;321(19):1946. doi:10.1001/jama.2019.3468

 

Author + Affiliation:
Dr Omid Ahmadi – ENT registrar, Waikato hospital

Date of Publication +/- Review:
Mr James Sanders – ENT Specialist, Waikato Hospital

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