eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Epiglottitis, Adult: Differential Diagnoses & Workup

Author: Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Contributor Information and Disclosures

Updated: Apr 10, 2009

Differential Diagnoses

Peritonsillar Abscess
Retropharyngeal Abscess
Toxicity, Caustic Ingestions

Other Problems to Be Considered

Airway obstruction
Foreign body aspiration
Bacterial laryngotracheobronchitis 
Laryngotracheobronchopneumonitis
Retropharyngeal abscess
Peritonsillar abscess
Laryngitis
Laryngeal diphtheria
Caustic ingestions
Acute angioedema
Sepsis

Workup

Laboratory Studies

  • For those in extremis, samples for laboratory tests should not be drawn and epiglottic swab culture should not be obtained until the airway has been secured. Most adults present in a less acute fashion, and immediate testing is appropriate.
  • Epiglottic swabs may be taken when the airway is secured or capable of being secured rapidly if needed.
  • Blood cultures may be taken, particularly if the patient is systemically unwell. The cultures are positive in approximately 25% of adult cases. Given the relatively large number of infectious agents besides H influenzae type b and Streptococcus species that may cause adult epiglottitis, blood culture and sensitivities may be particularly helpful in this population.

Imaging Studies

  • Radiographic evaluation for suspected epiglottitis is being replaced by direct visualization of the epiglottis using nasopharyngoscopy/laryngoscopy as the preferred method of diagnosis. Only 79% of epiglottis cases are diagnosed by neck soft tissue radiographs, underscoring the importance of direct visualization by fiberoptic endoscopy in obtaining a timely and accurate diagnosis.
  • For presentations in extremis, avoid radiography until the airway is secure because of the danger of sudden obstruction.
  • Most adults can safely undergo imaging. In evaluating stable patients with suspected epiglottitis, lateral neck soft tissue radiographs are useful screening tools. The classic lateral neck radiograph findings are a swollen epiglottis (ie, a "thumb sign"), thickened aryepiglottic folds, and obliteration of the vallecula. Perform radiography with portable equipment, if indicated; this may confirm the diagnosis.
    • The epiglottis is usually 3-5 mm in thickness; in one small retrospective study of 30 patients with epiglottitis, using a criteria of 7-mm thickness provided 100% sensitivity and specificity for adult acute epiglottitis.9
    • The same small retrospective study yielded 83% sensitivity and 100% specificity for an aryepiglottic fold width greater than 4.5 mm.9
    • Another useful tool in differentiating epiglottitis is to examine the vallecula (pre-epiglottic space). To locate the vallecula, use a soft tissue lateral neck radiograph taken while the patient's mouth is closed. The hyoid is the air pocket found at the level of the hyoid bone just anterior to the epiglottis. To locate the hyoid, trace from the tongue base to the level of the hyoid bone. The vallecula is normally well delineated, deep, and roughly parallel to the pharyngotracheal air column. Identification of an abnormal-appearing vallecula on neck radiograph allows the clinician to more accurately interpret the presence of epiglottitis.
  • Chest radiography
    • Avoid radiography until the patient's airway is secure.
    • Obtain a chest radiograph (CXR) for endotracheal tube (ET) placement.
    • Chest radiograph may reveal pneumonia.
  • Initial study regarding the applicability of using bedside ultrasonography in the evaluation of the normal epiglottis found it to be both easy to perform and accurate.10 Further analysis regarding usage of bedside ultrasonography in evaluating epiglottic disease and pathologic epiglottic enlargement may help to determine if ultrasonography has a future clinical role in management of acute epiglottitis.

Procedures

  • Consider nasopharyngoscopy for patients who are not in extremis and when epiglottitis diagnosis is suspected.
  • Orotracheal intubation may be required with little warning.
  • Cricothyrotomy may be necessary for any patient with epiglottitis. Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present at the patient's bedside. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) also may be considered to ventilate the patient temporarily.11 In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy. PTJV can produce high intratracheal pressures that appear to lift up and open the glottis with escape of the pressurized gasses causing the glottis edges to flutter, thereby allowing improved identification of the glottic aperture.

More on Epiglottitis, Adult

Overview: Epiglottitis, Adult
Differential Diagnoses & Workup: Epiglottitis, Adult
Treatment & Medication: Epiglottitis, Adult
Follow-up: Epiglottitis, Adult
Multimedia: Epiglottitis, Adult
References
Further Reading
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References

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  5. Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. Jun 2006;22(6):443-4. [Medline].

  6. Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72. [Medline].

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  8. Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3. [Medline].

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Further Reading

Clinical guidelines

1) General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). 2) Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine.

Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices (ACIP). Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep 2008 Mar 14;57(10):258-60. PubMed

Kroger AT, Atkinson WL, Marcuse EK, Pickering LK, Advisory Committee on Immunization Practices (ACIP) Centers for Disease. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) [published errata appear in MMWR Morb Mortal Wkly Rep 2007 Mar 23;56(11):256]. MMWR Recomm Rep 2006 Dec 1;55(RR-15):1-48.

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Keywords

epiglottitis, supraglottitis, inflammation of the epiglottis, sudden airway obstruction, Haemophilus influenzae b vaccine, H influenzae, Haemophilus influenzae type b, Hib vaccine, Hib vaccination

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Contributor Information and Disclosures

Author

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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