Epiglottitis 

Epiglottitis is an acute inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds (see the image below). Anecdotally, George Washington probably died of epiglottitis in 1799.

See also Pediatric Epiglottitis and Emergent Management of Pediatric Epiglottitis.

In adults, the most common organisms that cause acute epiglottitis are Haemophilus influenzae (25%), followed by H parainfluenzae, Streptococcus pneumoniae, and group A streptococci. Less common infectious etiologies include other bacteria (eg, Staphylococcus aureus, mycobacteria, Bacteroides melaninogenicus, Enterobacter cloacae, Escherichia coli, Fusobacterium necrophorum, Klebsiella pneumoniae, Neisseria meningitidis, Pasteurella multocida), herpes simplex virus (HSV), other viruses, infectious mononucleosis, Candida (in immunocompromised patients), and Aspergillus (in immunocompromised patients).

Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is becoming an increasingly important pathogen; as of 2007, MRSA rarely causes epiglottitis.^[1]

Noninfectious causes of epiglottitis include: thermal causes (including those associated with crack cocaine smoking and marijuana smoking, as well as throat burns affecting the epiglottis of bottle-fed infants), caustic insults (eg, automatic dishwasher soap ingestion), and foreign body ingestion (eg, following ingestion and expulsion of a bottle cap^[2] ). Epiglottitis may also occur as a reaction to head and neck chemotherapy.^[3]

In United States, epiglottitis is an uncommon disease with an incidence in adults of about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men (male-to-female ratio, approximately 3:1), occurring during the fifth decade of life (average age, about 45 y). The ratio of incidence in children to adults was 2.6:1 in 1980 and dropped to 0.4:1 in 1993, a dramatic decrease in occurrence since the introduction of the Haemophilus influenzae type b vaccine (Hib). However, keep in mind that vaccine failures are possible.

Globally, epiglottitis is generally more common in nations that do not immunize against H influenzae type b. For example, in Sweden from 1987 to 1989, the incidence was 14.7 per 100,000 people per year in children aged 0-4 years and 3.2 per 100,000 people per year overall.^[4] A large-scale Hib vaccination program in 1992-1993 resulted in a substantial decrease in Swedish cases of acute epiglottitis.

A retrospective review of a Danish population demonstrated a mean national incidence of epiglottitis in children of 4.9 cases per 100,000 per year in the decade before Hib vaccination. From 1996 to 2005, with the introduction of widespread Hib vaccination, an incidence of only 0.02 cases of epiglottitis per 100,000 per year was seen. During this period, the incidence of acute epiglottitis in adults remained constant, at 1.9 cases per 100,000 per year.^[5]

A retrospective review from the tropical country of Singapore over 8 years, ending in 1999, demonstrated 32 cases of acute epiglottitis, only 1 of which occurred in a child.^[6] During this time, Hib immunization was not routine, so Hib immunization cannot be used to explain the increased adult epiglottitis prevalence found in this study.

The prognosis in adults with acute epiglottitis is good with appropriate and timely treatment. Most patients can be extubated within several days. However, unrecognized epiglottitis may rapidly lead to airway compromise and resultant death.

In spite of acute epiglottitis generally having a good prognosis, the risk of death for persons is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures. Reported cases do include sudden fatal cardiorespiratory arrest occurring in patients without previous evidence of respiratory obstruction while in an intensive care unit (ICU) setting, emphasizing the importance of providing close monitoring and adequate airway protection in these patients. The adult mortality rate is around 7%.

Complications

Complications of epiglottitis may include the following:

• Meningitis
• Epiglottic abscess
• Cervical adenitis
• Vocal granuloma
• Subsequent necrotizing fasciitis of the head and neck (rare)
• Cartilaginous metaplasia of the epiglottis
• Pneumonia
• Pulmonary edema
• Empyema
• Pneumothorax
• Pneumomediastinum (rare)
• Pericarditis
• Septic arthritis
• Cellulitis
• Septic shock
• Death (asphyxia)

For patient education information, see the Cold & Flu Center as well as Epiglottitis.