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Epiglottitis

  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jun 06, 2016
 

Background

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.

Soft-tissue lateral neck radiograph reveals edema Soft-tissue lateral neck radiograph reveals edema of epiglottis consistent with acute epiglottitis.

See also Pediatric Epiglottitis and Emergent Management of Pediatric Epiglottitis.

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Etiology

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 are not uncommon and produce similar disease. Etiologies 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]

A retrospective study by Suzuki et al indicated that risk factors for severe epiglottitis in adults includes older age, a body mass index of over 25.0 kg/m2, and the presence of diabetes mellitus, epiglottic cyst, or pneumonia, at admission. The study included 6072 patients with epiglottitis, including 9.4% with a severe form of the condition.[4]

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Epidemiology

Epiglottitis is classically associated with Haemophilus influenzae type b (Hib) infection and children. However, as has been observed with other infections caused by this agent, the overall incidence of epiglottitis has dramatically dropped in young children globally, as well as older age groups and adults, upon general adoption of Hib vaccine; furthermore, the most typical patient affected by epiglottitis in industrialized areas with vaccination programs is now an urban male in his mid 40s. Groups with higher morbidity include infants younger than 1 year and adults older than 85 years.[5, 6]

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.[7] 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.[8]

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.[9] 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.

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Prognosis

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)
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Patient Education

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

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Contributor Information and Disclosures
Author

Sandra G Gompf, MD, FACP, FIDSA Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital

Sandra G Gompf, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

References
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Soft-tissue lateral neck radiograph reveals edema of epiglottis consistent with acute epiglottitis.
 
 
 
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