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

Epiglottitis, Adult

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

Updated: Apr 10, 2009

Introduction

Background

Epiglottitis is an acute inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds.

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.

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Soft-tissue lateral neck radiograph reveals edema...

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


Pathophysiology

Epiglottitis is an acute inflammation involving the epiglottis, vallecula, aryepiglottic folds, and arytenoids.

Frequency

United States

Epiglottitis is an uncommon disease. Incidence in adults is about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men, occurring during the fifth decade of life. The ratio of incidence in children to adults was 2.6:1 in 1980 and dropped to 0.4:1 in 1993. Occurrence has decreased dramatically since the introduction of Haemophilus influenzae type b vaccine. However, keep in mind that vaccine failures are possible.

A retrospective case series of 107 patients admitted to a pediatric hospital's ICU from 1997-2006 concluded that bacterial tracheitis is now 3 times more likely to be the cause of pediatric respiratory failure compared to viral croup and epiglottitis combined. The authors attributed this change in the epidemiology of acute infectious upper airway disease to H influenzae B vaccine as well as the use of corticosteroids for the treatment of viral croup.1

International

Epiglottitis is generally more common in nations that do not immunize against H influenzae type b. For example, in Sweden from 1987-1989, 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.2 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 H influenzae type b vaccination. From 1996-2005, with the introduction of widespread H influenzae type b vaccination, an incidence of only 0.02 cases 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.3

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.4 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.

Mortality/Morbidity

  • Risk of death for persons with epiglottitis is high due to sudden airway obstruction and difficulty intubating patients with extensive swelling of supraglottic structures.
  • The adult mortality rate is around 7%.
  • The mortality rate in pediatric cases is less than 1%.

Sex

  • Epiglottitis is more common in males than in females. The male-to-female ratio is approximately 3:1.

Age

  • The average age among adults is approximately 45 years.
  • Epiglottitis is now more common in adults than in children in the United States.
  • In the pediatric population, epiglottitis is most common in those aged 3-7 years, although persons of any age may be affected.

Clinical

History

The onset and progression of symptoms of epiglottitis is rapid (George Washington woke up with a sore throat and died that night). Although, in adolescents and adults, a less fulminant presentation is frequently demonstrated.

Historically, acute epiglottitis was most common in children aged 2-4 years. Since the introduction of the Hib vaccine and the accompanying dramatic reduction in H influenzae type b invasive disease incidence, epiglottitis has become rare in children. A comparison made between a large US children's hospital's chart review from 1995-2003 and a prior report from the same hospital completed 27 years earlier, showed a 10-fold decline in acute epiglottitis admissions, with streptococci becoming the major pathogens.5 Epiglottitis incidence in adults has remained constant.

In a 2005 retrospective review of patients with acute epiglottitis, symptoms of stridor, voice muffling, rapid clinical course, and a history of diabetes mellitus were significantly associated with the need for airway intervention.6

  • Sore throat (95%)
  • Odynophagia/dysphagia (95%)
  • Muffled voice (54%)
  • Usually, no prodromal symptoms occur in children. Adults may have preceding upper respiratory infection (URI) symptoms.

Physical

Physical findings of epiglottitis may include the following:

  • Fever
  • Drooling/inability to handle secretions
  • Cervical adenopathy
  • Stridor - A late finding indicating advanced airway obstruction
  • Muffled voice (54%)
  • Tripod position - Sitting up on hands with the tongue out and the head forward
  • Hypoxia
  • Respiratory distress
  • Severe pain on gentle palpation over the larynx
  • Mild cough
  • Fever
  • Irritability
  • Tachycardia
  • Toxic appearance of patient

Causes

  • In adults with acute epiglottitis, blood cultures for H influenzae are positive in about 25% of cases. In remaining adult cases, Haemophilus parainfluenzae, Streptococcus pneumoniae, and group A streptococci are frequently isolated from pharyngeal cultures.
  • 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).
  • Noninfectious causes of epiglottitis include the following: 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 cap7 ). Epiglottitis may also occur as a reaction to head and neck chemotherapy.
  • Before widespread Hib vaccination, H influenzae caused almost all pediatric cases.
  • Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is becoming an increasingly important pathogen; as of 2007, MRSA rarely causes epiglottitis.8

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

  1. Hopkins A, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. Oct 2006;118(4):1418-21. [Medline].

  2. Berg S, Trollfors B, Nylen O, Hugosson S, Prellner K, Carenfelt C. Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden. Scand J Infect Dis. 1996;28(3):261-4. [Medline].

  3. Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. Aug 2008;122(8):818-23. [Medline].

  4. Chan KO, Pang YT, Tan KK. Acute epiglottitis in the tropics: is it an adult disease?. J Laryngol Otol. Sep 2001;115(9):715-8. [Medline].

  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].

  7. Kavanagh KR, Batti JS. Traumatic epiglottitis after foreign body ingestion. Int J Pediatr Otorhinolaryngol. Jun 2008;72(6):901-3. [Medline].

  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].

  9. Yong MG, Choo MJ, Yum CS, et al. Radiologic laryngeal parameters in acute supraglottitis in Korean adults. Yonsei Med J. Aug 2001;42(4):367-70. [Medline].

  10. Werner SL, Jones RA, Emerman CL. Sonographic assessment of the epiglottis. Acad Emerg Med. Dec 2004;11(12):1358-60. [Medline].

  11. Chandradeva K, Palin C, Ghosh SM, Pinches SC. Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema. Br J Anaesth. May 2005;94(5):683-6. [Medline].

  12. Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol. Nov-Dec 2003;24(6):374-83. [Medline].

  13. Caballero M, Sabater F, Traserra J, Alos L, Bernal-Sprekelsen M. Epiglottitis and necrotizing fasciitis: a life-threatening complication of infectious mononucleosis. Acta Otolaryngol. Oct 2005;125(10):1130-3. [Medline].

  14. Carey MJ. Epiglottitis in adults. Am J Emerg Med. Jul 1996;14(4):421-4. [Medline].

  15. Ducic Y, Hebert PC, MacLachlan L, Neufeld K, Lamothe A. Description and evaluation of the vallecula sign: a new radiologic sign in the diagnosis of adult epiglottitis. Ann Emerg Med. Jul 1997;30(1):1-6. [Medline].

  16. Gagnon R, Bedard PM, Cote L, Lavoie A, Hebert J. Recurrent acute epiglottitis in adults: defective antibody response. Ann Allergy Asthma Immunol. May 2002;88(5):513-7. [Medline].

  17. Gerber AC, Pfenninger J. Acute epiglottitis: management by short duration of intubation and hospitalisation. Intensive Care Med. 1986;12(6):407-11. [Medline].

  18. Hussan WU, Keaney NP. Bilateral thoracic empyema complicating adult epiglottitis. J Laryngol Otol. Oct 1991;105(10):858-9. [Medline].

  19. Kornak JM, Freije JE, Campbell BH. Caustic and thermal epiglottitis in the adult. Otolaryngol Head Neck Surg. Feb 1996;114(2):310-2. [Medline].

  20. Lee AH, Ramsay AD. Cartilaginous metaplasia of the epiglottis. J Laryngol Otol. Nov 1990;104(11):903-4. [Medline].

  21. Mayo-Smith M. Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management. Chest. Sep 1993;104(3):964-5. [Medline].

  22. Mayo-Smith MF, Spinale JW, Donskey CJ, Yukawa M, Li RH, Schiffman FJ. Acute epiglottitis. An 18-year experience in Rhode Island. Chest. Dec 1995;108(6):1640-7. [Medline].

  23. MayoSmith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island. N Engl J Med. May 1 1986;314(18):1133-9. [Medline].

  24. Pino Rivero V, Pantoja Hernandez CG, Gonzalez Palomino A, Mora Santos ME, Pardo Romero G, Blasco Huelva A. [Sudden cardiorespiratory arrest in adults with acute epiglottitis. Report of 2 cases]. An Otorrinolaringol Ibero Am. 2007;34(1):1-8. [Medline].

  25. Wallenborn PA 3rd, Postma DS. Radiation recall supraglottitis. A hazard in head and neck chemotherapy. Arch Otolaryngol. Sep 1984;110(9):614-7. [Medline].

  26. Wetmore RF, Handler SD. Epiglottitis: evolution in management during the last decade. Ann Otol Rhinol Laryngol. Nov-Dec 1979;88:822-6. [Medline].

  27. Wick F, Ballmer PE, Haller A. Acute epiglottis in adults. Swiss Med Wkly. Oct 12 2002;132(37-38):541-7. [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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