Epiglottitis & Supraglottitis

Red flags

  • Stridor is a late sign - do not discount patients who are not stridulous. Act on clinical suspicion based on the history. Once stridor develops, you may only have minutes to act.
  • The airway disaster triad - see next subsection
  • Children with a sore throat and unusual symptoms eg noisy breathing, drooling or any of the symptoms above.
  • Any patient with a severe sore throat and no evidence of tonsillitis or pharyngitis on examination.
  • Anyone with the airway disaster triad and trismus or painful face/neck swelling might have a deep neck space infection

 

IMPENDING AIRWAY DISASTER TRIAD

  • Rapid onset aphagia or severe dysphagia, frequently associated with a severe sore throat
  • Rapid onset laryngeal voice change: hoarse, croaky, husky or no voice
  • Systemically very unwell: pyrexia, tachycardia, tachypnoea

There may be associated trismus or torticollis. Beware of any patient who develops these signs after admission: situations deteriorate rapidly. In the presence of neck trauma, any of the above should be taken very seriously. Stridor is a late sign of airway compromise. 

 

Why is this important?

  • Epiglottitis and supraglottitis cause inflammation and swelling of the tissues immediately above the vocal cords. The condition is unpredictable, and can lead to rapid decompensation and complete airway obstruction.
  • Patients who present with airway difficulty are already in severe danger – a high index of suspicion is essential in order to secure the airway.

 

When to involve the ENT Registrar

  • Immediately.  If a patient presents with symptoms and signs suggestive of epiglottitis or supraglottitis, you must seek senior ENT help on the basis of your clinical suspicion. It is dangerous to try to confirm the diagnosis on your own.
  • You will also need to contact a senior on call anaesthetist.  If the diagnosis is correct, the patient may need emergency intubation and critical care admission.
  • If in an Emergency Department, you should involve your registrar/consultant as soon as possible and transfer the patient to Resus.

 

Who to admit

All epiglottitis and supraglottitis patients need admission until the episode is resolved and the airway is known to be safe.

Do not be fooled by a relatively well-looking patient – rapid decompensation can occur.

 

Assessment and recognition

The epiglottis is a flap-like structure sitting above the airway at the base of the tongue. The supraglottis describes the part of the larynx from above the vocal cords to the epiglottis. 

In epiglottitis, the epiglottis appears swollen, like a red sausage or ball, rather than a thin flap. In supraglottitis, the other supraglottic tissues behind the epiglottis appear swollen and red.

Inflammation of these tissues causes stridor and respiratory distress by 1) reducing the radius of the airway (recall Poiseuille's Law) and 2) ball-valving or prolapsing into the airway because of the resulting increased pressure gradient (breathing harder). 

 

TRIAD OF SYMPTOMS & SIGNS

  • History of sore throat and dysphagia, both usually severe
  • Drooling or spitting out saliva
  • Increased work of breathing or respiratory distress
  • Hoarse, croaky voice or unable to speak
  • Abnormal airway noises e.g. stridor 
  • Leaning forward with outstretched arms
  • High fever 
  • Dehydration
  • Irritable or anxious
  • Referred otalgia 
  • Cervical lymphadenopathy

Epiglottitis in children is now rare due to the Hib (Haemophilus influenzae B) vaccine, but should still be suspected.  In adults, the condition is becoming more common, and may be linked to smoking, diabetes and the lapsing of childhood Haemophilus immunity.

 

INVESTIGATIONS

The initial diagnosis of epiglottitis or supraglottitis is based on the history. Examination, fibreoptic nasendoscopy or bloods must not take priority over getting help and securing the airway (if appropriate).  In children, distress can cause problems so wait for more help if possible and try to keep everyone calm.

Fibreoptic nasendoscopy is the key investigation, which should be performed once a team is assembled to deal with any airway compromise. Nasendoscopy can be performed by a competent endoscopist (trained SHO or ANP; registrar) viewing the oropharynx and larynx from just beyond the soft palate; do not advance too far as instrumenting the larynx can precipitate respiratory arrest

NOTE - The general prohibition on instrumenting the mouth or performing nasendoscopy in patients with an airway problem prevents over-zealous and uncontrolled instrumentation of the base of tongue/larynx by first responders. Controlled, careful and minimal instrumentation by trained personnel is lower risk.

Bloods: FBC, CRP, U+Es, blood cultures 

Blood gas if feasible. 

X-ray: some textbooks mention the “thumb-print” sign on lateral neck X-ray, but in practice it is hazardous to send a patient with clinical suspicion of airway compromise to radiology!

 

Differential diagnosis 

Patient very unwell; rare: 

  • Deep neck space infection eg:
    • Retropharyngeal abscess 
    • Parapharyngeal abscess

Patient moderately unwell; common:

  • Croup (in children)
  • Quinsy or tonsillitis

Patient slightly unwell; common: 

  • Laryngitis 

 

Immediate and overnight management

For immediate measures, see Stridor 

If the airway is not immediately compromised, or has already been secured:

  • Broad spectrum IV antibiotics 
  • Regular high dose IV steroid (with a view to tapering in a day or two)
  • As-required adrenaline nebulisers (see Stridor)
  • Remain nil by mouth until airway has improved
  • Humidified oxygen
  • IV fluid resuscitation

If  the patient has a respiratory arrest, there may be a need for an emergency surgical airway. See open cricothyroidotomy and needle cricothyroidotomy.

Once the airway has been fully assessed by senior members of the ENT and anaesthetic teams, the patient should be transferred to a suitable area (usually critical care).

 

Further management

Patients with supraglottitis or epiglottitis usually recover well once their airway has been secured and antibiotic therapy started.  Repeat nasendoscopy is essential to monitor progress. If a patient does not progress, a CT may help to exclude an associated problem such as a localised abscess or neck space infection. 

The decision to step down from high-dependency to ward-based care is made jointly between the ENT and critical care teams.  Patients should continue to be closely observed for recurrence of respiratory distress.  Adult patients, particularly smokers, should be followed up in clinic with a view to excluding an underlying malignancy.

 

 Page last reviewed: 17 September 2017