Shoutout to Dr. Anthony Torres who presented a great case on Epliglottis!
Here are the main takeaways:
- Epiglottitis is now primarily an adult diagnosis. The vaccine to H. Flu has largely eradicated pediatric epiglottitis, however this immunity fades!
- Features: three D’s (not specific) – Drooling, Dysphagia, Distress. (Also, usually no cough, but + Stridor)
- Inspiratory vs expiratory stridor can help you identify the location of obstruction. This is a simple diagram to keep it straight, however an understanding of intraluminal pressures compared to atmospheric pressures can help you think through where an obstruction is . Inspiration causes decrease of intraluminal pressures compared to the atmosphere in extrathoracic lumens which ends up being the supraglottic structures (the trachea remains open by c cartilage, but this does not occur supraglotically, leading to inspiratory stridor in supraglottic inflammation. Conversely, expiration decreases the size of intrathoracic lumens causing expiratory stridor in intra thoracic lumens. The glottis, subglottis and cervical trachea are therefore exceptions to these rules as they are both extrathoracic, but also held open by c cartilage, leading them to have biphasic stridor with fixed obstructions. The caveat is that you can also have biphasic stridor when you have multiple obstructions.
- “Thumbprint sign” on lateral neck XR can be helpful, but the gold standard is direct visualization/fiberoptic scope! If the suspicion is high enough, this should bypass both lateral neck XR and CT! I’ve included the video from the actual scope below. Take a look for yourself!
- Early abx and ENT involvement is key! Call them based on clinical concern and picture! Cover for staph/strep/Hflu/and H. Paraflu. (Unasyn)
- Airway management will usually involve upright, awake, fiberoptic scope (likely by ENT or anesthesia, or the most experienced intubator in the room).
- Steroids are controversial..but I’d given them (ENT agrees). They have not been shown to reduce the need for intubation, the duration of intubation, the duration of intensive care stay, or the duration of hospitalization after corticosteroids, but epiglottitis is also a rare diagnosis and hard to study. (Solumedrol 125)
- Admit to the ICU