Acute Epiglottitis Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a critical "can't miss" cause of acute airway obstruction in adults presenting to the Emergency Department with a severe sore throat. Misdiagnosis leads to rapid deterioration and death.
High-Yield Definition: Acute epiglottitis (or more accurately, 'supraglottitis' in adults) is a cellulitis of the epiglottis and adjacent supraglottic structures, which can lead to life-threatening airway obstruction. (Source: UpToDate, 2024)
Clinical One-Liner: Basically, it’s a severe throat infection where the 'lid' of the airway swells up so quickly it can choke the patient.
II. Etiology & Risk Factors
Etiology: Infectious. Since the introduction of the Haemophilus influenzae type b (Hib) vaccine in our national immunisation programme, the classic pediatric cause is now rare. In adults, the microbiology has shifted.
Common culprits: Streptococcus pneumoniae, Beta-haemolytic streptococci (Groups A, B, C), and Staphylococcus aureus. H. influenzae (both type b and non-typeable) can still occur, especially in under-immunised or elderly individuals. (Source: StatPearls, 2024)
Risk Factors:
Modifiable: Smoking, immunosuppression.
Non-Modifiable: Male sex (approx. 3:1 ratio), middle age (peak 40-50s), Diabetes Mellitus, hypertension.
III. Quick Pathophysiology
Bacterial invasion of the epithelial layer of the epiglottis and supraglottic tissues leads to acute inflammation and oedema. Because the mucosa on the lingual surface of the epiglottis is loosely attached, it can swell massively and rapidly. This enlarged, inflamed structure then protrudes posteroinferiorly, causing mechanical obstruction of the airway at the laryngeal inlet. This is why the patient's airway is so precarious.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Stridor (inspiratory): Audible high-pitched noise. → Action: This is a late sign of critical obstruction. Do NOT leave the patient. Call your senior, call the anaesthetist, and call ENT immediately. Prepare the difficult airway trolley.
Muffled or "Hot Potato" Voice: Change in phonation. → Action: Maintain NBM (Nil By Mouth). Secure IV access immediately.
Drooling / Inability to Swallow Saliva: Pooling of secretions. → Action: Let the patient sit up and lean forward. Do NOT force them to lie flat.
Respiratory Distress (Tachypnoea, use of accessory muscles): → Action: Apply high-flow oxygen. Keep the patient calm. Defer all non-essential procedures.
History: The adult presentation is often more insidious than in children.
Common (>50%): Severe sore throat, odynophagia (painful swallowing) that is often out of proportion to pharyngeal findings.
Less Common (10-50%): Fever, muffled voice, neck tenderness.
Pertinent Negatives: Ask about cough. Its absence with a severe sore throat is suspicious. Ask about immunisation history.
Physical Examination:
Clinical Pearl:Your single most important rule is: DO NOT ATTEMPT TO VISUALISE THE PHARYNX WITH A TONGUE DEPRESSOR. This can provoke laryngospasm and complete airway closure. Examination must be gentle.General: Observe for anxiety, preferred seating position (often leaning forward), and drooling. Note the respiratory rate and work of breathing.
Vitals: Check for fever and tachycardia. Hypotension is a pre-terminal sign.
Neck: Palpate gently for anterior neck tenderness.
V. Diagnostic Workflow
Differential Diagnosis:
Peritonsillar Abscess (Quinsy):
Points For: Severe sore throat, fever, muffled voice.
Points Against: Usually presents with trismus and a visible unilateral swelling of the soft palate/tonsil with uvular deviation. Epiglottitis lacks these specific findings.
How to Differentiate: Careful oral examination (if airway is deemed safe by a senior) or nasoendoscopy by ENT.
Retropharyngeal Abscess:
Points For: Sore throat, dysphagia, fever.
Points Against: Often associated with neck stiffness/torticollis and a preceding upper respiratory tract infection or trauma.
How to Differentiate: A lateral neck X-ray showing widening of the prevertebral soft tissues is suggestive. CT neck is confirmatory.
Anaphylaxis / Angioedema:
Points For: Rapid onset of airway compromise, stridor.
Points Against: Usually associated with other signs like urticaria, facial swelling, and a clear trigger. Lacks the preceding severe sore throat and odynophagia.
How to Differentiate: Clinical history and response to IM adrenaline.
Investigations Plan: This is done only after securing the airway or in a stable patient under close observation with senior staff present.
Bedside / Initial (Only if stable):
Pulse oximetry.
Secure IV access. Send bloods.
First-Line Labs & Imaging:
Labs: FBC (leukocytosis), RP (for baseline), blood cultures (before antibiotics).
Imaging (Portable Lateral Neck X-ray): Only attempt in a stable, cooperative patient who can sit upright. Look for the classic "thumbprint sign" – a swollen, enlarged epiglottis. A normal X-ray does not rule it out.
Confirmatory / Gold Standard:
Flexible Nasoendoscopy: This is the diagnostic gold standard. It allows direct visualisation of a swollen, cherry-red epiglottis. This should only be performed by ENT in a controlled setting (A&E resus bay or OT) with full airway equipment ready.
VI. Staging & Severity Assessment
There is no formal staging system. Assessment is based on the degree of airway compromise. Any patient with stridor, drooling, or respiratory distress is considered to have a severely threatened airway and requires immediate escalation and intervention. Patients with a severe sore throat but a normal voice and no respiratory signs can be observed closely, but deterioration can be rapid.
VII. Management Plan
Immediate Stabilisation (The ABCDE Plan):
A - Airway: This is paramount.
Call for senior help immediately (Medical, ENT, Anaesthetics).
Keep patient NBM.
Allow patient to maintain a position of comfort (usually sitting up).
Avoid any anxiety-provoking procedures.
If signs of compromise are present, the patient needs a definitive airway. This is usually done via fibreoptic intubation by an anaesthetist in the operating theatre. Be prepared for an emergency surgical airway (cricothyroidotomy).
B - Breathing:
Administer high-flow oxygen (e.g., 15L/min via a non-rebreather mask), humidified if possible.
Monitor SpO₂ continuously.
C - Circulation:
Secure large-bore IV access.
Start IV fluids if dehydrated or hypotensive.
D - Disability: Check GCS. Hypoxia causes confusion and agitation.
E - Exposure: Check temperature.
Definitive Treatment (The Ward Round Plan):
Admit to HDU/ICU for close airway monitoring.
First-Line Pharmacotherapy:
IV Antibiotics: To cover the most likely pathogens.
IV Ceftriaxone 2g daily.
Consider adding IV Vancomycin if the patient is septic, immunocompromised, or has risk factors for MRSA. (Source: UpToDate, 2024)
IV Corticosteroids: To reduce inflammation and oedema. The evidence is not robust, but it is common practice.
IV Dexamethasone 10mg single dose, then 4mg every 6 hours. (Source: DrOracle AI, based on clinical guidelines)
Continue IV antibiotics for 2-3 days before considering a switch to oral antibiotics (e.g., Augmentin) to complete a 7-10 day course, based on clinical improvement.
Long-Term & Discharge Plan:
Ensure completion of the antibiotic course.
Reinforce the importance of routine vaccinations.
Smoking cessation advice.
VIII. Complications
Immediate:
Complete Airway Obstruction: Management: Intubation or surgical airway.
Epiglottic Abscess: Management: May require surgical drainage by ENT.
Sepsis: Management: Fluid resuscitation and broad-spectrum antibiotics.
Short-Term:
Pneumonia (from aspiration): Management: Continue appropriate antibiotics.
Complications of intubation/tracheostomy.
IX. Prognosis
With prompt recognition and airway management, the prognosis is excellent. The mortality rate in adults is low (<1-5%) but is almost always due to a failure to secure the airway in time. The most significant prognostic factor is the degree of airway obstruction on presentation.
X. How to Present to Your Senior
"Dr., for review please. This is [Patient Name/Bed Number], a [Age]-year-old [man/woman] with a background of [e.g., T2DM], who presented with a 1-day history of severe sore throat and painful swallowing.
On assessment, he is sitting forward, has a muffled voice, and is slightly tachypneic. He has no stridor at rest.
My main differential is acute epiglottitis. I have kept him NBM, secured IV access, and am giving high-flow oxygen. I have sent off the initial bloods and blood cultures.
I have NOT examined his throat with a tongue depressor. I need your help to urgently review for airway assessment and to liaise with ENT and Anaesthetics."
XI. Summary & Further Reading
Top 3 Takeaways:
Suspect epiglottitis in any adult with a severe sore throat out of proportion to exam findings, especially with a muffled voice or odynophagia.
Airway management is the absolute priority. Do not provoke the patient, call for senior help early, and do not use a tongue depressor.
Treatment involves admitting for observation and starting IV Ceftriaxone and IV Dexamethasone once the airway is deemed safe.
Key Resources:
UpToDate: Search for "Epiglottitis in adults".
StatPearls (NCBI): Search for "Epiglottitis".
For a general overview of difficult airway principles, refer to anaesthesiology society guidelines. While we lack a specific national CPG for this, the principles of airway management are universal.
