Epiglottitis (also called supraglottitis) is more common in children, right?
You would be surprised. Since the introduction of the conjugate Haemophilus influenzae B vaccine in the early 1990s, the incidence of acute epiglottitis in children has fallen. As a result, epiglottitis is now 3 times more common in adults as in children.
Haemophilus influenzae remains the most commonly identified agent in both adults and children, but other bacteria such as S.aureus, streptococci, and viruses have been implicated. In immunosuppressed subjects such those with HIV, Candida and Pseudomonas can cause acute epiglottitis.
Typically, epiglottitis presents with sore throat, anterior tenderness over the neck in the region of the hyoid, drooling, dysphagia and odynophagia. While the triad of drooling, dysphagia and (respiratory) distress- 3D- is considered pathognomonic, respiratory distress is commoner in children because of the small size of the supraglottis. Symptoms can progress rapidly in children with respiratory obstruction and death within 12 hours of onset of symptoms, and therefore the paediatrician must have a high index of suspicion.
Children with epiglottitis look anxious, breath through an open mouth, with the neck hyperextended and the chin thrust forward. They often assume a posture where they bend forward, arms stretched, splinting their trunk, much as a subject with emphysema would (the tripod sign).
Stridor occurs in a minority of patients. Cough and hoarseness are not usual features and should raise suspicion of an alternative diagnosis such as croup in children, or laryngitis in adults. However, the voice can be muffled.
The most important clue on examination is the presence of sore throat with a normal appearing pharynx. Direct or indirect Laryngoscopic examination should be postponed, particularly in children as it carries a risk of respiratory arrest, and in both adults and children, should be carried out in a setting where emergency intubation is possible. Attention to airway takes primacy in all subjects, regardless of age, if epiglottitis is suspected.
An alternative, non-invasive way of diagnosing epiglottitis is through the lateral neck X-ray, which shows an enlarged epiglottis- called the thumb sign, along with swollen ary-epiglottic folds, often in association with straightening of the curvature of the normally slightly lordotic cervical spine (Figure 1).
Figure 1. The Thumb Sign in Acute Epiglottitis
Treatment should comprise a combination of 3rd generation cephalosporin such as cefotaxime or ceftriaxone with an anti-staph agent such as clindamycin or vancomycin.
In subjects who have developed epiglottitis despite immunisation, or whose immunisation history is not known, or in subjects who have had epiglottitis in the past and now present with another invasive infection possibly due to H.influenzae B such as cellulitis, osteomyelitis, meningitis or septic arthritis, it is easy to check for functional antibodies to H.influenzae B. If the titres are suboptimal, the subject should receive a single dose of Menitorix vaccine- a combination of conjugate vaccine against H.influenzae B and Meningococcus C.
You would be surprised. Since the introduction of the conjugate Haemophilus influenzae B vaccine in the early 1990s, the incidence of acute epiglottitis in children has fallen. As a result, epiglottitis is now 3 times more common in adults as in children.
Haemophilus influenzae remains the most commonly identified agent in both adults and children, but other bacteria such as S.aureus, streptococci, and viruses have been implicated. In immunosuppressed subjects such those with HIV, Candida and Pseudomonas can cause acute epiglottitis.
Typically, epiglottitis presents with sore throat, anterior tenderness over the neck in the region of the hyoid, drooling, dysphagia and odynophagia. While the triad of drooling, dysphagia and (respiratory) distress- 3D- is considered pathognomonic, respiratory distress is commoner in children because of the small size of the supraglottis. Symptoms can progress rapidly in children with respiratory obstruction and death within 12 hours of onset of symptoms, and therefore the paediatrician must have a high index of suspicion.
Children with epiglottitis look anxious, breath through an open mouth, with the neck hyperextended and the chin thrust forward. They often assume a posture where they bend forward, arms stretched, splinting their trunk, much as a subject with emphysema would (the tripod sign).
Stridor occurs in a minority of patients. Cough and hoarseness are not usual features and should raise suspicion of an alternative diagnosis such as croup in children, or laryngitis in adults. However, the voice can be muffled.
The most important clue on examination is the presence of sore throat with a normal appearing pharynx. Direct or indirect Laryngoscopic examination should be postponed, particularly in children as it carries a risk of respiratory arrest, and in both adults and children, should be carried out in a setting where emergency intubation is possible. Attention to airway takes primacy in all subjects, regardless of age, if epiglottitis is suspected.
An alternative, non-invasive way of diagnosing epiglottitis is through the lateral neck X-ray, which shows an enlarged epiglottis- called the thumb sign, along with swollen ary-epiglottic folds, often in association with straightening of the curvature of the normally slightly lordotic cervical spine (Figure 1).
Figure 1. The Thumb Sign in Acute Epiglottitis
Treatment should comprise a combination of 3rd generation cephalosporin such as cefotaxime or ceftriaxone with an anti-staph agent such as clindamycin or vancomycin.
In subjects who have developed epiglottitis despite immunisation, or whose immunisation history is not known, or in subjects who have had epiglottitis in the past and now present with another invasive infection possibly due to H.influenzae B such as cellulitis, osteomyelitis, meningitis or septic arthritis, it is easy to check for functional antibodies to H.influenzae B. If the titres are suboptimal, the subject should receive a single dose of Menitorix vaccine- a combination of conjugate vaccine against H.influenzae B and Meningococcus C.
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