Adult epiglottitis Heightened awareness saves livesBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6930.719 (Published 12 March 1994) Cite this as: BMJ 1994;308:719
- W H Konarzewski
EDITOR, - M J Stuart and T J Hodgetts draw attention to the fact that epiglottitis is just as life threatening in adults as in children.1 I am aware of two adults who died of epiglottitis in the past seven years. Both presented with severe sore throats but no symptoms of upper airway obstruction until sudden and fatal occlusion of their airways. One had been discharged home and the other was in hospital.
Stuart and Hodgetts also point out that cricothyrotomy may be lifesaving. This is illustrated by a third case. A 20 year old man presented with a sore throat and stridor, which worsened rapidly as he was transferred from the casualty department to the intensive therapy unit. Cricothyrotomy was performed urgently with a Mini-Trach (Portex). His symptoms were rapidly relieved, and oxygenation was improved by passing 6 litres of oxygen/minute down the Mini-Trach tube by an 8 gauge suction catheter. Subsequently he underwent uneventful general anaesthesia and a formal tracheostomy.
Adult epiglottitis is serious but curable. Hopefully, with increased awareness of its presentation and treatment, it will claim fewer lives.
Causative organism may be elusive
- J Raphael
EDITOR, - M J Stuart and T J Hodgetts recommend that antibiotics effective against Haemophilus influenzae should be given to adults with epiglottitis.1 I take issue with this. Although the recommendation is reasonable for the disease in children, which is almost always due to this microorganism, I do not believe that it is sufficient in adult epiglottitis.
I recently helped to manage acute epiglottitis in an adult who required emergency intubation. The patient deteriorated during the first two days of antibiotic treatment with the anti-haemophilus agent cefuroxime, developing both local and systemic complications. The patient had further neck swelling and developed the sepsis syndrome, which was confirmed by haemodynamic measurements with a pulmonary artery balloon flotation catheter; the systemic sepsis resulted in acute renal failure. Because of clinical deterioration benzylpenicillin was added empirically to the antimicrobial regimen. The patient improved over the next few days and was extubated. A group A streptococcus was subsequently cultured from a supraglottic swab and proved sensitive to benzylpenicillin but resistant to cefuroxime. The patient returned home a fortnight later; repeat fibreoptic laryngoscopy showed a normal airway, and renal function recovered spontaneously after conservative fluid management.
Although the organism most commonly identified in acute epiglottitis is H influenzae, positive bacterial cultures have been obtained in at most a third of the cases in all large series of the condition, making recommendations on the likeliest causative organism limited.2,3 In a study by Mayo-Smith et al,4 in which a large number of pharyngeal swabs were taken, the commonest pathogen found was group A streptococcus (five of 11 positive cultures), followed by H influenzae (three of 11); the other pathogens were Streptococcus pneumoniae and H parainfluenzae.4 Thus organisms other than H influenzae are important causes of this serious condition, and the case I describe serves as a lesson that giving broader spectrum antibiotic cover in adult epiglottitis is prudent.
Establish an airway early
- A D Hingorani,
- A T Jones,
- J Dziersk,
- D Golding-Wood,
- J M Leigh
EDITOR, - Having recently admitted a patient with acute epiglottitis who had had a cardiorespiratory arrest before admission and who later died, we endorse the views of M J Stuart and T J Hodgetts1 that epiglottitis may affect people of any age and that the occasionally fatal complication of upper airway obstruction is not restricted to children.2 The authors advocate conservative management of the airway in adults in whom respiratory distress is not evident at presentation. We would argue, however, that an elective, “prophylactic” artificial airway should be established at diagnosis in all adult patients (as is routine in paediatric patients) as the risk of airway obstruction is high, there are no reliable early markers of compromise of the airway, and progression to complete closure of the airway may be rapid.
Acute epiglottitis is relatively rare in adults,2,3 and consequently the experience at individual centres is limited. Although estimates vary, one study has shown that the mortality from this condition in adults is similar to that in children before the policy of securing a prophylactic airway in all cases was introduced.2 This policy is thought to have reduced the mortality from acute epiglottitis in paediatric patients from 6.1% to 0.9%.4 We believe that as airway obstruction is the main cause of death in acute epiglottitis, irrespective of age, it is logical to advocate the same management for adults as for children.
Don't waste time with radiography
- S J Ward
EDITOR, - Partial upper airway obstruction is a common adult emergency presenting to accident and emergency departments. The commonest cause is a reduced level of consciousness. Other causes include foreign bodies, trauma, burns, anaphylaxis, angioneurotic oedema, and tumours. Infections, including epiglottitis,1 acute bacterial tracheitis, and acute hypertrophic tonsillitis, may occur. In all of these, life threatening complete airway obstruction may be precipitated quickly and sometimes by minor iatrogenic actions or procedures.
Airway obstruction is a clinical diagnosis, and sometimes a high index of suspicion is needed. I do not recommend radiography of the soft tissue of the lateral neck in the management of patients because the high false negative rate and diagnostic inaccuracy may lead to a false sense of security. The journey to and from the x ray department may precipitate deterioration, and facilities for resuscitation may not be immediately available. Staff experienced in advanced airway management, including anaesthetists and ear, nose, and throat surgeons, should be informed urgently.
Phlebotomy and intravenous access may precipitate acute obstruction of the airway. The patient should be nursed in whatever position he or she finds most comfortable. An oxygen mask may not be tolerated and should not be forced on the patient. A calm and a reassuring approach by all staff is essential to relieve anxiety. Indirect laryngoscopy should be performed only by experienced staff, and facilities for creating a surgical airway should be immediately available if necessary.
Consider underlying malignancy
- G A Vernham
EDITOR, - M J Stuart and T J Hodgetts highlight the need to include acute epiglottitis in the differential diagnosis of adults presenting with symptoms of acute pharyngitis with or without respiratory distress.1 Fear of missing a case in children is akin to the fear of missing a case of meningitis, and consequently most doctors remain alert to the possibility of the condition. I suspect, however, that epiglottitis is more likely to be missed in adults.
Not only is it critical to diagnose acute epiglottitis early but the possibility of serious underlying disease must be considered. I became aware of an association between adult epiglottitis and malignancy when treating a patient with acute epiglottitis due to infection with Branhamella catarralis who was subsequently diagnosed as having acute myeloid leukaemia.2 There have been other reports of acute epiglottitis in patients with leukaemia,3 and Lederman et al described seven cases of pneumococcal epiglottitis, six of which were associated with some form of malignancy.4
Thus an underlying malignancy or other immunosuppressive disease5 should be suspected in cases of adult epiglottitis. This association may simply represent opportunistic infection occurring in immunocompromised patients and need not indicate a specific link. Assessment of the whole patient is, however, vitally important, even when the presenting symptoms and signs seem to be localised.