Endgames Case Report

Acute epiglottitis

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5235 (Published 19 September 2013) Cite this as: BMJ 2013;347:f5235
  1. Robert Charles, core trainee year 2, anaesthetics,
  2. Marc Fadden, foundation year 1 trainee,
  3. Jacqueline Brook, consultant, anaesthetics
  1. 1Anaesthetic Department, Dewsbury District Hospital, Dewsbury WF13 4HS, UK
  1. Correspondence to: R Charles robertcharles{at}nhs.net

A 30 year old man presented to the emergency department with a two day history of fever, sore throat, and progressive difficulty in swallowing. He had no allergies and had taken one dose of benzylpenicillin, prescribed by his general practitioner, earlier that day. His medical history included recurrent tonsillitis, which had been treated with antibiotics; he smoked 15 cigarettes a day.

On initial examination he had tachycardia (115 beats/min) and fever (38.5°C). The remainder of his respiratory and cardiovascular examination was normal. Oropharyngeal examination showed a swollen uvula and enlarged red tonsils without pus. There was no lip or tongue swelling and no obvious rash.

Ten minutes later he developed progressively worsening stridor. He was unable to complete sentences and was drooling. His respiratory rate was 34 breaths/min and his oxygen saturation was 89% on 15 L oxygen. A wheeze was present throughout his chest. He was still tachycardic at 120 beats/min and his blood pressure had increased to 170/100 mm Hg. Administration of adrenaline nebulisers improved the stridor slightly. Blood cultures were taken and intravenous antibiotics and steroids administered. A working diagnosis of acute epiglottitis was made; an urgent anaesthetic and ear, nose, and throat (ENT) review was requested.

Questions

  • 1 What are the causes and clinical features of acute epiglottitis?

  • 2 What other inhalational therapy could be instituted to improve oxygenation?

  • 3 How should this patient be managed further?

Answers

1 What are the causes and clinical features of acute epiglottitis?

Short answer

Acute epiglottitis can be caused by bacteria (such as Haemophilus influenzae type B), viruses (such as herpes simplex), fungi (such as Candida albicans), and non-infectious insults (such as physical trauma, chemicals, and heat). Clinical features include stridor, dyspnoea, and drooling.

Long answer

Acute epiglottitis may progress rapidly into life threatening upper airway obstruction. The incidence of epiglottitis in children in the United Kingdom has fallen considerably since the implementation of the Haemophilus …

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