What You Might Not Know About Epiglottitis – Closing the Clinical Knowledge Gap

Andrea Eberly, MD, MS, FAAEMEmergency Medicine, Family Medicine, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Emergency Medicine, Pediatric Medicine, Personal Education, Physician Assistant, Urgent Care

Epiglottitis - What you may not know about epiglottitis

Epiglottitis - Closing Clinical Knowledge Gaps

When You Might Not Know About Epiglottitis

All clinicians learn that patients with severe epiglottitis accompanied by drooling, and tripod positioning  are in grave danger of sudden airway collapse and cardiac arrest. These patients (usually pediatric) should be transported as rapidly as possible to a controlled operation room environment for advanced definitive airway management. Due to the risk of imminent airway collapse, they should most definitely not undergo a quick exploratory look of their epiglottis in the emergency department.

Typically, medical training does not address the management of a different category of the disease – non-life threatening epiglottitis in a stable adult, in which quick-look laryngoscopy is part of the diagnostic work-up. Skipping it has led to missed diagnoses and avoidable liability.

Adult epiglottitis is becoming more common, with the milder, stable cases most often misdiagnosed as  "strep throat". This misdiagnosis leads to discharge with a prescription of ineffective oral antibiotics (covering streptococci) rather than admission to the ICU with IV antibiotics covering H. influenza (the most likely pathogen in adult epiglottitis). Possibly due to the rate of missed diagnosis of milder cases, adult mortality from epiglottitis is HIGHER than that of children.

The literature states that in stable patients (no respiratory distress, drooling or tripod position) with significant throat pain and a muffled voice and normal (red flag!) visual exam of the retropharynx, some type of direct assessment of the epiglottis is necessary. 

Put differently: a  STABLE* patient with severe odynophagia/dysphagia and a muffled voice who has a normal retropharynx (key red flag!) upon simple visual inspection should not be diagnosed as having strep throat until the epiglottis has been visualized one way or the other.

A lateral neck x-ray will suggest the diagnosis in 79 - 90% of stable patients with a sore throat and epiglottitis. If the x-ray is normal or non-diagnostic but epiglottitis is in the differential, a direct bedside look at the peri-epiglottic area with the laryngoscope is recommended (as a matter of fact, some authors recommend that direct laryngoscopy should replace the x-ray in stable patients with possible epiglottitis) and non-difficult airway anatomy (Mallampati class I or II).

For the bedside laryngoscopic look, Rosen’s (2018) recommends a conscious sedation procedure with setup for a rescue airway. In many hospitals, the anesthesia team will execute this bedside procedure. If a quick-look at the epiglottis shows that the supraglottic/epiglottic area is swollen and erythematous, the patient should be admitted (usually to the ICU) and empiric intravenous antibiotics such as cefotaxime or ceftriaxone that cover Hemophilus influenzae should be initiated until cultures return. The quick-look may rarely also reveal other surprise diagnoses such as a deep-seated abscess. Sometimes, the epiglottis can be directly visualized upon deep inspection of the larynx (see image).

Figures:

Direct visualization of a normal epiglottis
Figure 1. Direct visualization of a normal epiglottis

Mild to moderate epiglottitis; patient usually appears stable
Figure 2. Mild to moderate epiglottitis; patient usually appears stable

(A) normal airway (B) life-threatening epiglottitis
Figure 3. (A) normal airway  (B) life-threatening epiglottitis

Closing the Gap:

Shifting from anticipating a quick discharge to initiating laryngoscopy in an awake, stable* adult with a sore throat does not come easily to most busy clinicians. The bottom line is to monitor for a cognitive bias when seeing stable adults with sore throats in order to not miss early adult epiglottitis with a subsequent fatal outcome.

*A stable patient is defined as an alert and oriented patient with stable vital signs, no respiratory distress, no drooling, and no need for tripod-positioning to facilitate breathing. 

Review – Adult Epiglottis:

In adults, the term supraglottitis would capture the disease process better because the epiglottis itself may be normal in the setting of severe supraglottic swelling that may involve the base of the tongue, vallecula, aryepiglottic folds, arytenoid soft tissues, and the lingual (not the pharyngeal!) tonsils. Though a variety of viral and bacterial disease agents may be the culprit, Hemophilus influenza continues to be associated with the most severe disease process in adults.

Rarely, an epiglottic abscess may be present, in which case  Streptococcus and Staphylococcus species are the predominant organisms. Occasionally, epiglottitis may also be secondary to thermal injury. The disease occurs slightly more frequently in males, has no seasonal peak, and does not involve infraglottic structures.

Usually, patients have experienced a prodromal upper respiratory tract infection that may have started anywhere from a few hours to 7 days before presenting to the health care system. At the time of presentation, classic signs and symptoms are dysphagia, odynophagia, and a muffled or "hot potato" voice (similar to the hot potato voice of peritonsillar abscess, and different from the duck quack muffled voice of retropharyngeal abscesses).

Although some patients present with simultaneous pharyngeal pathology, including pharyngitis, tonsillitis, peritonsillar abscess, and deep space infections, the majority of patients with epiglottis have no oropharyngeal findings on exam, making it important to maintain a high degree of suspicion for epiglottitis in any patient presenting with a muffled voice, dysphagia, and odynophagia and a normal exam. 

Drooling and dysphonia are signs of imminent airway collapse. The sniffing position is the last sign to appear immediately before respiratory arrest. These patients must be brought to an operating room for advanced definitive airway management.

Pearl:

In the classroom, Hot Potato Voice is often taught to be associated with peritonsillar abscess. This leads to a missed diagnosis in the clinical setting when the hot potato voice is due to something other than a peritonsillar abscess.

All of the following space-occupying lesions can present with a Hot Potato Voice:

  1. Lymphoid masses
  2. Quinsy – peritonsillar cellulitis or abscess
  3. Epiglottitis
  4. Tumors of vallecula between the epiglottis and the base of the tongue
  5. Lingual thyroid gland
  6. Foreign body

Hoarseness, on the other hand, is typically ABSENT in epiglottitis.

In a patient that presents with hoarseness, laryngitis is the more likely diagnosis.

References:

Melio RM. Upper Respiratory Tract Infections (Chapter 65).  In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 857-870.e1.

Gompf SG. Epiglottitis Workup. (Updated April 28, 2020) (Accessed December 22, 2020).

Lindquist B, Zachariah S, Kulkarni A. Adult Epiglottitis: A Case Series. Perm J. 2017. 21

Bellis M, Herath J, Pollanen MS. Sudden Death Due to Acute Epiglottitis in Adults: A Retrospective Review of 11 Postmortem Cases. Am J Forensic Med Pathol. 2016 Dec. 37 (4):275-8.

A. Ames, V. M. M. Ward, R. M. D. Tranter, M. Street.Adult epiglottitis: an under‐recognized, life‐threatening condition.BJA: British Journal of Anaesthesia, Volume 85, Issue 5, 1 October 2000, Pages 795–797, 

Epomedicine. Hot Potato Voice [Internet]. Epomedicine; 2017 Oct 28 [cited 2020 Dec 17]. Discussion of hot potato voice with a YouTube example of a hot potato voice (in this case, from a peritonsillar abscess)


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