What are the approach considerations in the workup of epiglottitis?

Updated: Apr 28, 2020
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Answer

Airway management is the most urgent consideration, and patients should first be assessed for level of distress before any other workup. Adults generally present in a less acute fashion than children. [4] Ensure that an anesthesiologist and an otolaryngologist are available. Patients may deteriorate precipitously, and airway equipment, including that for cricothyrotomy, should be present at the patient's bedside. Some authors have attempted to grade degrees of epiglottitis severity to guide treatment, and this is a practical approach.

Radiographic evaluation for suspected epiglottitis is being replaced by direct visualization of the epiglottis using nasopharyngoscopy/laryngoscopy as the preferred method of diagnosis. Only 79% of epiglottis cases are diagnosed by neck soft-tissue radiographs, underscoring the importance of direct visualization by fiberoptic endoscopy in obtaining a timely and accurate diagnosis.

Unstable patients

A patient in extremis requires immediate airway management. Signs and symptoms associated with a need for intubation include respiratory distress, airway compromise on examination, stridor, inability to swallow, drooling, sitting erect, and deterioration within 8-12 hours.

Enlarged epiglottis (thumb sign) on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach.

Intubation, or immediate formal tracheostomy or cricothyrotomy, may be performed in the operating room. Needle-jet insufflation (also known as percutaneous transtracheal jet ventilation [PTJV]) may be considered to ventilate the patient temporarily. [5]

In cases of initial failure to intubate by direct laryngoscopy, PTJV may facilitate success in subsequent attempts at tracheal intubation by direct laryngoscopy. PTJV can produce high intratracheal pressures that appear to lift up and open the glottis, with escape of the pressurized gasses causing the glottis edges to flutter, thereby allowing improved identification of the glottic aperture.

Stable patients

Patients without signs of airway compromise, respiratory difficulty, stridor, or drooling, and those who have only mild swelling on laryngoscopy, may be managed without immediate airway intervention by close monitoring in the intensive care unit (ICU). Because of the rapidity with which airway obstruction can occur in these patients, repeat serial evaluations of airway patency and maintenance of a low clinical threshold for airway placement are indicated.

Laryngoscopy is recommended before extubation. An ear, nose, and throat (ENT) specialist and an anesthesiologist should be immediately available at all times.


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