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Respiratory System

Acute Epiglottitis

A rapidly progressive bacterial infection causing inflammation and swelling of the epiglottis and surrounding supraglottic structures, potentially leading to life-threatening airway obstruction. Primarily affects young children, but incidence significantly reduced by Hib vaccination. Still occurs in unvaccinated individuals and occasionally in adults.

Also known as: Supraglottitis

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Referral and warning signs

When to refer

IMMEDIATE URGENT referral/transfer to hospital (H/RR) with capabilities for paediatric airway management (paediatric anaesthesia/ENT/ICU) for ALL suspected cases. This is a life-threatening emergency.

Red flags

  • Rapid onset fever, sore throat, difficulty swallowing
  • Drooling
  • Stridor
  • Tripod/Sniffing position
  • Muffled voice
  • Toxic appearance, anxiety, air hunger

Signs and symptoms

  • Rapid onset (hours) of high fever.
  • Severe sore throat.
  • Dysphagia (difficulty swallowing), Odynophagia (painful swallowing).
  • Drooling.
  • Muffled voice ('hot potato voice').
  • Inspiratory stridor.
  • Respiratory distress, anxiety, air hunger.
  • Characteristic 'tripod' or 'sniffing' position (sitting upright, leaning forward, neck extended, chin thrust out, mouth open).
  • Patient often appears toxic, anxious, and acutely ill.

Risk factors

  • Lack of Haemophilus influenzae type b (Hib) vaccination.
  • Age 2-6 years (historically), but can occur at any age.
  • Immunodeficiency.

Diagnosis

Clinical assessment

Clinical diagnosis based on high index of suspicion in a patient with rapid onset fever, sore throat, drooling, stridor, and characteristic posture. DO NOT attempt to visualize the epiglottis with a tongue depressor in a suspected case outside a controlled setting (e.g., operating room) - can precipitate complete airway obstruction. Lateral neck X-ray may show classic 'thumb sign' (swollen epiglottis) but should not delay management if unstable. Definitive diagnosis via direct laryngoscopy in controlled setting (OR). Differential diagnosis: Croup (usually viral, barking cough, slower onset, less toxic), Bacterial tracheitis, Retropharyngeal/Peritonsillar abscess, Foreign body aspiration, Angioedema.

Investigations

  • Direct Laryngoscopy (in OR): Visualizes swollen, cherry-red epiglottis. Allows for intubation.
  • Lateral Neck X-ray: May show 'thumb sign'. Perform only if stable and doesn't delay airway management.
  • Blood cultures, Epiglottic cultures (after airway secured): Identify causative organism (often H. influenzae type b, also Strep. pneumoniae, Staph. aureus, Group A Strep).

Diagnostic criteria

Strong clinical suspicion is paramount. Definitive diagnosis by visualization of swollen epiglottis.

Management

Non-pharmacological management

  • Airway Management is the TOP priority - Treat as Medical Emergency.
  • - Keep patient (especially child) calm, allow position of comfort (often tripod). Avoid agitation.
  • - Minimize procedures (e.g., IV attempts, throat exam) until airway secured.
  • - Administer humidified oxygen.
  • - Prepare for immediate intubation (ideally in OR by experienced personnel - anaesthesia/ENT). May require smaller ETT size. Tracheostomy equipment should be available.
  • - Once airway secured, obtain cultures (blood, epiglottis).
  • - Admit to ICU/HDU setting.

Pharmacological treatment

  • Antibiotics: Start IV antibiotics immediately after securing airway/obtaining cultures.
  • - Ceftriaxone 50-100 mg/kg/day IV (max 2-4g/day) OR Cefotaxime.
  • - Chloramphenicol is an alternative if cephalosporins unavailable/contraindicated.
  • - Continue IV antibiotics until clinically improved, then consider switch to oral course (e.g., Amoxicillin/Clavulanate, Cefuroxime axetil) to complete 7-10 day total course based on sensitivities.
  • Corticosteroids: Role uncertain, may be considered to reduce inflammation (e.g., Dexamethasone) but airway management remains key.
  • Racemic Epinephrine Nebulization: Generally NOT effective or recommended.

Monitoring

  • Continuous monitoring of respiratory status, oxygen saturation, vital signs.
  • Monitor for signs of airway obstruction relief after intubation/treatment.
  • Monitor clinical response to antibiotics.

Complications

  • Sudden complete airway obstruction
  • Respiratory arrest
  • Death
  • Epiglottic abscess
  • Pneumonia
  • Meningitis, sepsis (if bacteraemia)
  • Pulmonary oedema (post-obstructive)

Prevention

  • Haemophilus influenzae type b (Hib) vaccination (part of routine childhood immunization schedule - Pentavalent vaccine).
  • Rifampicin prophylaxis for close household/daycare contacts if index case caused by Hib (consult guidelines).

Patient education

  • (Usually to parents/guardians) Explain the critical nature of the illness and the need for immediate airway management.
  • Explain procedures (intubation, antibiotics).
  • Discuss Hib vaccination status and importance.
  • Explain potential need for contact prophylaxis.

Uganda-specific notes

Incidence drastically reduced due to Hib vaccine in Pentavalent. Still consider in unvaccinated/partially vaccinated children or adults. Requires immediate recognition and transfer to facility capable of securing airway. Avoid examining throat.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 5, Section 5.2.4

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