Acute Epigottitis

Hemophilus influenzae type B REF: P L Dhingra 4th edition page 266, 399

“Acute epiglottitis in children is caused by Hemophilus influenzae type B. It produces a typical “Thumb sign” on lateral X-ray film. Ampicillin was considered the drug of choice but now many organisms have become resistant to it and ceftriaxone is preferred”

“It is a serious condition and affects children of 2-7 years of age but can also affect adults H. influenzae B is the most common organism responsible for this condition in children”

DIFFERENCES BETWEEN ACUTE EPIGLOTTITIS AND ACUTE LARYNGO-TRACHEO­BRONCHITIS IN CHILDREN:

Haemophilus

Thumb sign is typically seen in acute epiglottitis due to swollen epiglottis.

It is better appreciated in lateral view of neck.

Normally, the epiglottis is quite thin in the anteroposterior (AP) dimension, resembling a little finger, whereas the abnormal, inflamed epiglottis appears shorter and has an increased AP dimension, resembling a thumb.

Acute epiglottitis is usually caused by infection with H influenzae type B.

Ans. is ‘a’ i.e., Chancroid; ‘c’ i.e., Acute epiglottitis

Ans. is `b’ i.e., Haemophilus influenzae type b

“In published case series, it is almost always caused by Haemophilus influenzae type B”. – CPDT

Epiglottitis

• It is the inflammation of epiglottis with inflammatory edema of hyopharynx.

o It is a true medical emergency.

o H.influenzae is the most common causative organism.

o Other organisms are —> Pneumococci, Streptococcus pyogenes, N.meningitidis, Staphylococcus

Clinical manifestations

• Onset is sudden
• Symptoms are —-> fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis and soft stridor.

o Patients often sit in sniffing dog position.

o Respiratory arrest may occur.

Imaging

• “Cherry red” swollen epiglottis by laryngoscope.

o Radiograph —> “Thumbprint” sign. Treatment

o Immediate endotracheal intubation.

o IV antibiotics to cover H.influenzae.

Though the introduction of Hib vaccine has reduced the annual incidence of acute epiglottitis but still most of the pediatric cases seen today are due to haemophilus influenzae B. —Harrison 17th/ed p212

In adults it can be caused by group A streptococcus, S. pneumoniae, S. aureus and Klebsiella pneumoniae

In epiglottis: A plain lateral soft tissue radiograph of neck shows the following specific features

• Thickening of the epiglottis—the thumb sign
• Absence of a deep well-defined vallecula—the vallecula sign

Steeple sign i.e. Narrowing of subglottic region is seen in chest X-ray of patients of laryngotracheobronchitis (i.e. croup).

Acute Epiglottitis         

• Respiratory arrest is more likely in patients with rapidly progressive disease arid occurs within hours of onset of the illness
• Other complications are rare but include epiglottic abscess, pulmonary edema secondary to relieving airway obstruction and thrombosis of internal jugular vein (Lemierre’s syndrome)
• The main complication is death from respiratory arrest due to acute airway obstruction

• Ampicillin or third generation cephalosporin are effective against H. influenzae and are given by parenteral route. – Dhingra 5/e, p 308
• According to Harrison DOC are:

Ampicillin + Sulbactam (Not ampicillin alone)

Cefuroxime

Cefotaxime

Ceftriaxone

• According to Scott’s Brown 7/ed vol-2 pg-2251

The antibiotics of choice are second and third generation cephalosporin. Ampicillin was often prescribed but resistant H.influenza are now emerging

• According to Turner 10/e, p 390 

Chloramphenicol is the antibiotic of choice and it should be given intramuscularly or preferably intravenously. Amoxycillin or ampicillin is no longer advised as haemophilus organism are now sufficiently often resistant to make its use inappropi­rate.

Treatment of epiglottitis

• Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately.
• After an airway is established, cultures of the blood and epiglottis should be obtained and patient started on appropriate intravenous antibiotics to cover H. influenzae (Ceftriaxone or equivalent cephalosporins).

Third generation cephalosporins are preferred as first line agents because of increasing resistance to ampicillin. Ceftriaxone is the treatment of choice for epiglottitis.

Other antibotic options are :-

• Ampicillin plus sulbactam
• Cefuroxime
• Clindamycin
• Chloramphenicol
• Cefotaxime

Intravenous antibiotics should be continued for 2-3 days, followed by oral antibiotics to complete a 10 days course.