Acute epiglottitis in adults

Acute epiglottitis in adults is often referred to as supraglottitis as the inflammation is generally not confined to the epiglottis but can also affect supraglottic structures such as the pharynx, uvula, base of the tongue, aryepiglottic folds or the false vocal cords. Acute epiglottitis is classically described as a haemophilus influenzae type b bacterial infection of the epiglottis in children [1]. In adults only 20% of epiglottitis is caused by haemophilus influenzae [1, 2]. Recent epidemiological studies have recorded a decline in the incidence of epiglottitis in children since the haemophilus b conjugate vaccines were introduced [3, 49, 50]. In Switzerland the annual disease frequency of meningitis and epiglottits among 0–4 year olds decreased drastically by approximately 80% following the initiation of vaccination in 1990 [49]. In contrast, a steady increase in adult cases was noted (1975: 0.78/100’000; 1992: 2.9/100’000) [3, 52]. Overall mortality for adult epiglottitis is higher, (being estimated at 4–7% [4, 5]), than in children (2–3%) [3, 51], largely due to misdiagnosis and inappropriate treatment [6]. Using a well-standardised management of acute epiglottitis in children, including airway stabilisation, mortality could be reduced from 7.1 to 0.9% [15]. The use of the same management scheme in adults is the subject of controversial discussion. Acute epiglottitis can be a serious life-threatening disease because of its potential for sudden upper airway obstruction. It is a well-recognised entity in children but it is uncommon in adults and therefore is often misdiagnosed. In this retrospective study we present twelve cases of acute epiglottitis in adults. The diagnosis was made by visualisation of the epiglottis using fibreoptic laryngoscopy. The illness was managed using a standardised management protocol (see Appendix). The most frequent symptoms were odynophagia (100%), inability to swallow secretions (83%), sore throat (67%), dyspnoea (58%) and hoarseness (50%). Body temperature was elevated (>37.2 °C) in 75% and 50% of the patients had tachycardia (>100 bpm). The supposedly typical sign of stridor was found in only 42% of the cases. A routine oropharyngeal examination does not exclude epiglottitis, 44% of our patients had a normal oropharynx and the diagnosis could only be made following fibreoptic laryngoscopy. Nasotracheal intubation was necessary in four patients. A 40-year-old man with sore throat, hoarseness, cough and odynophagia was initially seen by a physician. With the suspected diagnosis of an infection-induced exacerbation of bronchial asthma, he was treated with antibiotics, paracetamol und corticosteroids. On admission six hours later the patient was in coma. The diagnosis was not made until conventional oral endotracheal intubation (without a tracheotomy set placed at the bedside) was attempted. Unfortunately the intubation failed and the patient died. Medical management of epiglottitis in adults includes antibiotics, NSAIDs and possibly inhalation with adrenaline. The maintenance of an adequate open airway is the main concern in adults as well as in children. Although most adults have no signs of airway obstruction, the clinical threshold for insertion of an airway should remain low, as it is the only way of preventing death. A high index of suspicion is needed to recognise this rare disease correctly and patients must be admitted to a hospital with intensive care facilities, where the diagnosis can be confirmed and intubation performed if necessary and thus reduce the mortality rate.