What is the treatment for acute supraglottitis?

Management of Acute Supraglottitis

The treatment of acute supraglottitis requires immediate airway management, broad-spectrum antibiotics, and adjunctive therapy with corticosteroids as the cornerstones of management to prevent life-threatening airway obstruction.

Airway Management

Airway management is the most critical aspect of treatment:

• Immediate assessment of respiratory status to determine the need for airway intervention
• Secure airway based on severity:
  • For patients with severe respiratory distress, stridor, or signs of impending airway obstruction: immediate endotracheal intubation or tracheostomy in an operating room setting 1, 2
  • For patients without respiratory distress: close monitoring in an intensive care unit with equipment for emergency airway intervention readily available 2, 3

Risk factors for airway intervention:

• Presence of diabetes mellitus (significantly increases likelihood of requiring intubation) 3
• Stridor (present in 33% of cases and indicates significant airway narrowing) 3
• Progressive symptoms despite initial treatment 2

Antimicrobial Therapy

• First-line antibiotic therapy: Ceftriaxone (most commonly used inpatient antibiotic for supraglottitis) 1
• Alternative options:
  • Amoxicillin-clavulanate (covers common respiratory pathogens including Streptococcus species) 4
  • For penicillin-allergic patients: respiratory fluoroquinolones (levofloxacin, moxifloxacin) 4

Antimicrobial therapy should target the most common pathogens:

• Streptococcus species (most common identified pathogen in adult supraglottitis at 11.9%) 1
• Haemophilus influenzae (historically common but decreasing due to vaccination) 1

Adjunctive Therapy

• Systemic corticosteroids: All patients should receive systemic corticosteroids (such as dexamethasone) to reduce airway edema 1, 3

  • Corticosteroid use is associated with shorter ICU stays (≤24 hours) 3
  • Helps in symptom alleviation and hastens resolution of airway swelling 3

• Adrenaline (epinephrine) nebulization: Used in approximately 66% of cases to temporarily reduce mucosal edema 1

Monitoring and Supportive Care

• ICU admission: Most patients require ICU monitoring for at least 24 hours 2, 3
• Continuous monitoring: Pulse oximetry, respiratory rate, and work of breathing
• Positioning: Semi-upright position to optimize airway patency
• Hydration and antipyretics: Maintain adequate hydration and control fever

Special Considerations

• Diagnostic confirmation: Fiberoptic nasopharyngoscopy is the gold standard for diagnosis 3
• Imaging: Lateral neck X-ray may show the "thumb sign" (swollen epiglottis), present in 65% of cases 1
• Complications to monitor for: Ludwig's angina (severe cellulitis of submandibular, submental, and sublingual spaces) is the most frequent complication, especially in patients presenting with dysphagia and fever 1

Duration of Treatment

• Continue antibiotics for 7-10 days
• Monitor for clinical improvement (decreased pain, improved swallowing, resolution of fever)
• Consider repeat fiberoptic examination before discharge to confirm resolution of supraglottic edema

Prognosis

With appropriate and timely management, most adult patients with supraglottitis recover without complications. However, the condition remains potentially life-threatening, with approximately 46% of patients requiring endotracheal intubation and 12.7% requiring tracheostomy when intubation is not possible 1.