What is the progression and treatment of epiglottitis (inflammation of the epiglottis) in patients with streptococcal pharyngitis (strep throat)?

Epiglottitis Progression in Streptococcal Pharyngitis

Epiglottitis is a potentially life-threatening complication of streptococcal pharyngitis that requires immediate recognition and treatment to prevent airway obstruction and death. 1

Progression of Epiglottitis in Strep Throat

Epiglottitis represents a serious progression from standard streptococcal pharyngitis, with the following typical course:

1. Initial Phase:

   • Begins with standard strep throat symptoms (sore throat, fever)
   • Rapidly progresses to more severe symptoms within hours to days

2. Progressive Phase:

   • Odynophagia (100% of cases) 2
   • Inability to swallow secretions (83%) 2
   • Severe sore throat (67%) 2
   • Progressive dyspnea (58%) 2
   • Hoarseness (50%) 2
   • Elevated body temperature (>37.2°C) in 75% of cases 2
   • Tachycardia (>100 bpm) in 50% of cases 2

3. Critical Phase:

   • Stridor (42% of cases) - a late and ominous sign 2
   • Complete airway obstruction can occur in approximately 18% of adults with respiratory difficulty 3
   • Mortality rate of 17.6% overall, reduced to 6.4% with proper airway management 3

Diagnosis

• Direct visualization is the gold standard for diagnosis:

  • Fibreoptic laryngoscopy is preferred for adults 2
  • Lateral neck X-rays have utility but less sensitivity 1

• Important note: A normal oropharyngeal examination does not exclude epiglottitis - 44% of patients have a normal-appearing oropharynx 2

Treatment Approach

1. Airway Management (Highest Priority)

• Immediate airway assessment is critical - any signs of respiratory distress require urgent intervention
• Careful attention to the airway in a controlled intensive care environment is recommended for all suspected cases 1
• Endotracheal intubation is the safest means of securing the airway in severely affected patients 4
• Have equipment for emergency airway management readily available

2. Antimicrobial Therapy

For confirmed streptococcal epiglottitis, the following antibiotics are recommended:

• First-line treatment:

  • Penicillin V: 250 mg three times daily for 10 days (adults) 5
  • Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days 5

• For penicillin-allergic patients:

  • Clindamycin: 300-450 mg orally three times daily for 10 days 5
  • For difficult-to-eradicate cases: Clindamycin 600 mg/day in 2-4 divided doses for 10 days 6

• Alternative for recurrent/persistent cases:

  • Amoxicillin/clavulanate: 40 mg/kg/day in 3 divided doses for 10 days (maximum 750 mg of amoxicillin per day) 6

3. Supportive Care

• Analgesics for pain management:

  • Ibuprofen: 400mg every 6-8 hours (maximum 1200mg/day) for adults 5
  • Paracetamol: 500-1000mg every 4-6 hours (maximum 4000mg/day) for adults 5
  • Avoid aspirin in children due to risk of Reye syndrome 5

• Maintain hydration with plenty of fluids 5

Warning Signs Requiring Immediate Intervention

• Stridor
• Inability to swallow secretions
• Respiratory distress
• Sitting in tripod position
• Drooling
• Muffled voice

Common Pitfalls and Caveats

1. Misdiagnosis: Epiglottitis in adults is often misdiagnosed due to its rarity and variable presentation 2

2. Delayed intervention: Waiting for stridor is dangerous as it's a late sign - by then, complete obstruction may be imminent 2

3. Inadequate examination: Routine oropharyngeal examination can miss epiglottitis; fiberoptic laryngoscopy is essential when suspected 2

4. Underestimating severity: Adult epiglottitis, while often milder than pediatric cases, still carries a 7% mortality rate 1

5. Inappropriate airway management: Attempting conventional oral endotracheal intubation without preparation for emergency tracheostomy can be fatal 2

6. Inadequate monitoring: All patients with suspected epiglottitis require admission to a hospital with intensive care facilities for close monitoring 2

Remember that while Group A Streptococcus (S. pyogenes) is a documented cause of epiglottitis, it's relatively uncommon compared to H. influenzae as the causative organism 3. However, when epiglottitis occurs in the context of streptococcal pharyngitis, aggressive treatment is essential due to the potentially rapid progression to airway compromise.