Treatment of High Rising Epiglottitis Without Symptoms of Strep
High rising epiglottitis requires immediate airway management through endotracheal intubation or tracheostomy, followed by broad-spectrum antibiotics (typically covering Haemophilus influenzae), regardless of the absence of streptococcal symptoms. 1, 2
Immediate Management
Airway Assessment and Intervention
- Presence of stridor indicates a compromised airway requiring immediate intervention 1
- Options for securing the airway include:
- Mortality rates are similar between intubation (0.92%) and tracheostomy (0.86%), but significantly higher with medical management alone (6.1%) 4
Medication Management
- Systemic corticosteroids (dexamethasone) to reduce inflammation 1
- Broad-spectrum antibiotics targeting common pathogens:
- In adults, there is greater diversity in causative organisms than in children 1
- Coverage should include Haemophilus influenzae, which has historically been the most common cause 3, 2
- Appropriate antibiotics include:
- Amoxicillin-clavulanate
- Third-generation cephalosporins
- Clindamycin (for penicillin-allergic patients) 5
Clinical Pearls and Pitfalls
Warning Signs Requiring Vigilance
- Odynophagia (100% of cases)
- Inability to swallow secretions (83%)
- Sore throat (67%)
- Dyspnea (58%)
- Hoarseness (50%)
- Stridor (42%) - a late but critical sign 2
Important Cautions
- A normal oropharyngeal examination does NOT exclude epiglottitis - 44% of patients have a normal-appearing oropharynx 2
- Diagnosis requires visualization of the epiglottis via fibreoptic laryngoscopy 2
- Never attempt conventional oral endotracheal intubation without having a tracheostomy set immediately available 2
- The "watch and wait" approach should be abandoned as it significantly increases mortality 3
Hospital Management
- All patients must be admitted to a hospital with intensive care facilities 2
- Average duration of artificial airway management is 2-3 days 3
- Typical hospital stay is 6-7 days 3
- Supportive care includes:
- Analgesics for pain management
- Maintaining hydration
- Monitoring for signs of deterioration 5
Epiglottitis remains a potentially fatal condition that requires rapid diagnosis and intervention. The absence of streptococcal symptoms does not change the urgency or approach to management, as the primary concern is maintaining an adequate airway regardless of the causative organism.