What is the treatment for acute epiglottitis?

Treatment of Acute Epiglottitis

Acute epiglottitis requires immediate airway management and antibiotic therapy, with hospitalization in an intensive care setting for all patients due to the risk of sudden airway obstruction.

Clinical Presentation and Diagnosis

• Common symptoms include:

  • Odynophagia (painful swallowing) - present in 100% of cases 1
  • Inability to swallow secretions (83%) 1
  • Sore throat (67%) 1
  • Dyspnea (58%) 1
  • Hoarseness (50%) 1
  • Fever (>37.2°C) in 75% of cases 1
  • Tachycardia (>100 bpm) in 50% of cases 1
  • Stridor (only 42% of cases) 1

• Diagnosis:

  • Visualization of the epiglottis using flexible fiberoptic laryngoscopy is essential 1, 2
  • Note: Routine oropharyngeal examination may be normal in up to 44% of cases 1
  • Blood cultures should be obtained before starting antibiotics

Airway Management Algorithm

1. Initial Assessment:

   • Evaluate for signs of respiratory distress: stridor, oxygen desaturation, dyspnea
   • If present, prepare for immediate airway intervention 3

2. Airway Management Decision:

   • Severe respiratory distress: Immediate airway intervention (intubation or tracheostomy) 1, 4
   • Mild to moderate symptoms without respiratory distress: Close monitoring in ICU with equipment for emergency airway management readily available 4

3. Intubation Considerations:

   • Should be performed in an operating room setting
   • Equipment for emergency tracheostomy must be immediately available
   • Performed by the most experienced airway specialist available
   • Avoid examination or manipulation of the epiglottis before being prepared for definitive airway management 5

Antibiotic Therapy

• First-line treatment:

  • Broad-spectrum IV antibiotics covering Haemophilus influenzae type B and other common respiratory pathogens 6
  • Recommended regimens:
    • Ceftriaxone or cefotaxime plus vancomycin
    • Alternative: Ampicillin-sulbactam or amoxicillin-clavulanate

• Duration:

  • IV antibiotics until clinical improvement
  • Total course of 7-10 days 7
  • Can transition to oral antibiotics when clinically stable 7

Adjunctive Therapy

• Corticosteroids to reduce inflammation (dexamethasone or methylprednisolone)
• Nebulized epinephrine for temporary relief of airway edema
• IV fluids for hydration
• Antipyretics for fever control
• Humidified oxygen as needed

Monitoring and Hospital Course

• All patients should be admitted to an ICU setting for at least 24 hours 4

• Continuous monitoring of:

  • Oxygen saturation
  • Respiratory rate and pattern
  • Heart rate
  • Blood pressure
  • Level of consciousness

• Clinical improvement typically occurs within 24-48 hours of appropriate therapy

• Patients can be transferred to regular ward when:

  • No respiratory distress for >24 hours
  • Able to tolerate oral intake
  • Afebrile for >24 hours

Special Considerations

• Adult epiglottitis can be more unpredictable than pediatric cases 2
• Even patients with initially mild symptoms can deteriorate rapidly 3
• The threshold for airway intervention should remain low 1
• Mortality is primarily associated with airway obstruction and delayed diagnosis 1

Prevention

• Haemophilus influenzae type B vaccination has reduced incidence in children but adult cases still occur
• Healthcare workers with epiglottitis should be excluded from work until 24 hours of appropriate treatment and resolution of symptoms 7

Remember that acute epiglottitis is a medical emergency that requires prompt recognition and treatment to prevent potentially fatal airway obstruction.