What is the function and treatment of the epiglottis?

The Epiglottis: Function and Clinical Management

Anatomical Function and Structure

The epiglottis is a glosso-laryngeal structure that serves as the primary protective mechanism preventing aspiration during swallowing by covering the laryngeal inlet. 1

• The epiglottis receives innervation from the vagus, glossopharyngeal, and hypoglossal nerves, confirming its dual glosso-laryngeal nature through both anatomical and embryological evidence 1
• In newborns, the epiglottis is positioned above the soft palate with the tongue in contact with both hard and soft palate, making infants obligate nasal breathers during the first 3-4 weeks of life 2
• During rigid bronchoscopy, the epiglottis must be lifted anteriorly with a laryngoscope to allow passage of instruments through the vocal cords 2

Clinical Pathology: Epiglottitis

Presentation and Diagnosis

Epiglottitis presents with sudden onset of severe sore throat, odynophagia (painful swallowing), and potential rapid progression to airway obstruction, making it a life-threatening medical emergency. 3

Key clinical features include:

• Odynophagia (100% of cases), inability to swallow secretions (83%), sore throat (67%), dyspnea (58%), and hoarseness (50%) 4
• Fever >37.2°C in 75% of patients and tachycardia >100 bpm in 50% 4
• Stridor is present in only 42% of cases, making it an unreliable diagnostic sign 4
• A swollen, cherry-red epiglottis is visible only on direct visualization 3

Critical Diagnostic Pitfall

Never attempt to examine the throat with a tongue depressor or swab the throat in suspected epiglottitis, as manipulation can trigger sudden complete airway obstruction. 3

• Blood cultures are the preferred diagnostic sample due to the risk of precipitating airway obstruction during direct examination 3
• 44% of patients have a normal oropharyngeal examination, and diagnosis can only be made following fiberoptic laryngoscopy 4

Mortality and Management

Adult mortality from epiglottitis remains approximately 7%, significantly higher than the 1% mortality in pediatric populations with aggressive management. 3

Management principles include:

• Immediate admission to a hospital with intensive care facilities where intubation can be performed if necessary 4
• Medical management includes antibiotics, NSAIDs, and possibly inhalation with adrenaline 4
• Maintain a low clinical threshold for airway insertion, as it is the only way to prevent death 4
• Nasotracheal intubation may be necessary in patients with airway compromise 4

Surgical Applications of the Epiglottis

Aspiration Prevention Procedures

For intractable aspiration, surgical intervention may be considered, with procedures involving the epiglottis showing variable success rates. 2

• Supracricoid partial laryngectomy involves suturing the epiglottis to the aryepiglottic folds, with 52.1% to 68.1% of patients achieving normal swallowing by the first postoperative month 2
• However, aspiration pneumonia occurred in 21.7% of patients (15 of 69), with one death from aspiration pneumonia within 3 years and a 5-year actuarial survival rate of 68% 2
• Petiole supraglottopexy, where the epiglottic petiole is plicated to the false vocal folds and interarytenoid mucosa, has been used for intractable aspiration with mixed functional outcomes 2

Reconstructive Surgery

• The epiglottis can be used effectively for one-stage laryngotracheal reconstruction through pedicled composite epiglottic flaps, free composite epiglottic grafts, or pedicled epiglottic mucosal flaps 5
• This tissue is ideal because it is native to the area, highly viable, convenient to access, expendable to the patient, and provides both epithelium and skeletal support 5

Tongue Base Reduction Procedures

• Tongue base reduction with hyoepiglottoplasty involves epiglottal verticalization and achieved 100% success rate at 6-month follow-up in severe OSA patients with macroglossia, though 30% had swallowing abnormalities 6-19 months postoperatively 2

Postoperative Complications

Supraglottic edema involving the epiglottis can occur after head and neck surgery, laryngoscopy, or intubation, with problems often not apparent until after extubation. 6

• Periglottic trauma from laryngoscopy and intubation can cause supraglottic edema 6
• Begin corticosteroid therapy (dexamethasone) at least 12-24 hours before planned extubation in high-risk patients 6
• Intravenous dexamethasone with repeated doses before and after extubation decreases stridor and reintubation risk 6