What are the causes and signs/symptoms of epiglottitis in a patient with a history of bleeding disorders or anticoagulant use?

Epiglottitis: Causes, Signs, and Symptoms in Patients with Bleeding Disorders or Anticoagulant Use

Causes of Epiglottitis

Epiglottitis is most commonly caused by bacterial infection, resulting in inflammation and edema of the epiglottis and surrounding supraglottic structures. 1

• Haemophilus influenzae type B (Hib) was historically the predominant pathogen in children, but with widespread Hib vaccination, adult cases now comprise the majority of epiglottitis presentations 2, 1
• Other bacterial pathogens can cause epiglottitis in adults, though the specific organisms vary 3
• The condition represents an infectious process that leads to progressive airway obstruction through inflammatory edema 1, 3

Signs and Symptoms

Cardinal Presenting Features

The classic presentation includes fever, sore throat, and evidence of impending airway obstruction. 1

• Fever is a consistent finding in acute epiglottitis 2, 1
• Sore throat or throat soreness typically precedes respiratory symptoms by days 2, 1
• Acute onset shortness of breath develops as airway compromise progresses 2

Critical Airway Obstruction Signs

Signs of impending airway obstruction include muffled voice, drooling, tripod positioning, and stridor—these mandate immediate intervention. 1

• Stridor indicates significant airway narrowing and represents a medical emergency requiring swift recognition 2, 1
• Muffled voice results from supraglottic edema 1
• Drooling occurs due to inability to swallow secretions 1
• Tripod position (sitting upright, leaning forward with neck extended) is an adaptive posture to maximize airway patency 1
• Respiratory distress manifests as tachypnea and increased work of breathing 1, 4

Diagnostic Findings

• Lateral soft tissue neck X-ray reveals the characteristic "thumb sign" (swollen epiglottis resembling a thumb) 2, 5
• In severe cases, a "double thumb sign" may be visible, indicating more extensive airway edema and warranting closer monitoring or artificial airway support 5
• Direct visualization by laryngoscopy or nasopharyngoscopy is the gold standard for diagnosis, revealing an inflamed, edematous epiglottis 2, 3

Special Considerations in Patients with Bleeding Disorders or Anticoagulant Use

Heightened Bleeding Risk During Airway Management

Patients with bleeding disorders or on anticoagulants face increased risk of hemorrhage during airway instrumentation, which can rapidly convert a manageable airway into a "cannot intubate, cannot ventilate" scenario. 6

• Airway manipulation in anticoagulated patients can precipitate airway bleeding, classified as a critical site bleed that may cause severe disability and necessitate surgical intervention 6
• Hemoptysis and hypoxia from airway bleeding can lead to hypoxemic respiratory failure and death 6
• The combination of epiglottic edema and bleeding creates a particularly dangerous situation where both obstruction and hemorrhage compromise the airway 6

Assessment Priorities

Before any airway intervention, assess hemodynamic stability and coagulation status in anticoagulated patients. 6

• Document anticoagulant or antiplatelet medication use, including type, dose, and timing of last dose 6
• Obtain PT/INR and aPTT to evaluate anticoagulant activity 6
• Assess for comorbidities contributing to bleeding risk, including thrombocytopenia, uremia, and liver disease 6
• Check for personal or family history of bleeding disorders 6

Management Modifications

In patients requiring airway intervention while anticoagulated, do NOT routinely reverse anticoagulation or transfuse platelets unless life-threatening bleeding occurs. 7, 8

• Platelet transfusion should NOT be routinely administered for patients on antiplatelet agents, as the PATCH trial demonstrated higher odds of death with platelet transfusion in antiplatelet-treated patients with intracranial hemorrhage 7, 8
• Reversal agents (such as prothrombin complex concentrates or andexanet alfa) should be reserved for major bleeding with hemodynamic instability, not used prophylactically 6, 9
• If airway instrumentation causes bleeding, apply firm sustained compression and use resorbable packing for patients with bleeding disorders or on anticoagulants 6

Critical Pitfalls to Avoid

• Do NOT delay securing the airway to reverse anticoagulation in a patient with stridor and respiratory distress—airway obstruction kills faster than bleeding 1, 3
• Do NOT perform lateral neck X-rays if they will delay airway management in a patient with obvious clinical signs of epiglottitis and impending obstruction 1
• Do NOT assume adult epiglottitis follows a benign course—mortality remains approximately 7% in adults despite being only 1% in children, partly due to underrecognition 3
• Recognize that diabetes mellitus may be a risk factor, as seen in case reports of adult epiglottitis 2

Monitoring Requirements

All patients with epiglottitis require intensive care unit admission for close airway monitoring, with this need amplified in anticoagulated patients. 1, 4

• An airway specialist (otolaryngologist, anesthesiologist, or intensivist) should evaluate the patient immediately 1
• Prepare for emergent surgical airway (cricothyrotomy or tracheotomy) as backup, particularly in anticoagulated patients where bleeding may complicate intubation 4
• Monitor for abscess formation around the epiglottis, which may require surgical drainage 4