From the Guidelines
Thermal burns to the epiglottis are medical emergencies that require immediate attention and securing the airway as the top priority, with indications for urgent intubation including dyspnoea, desaturation, and stridor. The management of thermal burns to the epiglottis involves a complex decision-making process, and obtaining specialist advice early from a burns centre is recommended 1. Patients with thermal epiglottic burns may present with classic features of thermally-induced potential airway obstruction, including hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum, soot in the airway, singed facial or nasal hairs, or a history of confinement in a burning environment. However, clinical signs lack sensitivity and are unreliable predictors of the requirement for intubation 1.
Some key considerations in the management of thermal epiglottic burns include:
- Normal nasendoscopic mucosal appearance is reassuring and nasendoscopy can be repeated at intervals or if there is clinical deterioration 1
- Dyspnoea, desaturation, and stridor are indications for urgent intubation 1
- Awake intubation is an option in this group, but requires cooperative, stable patients with minimal airway soot and swelling 1
- Modified RSI is usually the most appropriate technique, and succinylcholine should be avoided from 24 h post-injury to avoid hyperkalaemia 1
- An uncut tracheal tube should be used to allow for subsequent facial swelling, and a gastric tube should be inserted after securing the airway 1
In terms of specific management strategies, patients managed conservatively should be observed in a high-dependency area, nursed head-up, and remain nil-by-mouth, with regular reassessment to detect deterioration early 1. Additionally, large volume fluid resuscitation should be avoided as it can worsen airway swelling 1. Overall, the management of thermal epiglottic burns requires a careful and nuanced approach, with a focus on securing the airway and preventing further complications.
From the Research
Thermal Burns and Epiglottis
- Thermal epiglottitis is a rare but potentially life-threatening disease that can result from thermal burns, including steam inhalation 2.
- The clinical presentation of thermal epiglottitis can be atypical, with a slow onset and lack of obvious oropharyngeal signs of thermal injury, making diagnosis challenging 2.
- A thorough history and physical examination, along with a high level of suspicion, are crucial in diagnosing thermal epiglottitis and preventing catastrophic airway obstruction 2.
Diagnosis and Management
- Epiglottitis, including thermal epiglottitis, typically presents with symptoms such as fever, sore throat, muffled voice, drooling, tripod position, and stridor 3.
- Radiographs can be helpful in diagnosing epiglottitis, but should not delay securing the airway 3.
- An airway specialist should ideally evaluate the patient immediately to prepare for potential airway securing 3.
- Intubation criteria for patients with thermal burns include full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability, suspected smoke inhalation, and singed facial hair 4.
- In adult epiglottitis, dyspnea and supraglottic edema extension are suggestively associated with the need for intubation 5.
Smoke Inhalation Injury
- Smoke inhalation injury can contribute to upper airway thermal burns, inflammation, and systemic effects, increasing morbidity and mortality 6.
- Diagnosis of smoke inhalation injury is mostly clinical, aided by bronchoscopy and other supplementary tests, and management remains mostly supportive 6.
- Clinicians should maintain a high index of suspicion for concomitant traumatic injuries and monitor patients closely for airway compromise 6.