How to manage epiglottitis symptoms in a patient?

Management of Epiglottitis

Epiglottitis is a life-threatening emergency requiring immediate airway assessment and management in an intensive care setting, with blood cultures for diagnosis (avoiding direct epiglottic manipulation) and empiric intravenous antibiotics targeting Haemophilus influenzae. 1, 2, 3

Immediate Airway Management

The maintenance of an adequate open airway is the primary concern and takes absolute priority over all other interventions. 3, 4

• Do NOT attempt to swab or directly manipulate the epiglottis during initial assessment, as this can precipitate sudden complete airway obstruction. 1
• Blood cultures are the preferred diagnostic specimen for epiglottitis; if visualization is attempted, it must be performed in a controlled setting with emergency airway equipment immediately available. 1
• The clinical threshold for securing an airway should remain low, as this is the only way to prevent death—even in adults who may initially appear stable. 3, 4
• Nasotracheal intubation should be performed by experienced personnel in a controlled environment (operating room or ICU) with tracheotomy equipment at bedside. 3, 5
• Respiratory distress, stridor, inability to swallow secretions, or any signs of airway compromise mandate immediate airway intervention. 2, 3, 4

Critical Warning Signs Requiring Immediate Intubation:

• Stridor (present in only 42% of cases, so its absence does not exclude severe disease). 3
• Inability to swallow secretions (83% of cases). 3
• Dyspnea (58% of cases). 3
• Sitting upright, leaning forward, drooling. 2, 5

Diagnostic Approach

Direct visualization by fiberoptic laryngoscopy is the gold standard for diagnosis and should be performed in a controlled setting with airway management capabilities. 2, 3

• Lateral neck radiography can support the diagnosis but has lower sensitivity than direct visualization. 2, 6
• A normal oropharyngeal examination does NOT exclude epiglottitis—44% of patients have normal oropharynx findings. 3
• The classic presentation includes odynophagia (100% of cases), sore throat (67%), hoarseness (50%), and fever >37.2°C (75%). 3

Common Diagnostic Pitfall:

Epiglottitis is frequently misdiagnosed in adults because symptoms may be attributed to more common conditions like pharyngitis or asthma exacerbation, leading to delayed recognition and potentially fatal outcomes. 3, 6

Medical Management

All patients require admission to an intensive care unit with continuous monitoring and immediate access to emergency airway equipment. 3, 4

Antibiotic Therapy:

• Initiate empiric intravenous antibiotics immediately, targeting Haemophilus influenzae type B (the primary causative organism). 6, 5
• Ampicillin plus chloramphenicol is the traditional regimen, though third-generation cephalosporins are now commonly used. 6, 5
• Continue antibiotics until clinical improvement and resolution of airway swelling. 5

Adjunctive Therapies:

• Humidified oxygen should be administered to all patients. 6
• Nebulized adrenaline (racemic epinephrine) may provide temporary relief and has prevented the need for intubation in some cases. 4
• NSAIDs for symptom control. 3
• Corticosteroids remain controversial with no definitive evidence supporting routine use, though many clinicians employ them. 6, 4

Prognosis and Mortality

Adult mortality from epiglottitis remains approximately 7%, significantly higher than the 1% mortality in children with aggressive management. 2

• The more variable presentation in adults (often milder initially) can lead to false reassurance and delayed intervention. 2, 6
• Death typically results from sudden complete airway obstruction or failed emergency intubation attempts. 3
• Any clinical suspicion of epiglottitis warrants an aggressive approach until the diagnosis is ruled out or the patient is clearly recovering. 2

Management Protocol Summary

1. Suspect epiglottitis in any patient with severe odynophagia and sore throat out of proportion to pharyngeal findings. 6
2. Immediately transfer to ICU with airway management capabilities; do NOT send for imaging alone. 3, 4
3. Obtain blood cultures; avoid direct epiglottic manipulation. 1
4. Perform fiberoptic laryngoscopy in controlled setting with intubation equipment ready. 2, 3
5. Secure airway early if any signs of respiratory compromise. 3, 4
6. Initiate IV antibiotics targeting H. influenzae immediately. 6, 5
7. Provide humidified oxygen and consider nebulized epinephrine. 6, 4