Hemorrhagic Epiglottitis: Most Common Cause
The most common cause of epiglottitis with hemorrhage is bacterial infection, historically dominated by Haemophilus influenzae type b (Hib), though in the post-vaccine era, Streptococcus and Staphylococcus species have become more prevalent etiologies. 1, 2
Primary Bacterial Pathogens
Historical Context: Haemophilus influenzae Type b
- Before widespread Hib vaccination, Haemophilus influenzae type b was the leading cause of epiglottitis, accounting for 97% of pediatric cases and 95% of adult cases 1, 3
- The introduction of Hib conjugate vaccines in the late 1980s dramatically reduced incidence by over 99% in vaccinated populations 1, 3
- In Finland, annual epiglottitis cases dropped from 50-60 cases in 1985-1986 to only 2 cases by 1992 following widespread vaccination 3
Current Era Pathogens
- In the post-vaccine era, Streptococcus and Staphylococcus bacteria are now the most common etiologies in adults, who now represent the majority of epiglottitis cases 2
- Other bacterial causes include groups C and G β-hemolytic streptococci, though these are less common 1
- Viral, fungal, caustic, thermal injuries, and autoimmune causes can also produce epiglottitis but are far less common than bacterial infection 2
Clinical Presentation and Hemorrhagic Features
Why Hemorrhage Occurs
- The epiglottis becomes massively swollen and develops a characteristic cherry-red coloring due to intense inflammation and vascular engorgement 4, 5
- The friable, inflamed tissue is prone to bleeding, particularly if manipulated during examination or intubation attempts 6, 7
- Hemorrhage can occur spontaneously from the severely inflamed tissue or be precipitated by airway manipulation 6, 7
Key Clinical Features
- Sudden onset of severe sore throat and odynophagia (painful swallowing) 4, 8
- Rapid progression to potential airway obstruction within hours 6, 4
- Adults typically present with severe dysphagia in a subacute manner, while children present more acutely with respiratory distress and fever 2
- Associated symptoms include drooling, muffled voice, dyspnea, and stridor 8, 2
Critical Management Considerations
Diagnostic Approach
- Blood cultures are the preferred diagnostic sample because direct throat examination risks precipitating complete airway obstruction 7, 4
- Never use a tongue depressor to examine the throat in suspected epiglottitis, as this can trigger sudden airway occlusion 7, 4
- Direct visualization by laryngoscopy is the gold standard for diagnosis but should only be performed with full airway management preparation 9
Immediate Airway Management
- Position the patient upright and leaning forward to optimize airway patency 7, 4
- Discuss immediately with an intensivist and prepare for emergency airway intervention 6, 7
- Assemble difficult airway equipment including videolaryngoscope, supraglottic airway devices, and surgical airway equipment before any intervention 7
- Maintain oxygenation as the primary goal without forcing the patient supine 6, 7
Mortality and Prognosis
- Adult mortality remains approximately 7%, significantly higher than the 1% mortality in pediatric populations with aggressive management 4, 9
- The higher adult mortality reflects more variable presentation patterns and potentially delayed recognition 9
- All patients require intensive care unit admission for close airway monitoring 8, 9
Common Pitfalls to Avoid
- Attempting throat examination with tongue depressors may precipitate complete airway obstruction and should be strictly avoided 6, 7
- Failing to prepare for difficult airway management before attempting intubation leads to significant complications 6
- Delaying specialist consultation (otolaryngology, anesthesiology, or intensivist) can result in catastrophic airway loss 8, 9
- Obtaining lateral neck radiographs should never supersede or postpone securing the airway, as they can be falsely negative 8, 2