Can acute epiglottitis present with a granulomatous appearance?

Can Epiglottitis Present with a Granulomatous Appearance?

Acute epiglottitis itself does not present with a granulomatous appearance—it is an acute bacterial cellulitis of the supraglottic structures caused predominantly by Haemophilus influenzae type B, Staphylococcus aureus, or beta-hemolytic streptococci, characterized by rapid-onset inflammation and edema, not granuloma formation. 1, 2, 3, 4

However, if you are visualizing granulomatous-appearing tissue in the epiglottic or supraglottic region, you must consider an entirely different differential diagnosis of chronic granulomatous diseases affecting the upper airway.

Understanding Acute Epiglottitis Pathology

• Acute epiglottitis is a fulminating bacterial infection causing cellulitis of the epiglottis and aryepiglottic folds with acute inflammation, edema, and variable suppuration—not granulomatous inflammation. 2, 3
• The typical pathogens are H. influenzae type B (historically most common in children), beta-hemolytic streptococci (53% in one adult series), and S. aureus—all causing acute pyogenic infection. 1, 4
• On direct visualization, acute epiglottitis appears as a swollen, edematous, cherry-red epiglottis with surrounding supraglottic edema, not as granular, nodular, or granulomatous tissue. 3, 5

Granulomatous Diseases That Can Affect the Epiglottis/Supraglottis

If you are seeing granulomatous-appearing lesions in the supraglottic region, consider these conditions:

Infectious Granulomatous Diseases

• Tuberculosis can cause granulomatous lesions in the larynx and supraglottis, presenting with ulceration, necrosis, or hyperplastic mucosa. 1
• Fungal infections (histoplasmosis, blastomycosis, coccidiomycosis) may cause granulomatous nasal and laryngeal lesions with ulceration and crust formation. 1
• Syphilis can produce granulomatous inflammation in the upper airway. 1
• Rhinoscleroma (Klebsiella rhinoscleromatis) presents as a polypoid granulomatous mass with epistaxis and obstruction. 1
• Leprosy may cause granulomatous nasal and upper airway lesions. 1

Non-Infectious Granulomatous Diseases

• Granulomatosis with polyangiitis (GPA, formerly Wegener's) causes necrotizing granulomatous vasculitis of the upper and lower respiratory tract, with friable, granular nasal mucosa covered with crust and blood on endoscopy. 1
  • Subglottic stenosis occurs in 16% of GPA patients and may present with dyspnea, hoarseness, or stridor. 1
  • The nasal mucosa appears granular and friable, not the acute edematous appearance of bacterial epiglottitis. 1
• Sarcoidosis can involve the upper respiratory tract with non-caseating granulomas, causing nasal obstruction, crusting, and nodular mucosal thickening on CT. 1
  • Nasal biopsy in sarcoidosis shows non-caseating granulomas (91% positive if mucosa appears abnormal). 1
  • Respiratory involvement occurs in <10% of sarcoid cases, with chronic cough being the most frequent symptom. 1

Critical Diagnostic Algorithm

When evaluating supraglottic pathology:

1. Acute presentation (<48 hours) with fever, severe odynophagia, drooling, stridor, and cherry-red swollen epiglottis = acute bacterial epiglottitis. 6, 3, 5

   • Obtain blood cultures immediately; never use tongue depressor or throat swab. 1, 6
   • Position patient upright and prepare for emergency airway management. 6, 3

2. Chronic presentation (weeks to months) with granular, nodular, friable, or ulcerated tissue = consider granulomatous disease. 1

   • Obtain tissue biopsy with special stains for acid-fast bacilli (tuberculosis), fungi, and histopathologic examination for granulomas. 1
   • Send cultures for mycobacteria and fungi. 1
   • Check c-ANCA/PR-3 for GPA, serum ACE for sarcoidosis. 1

3. Unilateral lesions with ulceration, necrosis, or polypoid appearance = exclude neoplasia first, then consider infectious granulomatous disease. 1

Key Pitfalls to Avoid

• Do not confuse chronic granulomatous inflammation with acute epiglottitis—the time course, appearance, and pathophysiology are completely different. 1, 2, 3
• Do not biopsy suspected acute epiglottitis—this can precipitate complete airway obstruction; blood cultures are the diagnostic test of choice. 1, 6
• Do biopsy chronic granulomatous-appearing lesions with appropriate special stains and cultures to establish the specific diagnosis. 1
• In GPA, nasal mucosal biopsy has only 47% sensitivity but 96% specificity when all three criteria (necrosis, granulomatous inflammation, vasculitis) are present. 1