EPIGLOTTITIS: A SERIOUS AIRWAY INFECTION

Annicchiarico C, Capotosto P. Epiglottitis: A serious airway infection. International Journal of Infection. 2023;7(2):35-38.

C. Annicchiarico^1* and P. Capotosto²

¹ Independent Researcher, University of Bari, Bari, Italy;
² Gastroenterology and Endoscopy, Santagostino Medical Center, Santagostino Cimiano, Milan.

*Correspondence to:
Ciro Annicchiarico,
Independent Researcher,
University of Bari,
70100 Bari, Italy.
e-mail: annicchiarico.ciro63@gmail.com

Received: 06 March, 2023 Accepted: 04 July, 2023

ISSN 1972-6945 [online] Copyright 2023 © by Biolife-publisher This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties. Disclosure: all authors report no conflicts of interest relevant to this article.

ABSTRACT

Epiglottitis infection is a serious disease that mainly affects the airways, in which there is inflammation of the supraglottic structures, including the surrounding soft tissues and epiglottis. This disease can be caused by bacteria, most commonly due to Haemophilus influenzae type b (Hib), and viruses. The vaccine against (Hib) has dramatically reduced the incidence of epiglottitis. Gram-negative coccobacilli are frequently responsible for epiglottitis, in addition to other bacteria. Epiglottitis patients typically present in an irritable and anxious state with respiratory distress, severe sore throat, stridor (indicating airway obstruction), hoarse voice or loss of voice, dysphagia, drooling due to inability to swallow saliva, and sudden onset of fever. Reducing inflammation in epiglottitis is a crucial factor, and it is important to make a timely diagnosis and initiate treatment immediately.

KEYWORDS: Epiglottitis, epiglottis, airway, infection, inflammation

INTRODUCTION

Epiglottitis is a serious infection of the extra thoracic portion of the airways (1). The epiglottis, also called the “voice box”, is located at the base of the tongue and above the larynx (2). The epiglottis plays a crucial role in protecting the airway during swallowing by closing over the trachea to prevent food and liquids from entering the lungs (3).

Epiglottitis is an inflammation of the supraglottic structures, such as the posterior lingual surface and the surrounding soft tissues, including the epiglottis and aryepiglottic folds (2). Epiglottis can lead to serious and potentially life-threatening complications due to airway obstruction (4). It can be life-threatening because the swollen epiglottis can block the flow of air into the lungs (5).

Epiglottitis is most commonly caused by bacteria such as Haemophilus influenzae type b (Hib), but can also be caused by Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. Viruses can also cause epiglottitis, although it is less common, including those that cause the common cold or flu (6).

Epiglottis usually occurs in children between 2 and 8 years of age but can also occur at any age (7) The introduction of the conjugate vaccine against Hib has dramatically decreased the incidence of epiglottitis in both children and adults (8). Despite the significant decrease in the number of cases, not only has epiglottitis not been eliminated but it has become a difficult pathology to diagnose since in the immunized population, a greater percentage of cases can be attributed to organisms other than Hib, and therefore the disease can present with atypical characteristics.

DISCUSSION

Hib is a Gram-negative coccobacillus that is the most common pathogen responsible for epiglottitis (9). It possesses a polysaccharide capsule, which is a key virulence factor allowing it to evade the host immune system (10).  Usually, the pathological picture is completed by the intervention of other bacteria such as streptococcus, a Gram-positive microorganism which is also virulent.

Patients with epiglottitis appear particularly irritable and classically present high fever, odynophagia, as well as signs of respiratory distress (11).  These symptoms show rapid progression, typically over a few hours. The affected individual is often described as anxious and in a “toxic” state (12).  The attitude is characteristic: an upright position, with the extension of the arms, back, neck, and open mouth to maximize the diameter of the airways. Blackstock et al. have described the condition with the “4Ds” of epiglottitis: sialorrhea, dyspnoea, dysphagia, and dysphonia (13). Unfortunately, especially in atypical forms, not all signs and symptoms are necessarily present at the same time (Table I). Additionally, most patients have some degree of difficulty swallowing due to severe odynophagia. Patients may also have difficulty speaking due to pain and soft tissue swelling, and the voice may sound muffled (14). Stridor is a late symptom and indicates impending complete airway obstruction (2). Concomitant infections such as otitis media, pneumonia, or meningitis are present in approximately 50% of cases (15).

Table I. The symptoms of epiglottitis.

The immune system responds to the bacterial invasion by sending white blood cells to the site of infection (16). Cytokines and other inflammatory mediators are released, causing inflammation and swelling (17). The acute inflammatory response is part of the body’s attempt to contain and eliminate the bacteria, but it also contributes to the swelling that can obstruct the airway.

The diagnosis of epiglottitis is made by inspecting the supraglottic region, a procedure that should be performed under optimal conditions and in the operating room. The diagnosis must be made with careful clinical examination to avoid causing further airway obstruction (18).  Diagnostic attempts to directly visualize the posterior pharynx and epiglottis with the tongue depressor during the initial examination in the emergency department should be strongly discouraged.  The concern is that this type of manipulation can increase the risk of complete airway obstruction by exposing the affected area to local trauma and creating further emotional distress in the patient.

When the diagnosis of epiglottitis is suggested by patient history and clinical examination, the patient should be constantly monitored and all procedures likely to cause anxiety should be postponed or abandoned altogether, including intraoral examination and placement of a venous access (19).  The patient should remain in the most comfortable position, usually held by another person, until enough information is obtained to exclude or confirm the diagnosis.

During the disease, the number of white blood cells is generally high, with a prevalence of neutrophils, in accordance with the inflammatory state (20). Imaging studies such as neck X-rays or CT scans can help in diagnosis but are secondary to clinical assessment (21). X-rays are helpful because they can confirm the diagnosis, as well as rule out the presence of other conditions such as croup, retropharyngeal abscess, or the presence of a foreign body. The gold standard is the lateral X-ray of the neck obtained with hyperextension during inspiration, to highlight edematous epiglottitis, loss of air space at the vallecula, and thickening of the aryepiglottic folds (22).

Treatment should be done in a hospital intensive care unit. The patient will need to start empirical antibiotic therapy to cover the most likely pathogens. Once the specific pathogen is identified, antibiotics can be tailored to effectively target that organism.  Oxygen therapy and intravenous fluid injection to maintain hydration should be used as supportive therapy.

CONCLUSIONS

Reducing inflammation in epiglottitis is crucial for treatment. Understanding the mechanisms and biology of infectious epiglottitis is essential for effective prevention, timely diagnosis, and immediate treatment, and also critical for reducing the morbidity and mortality associated with this potentially life-threatening condition.

Conflict of interest

The authors declare that they have no conflict of interest.

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