1Department of Anaesthesia, 1G323 University Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0048, USA. 2Royal Sussex County Hospital, Eastern Road, Brighton, UK
Accepted for publication: May 27, 2000
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Abstract |
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Br J Anaesth 2000; 85: 7957
Keywords: complications, epiglottitis
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Introduction |
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Case reports |
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Case 3
A 56-yr-old man was admitted to the accident and emergency department with acute onset of a sore throat and dysphagia. He was sitting up, dyspnoeic, and drooling saliva. A flexible nasendoscopy showed an oedematous, enlarged epiglottis. An i.v. line was inserted, blood cultures taken and Augmentin 1.2 g and hydrocortisone 200 mg were given intravenously. The patient was transferred to the operating theatre. During an inhalational induction of anaesthesia with sevoflurane, he developed complete airway obstruction. Intravenous succinylcholine 100 mg was administered and orotracheal intubation was attempted but failed. An emergency cricothyroidotomy was then performed using a 13-gauge transtracheal catheter. Jet ventilation was commenced and continued whilst a surgical tracheostomy was performed. The trachea was decannulated 3 days later. Blood cultures were negative.
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Discussion |
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Haemophilus influenzae type B is found in as few as 17% of adult patients with suspected epiglottitis.7 There is also a high rate of negative blood cultures possibly suggestive of a viral cause (although only herpes simplex has been reported).5 Meningococcal epiglottitis is extremely rare and we present only the seventh reported case; the first was reported in 1995.8 Alternatively, epiglottitis may occur following mechanical injury such as the ingestion of caustic material or the inhalation of hot objects, smoke or vapours. Epiglottitis following illicit drug use has been described as a result of the accidental inhalation of a heated objects.9 Although there has been an association with cigarette smoking,10 there are no reports linking epiglottitis and the smoking of heroin. The causal organism or factor is, therefore, often less identifiable in adults than in children.
An adult with epiglottitis usually presents with symptoms of sore throat and painful dysphagia.3 Drooling and stridor are infrequent presenting signs. In fact the presence of stridor, dyspnoea and a short duration of symptoms prior to presentation, are all described as predictors of airway loss in the adult with epiglottitis.4 10 This is, however, controversial. For example, Wolf2 presented 30 patients in whom stridor was present and who were subsequently successfully treated conservatively. On the other hand, Mayo-Smith described a patient who had no history of stridor, yet suddenly developed airway obstruction and died.11 Indeed the three cases we present support the fact that the disease presentation and progression is variable and that there are no reliable markers that predict the need for invasive airway support.
The diagnosis of epiglottitis is essentially clinical but can be supported by indirect laryngoscopy. Typically, there is diffuse swelling of the aryepiglottic structures unlike the classic cherry red epiglottis in children. Otherwise, once the airway is deemed safe, a lateral, soft tissue radiograph may show a thickening of the epiglottis (thumb print sign; see Fig. 1). Ducic and colleagues have proposed the vallecula sign to improve the diagnostic accuracy of soft tissue radiographs.12 This stepwise approach attempts to identify the vallecula as it nears the level of the hyoid bone. In the absence of a deep and well-defined vallecula, the radiological findings support the diagnosis of epiglottitis.
If the clinical diagnosis of epiglottitis is made and the airway judged to be at risk, intervention should not be delayed by attempts to obtain cultures or radiographs. Treatment should begin promptly with intravenous antibiotics. Steroids have no accepted place and the benefit of epinephrine, either nebulized or intramuscular, has yet to be confirmed.
Either orotracheal intubation or tracheostomy may be performed under local anaesthesia but both are potentially stimulating procedures which may precipitate sudden loss of the airway. General anaesthesia may be performed with an inhalational induction but can be complicated by a relatively prolonged excitation phase in adults (as occurred in case 3). Friedman therefore recommended a rapid sequence induction with the facility to perform a cricothyroid puncture if intubation proves difficult.13 Bag and mask ventilation can simply worsen or complete the airway obstruction and should be avoided.
Neuromuscular blocking drugs are traditionally avoided in epiglottitis (although succinylcholine was listed on a recent protocol for the management of paediatric epiglottitis14). We used succinylcholine in two of the above case reports, including one intralingual injection. Although this route is described in children, we could find no reference to its use in adults.
In summary, a belief that epiglottitis is rare in adults has contributed to misdiagnosis and high mortality rates. We present three cases that are typical of adult epiglottitis, in that there is no one identifiable causal agent or factor that would allow rationalisation of a particular therapy. To advocate conservative management belies the aggressive nature of this disease. We believe there should be a greater emphasis on early interventional support of the airway.
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Footnotes |
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References |
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