Epiglottitis.

I have been seeing a lot of patients with the seemingly straightforward chief complaint of "sore throat" the last several weeks at the clinic.  Some patients are diagnosed with streptococcal pharyngitis with a rapid strep test, some are diagnosed as viral, while others' sore throats seem to be more seasonal allergy related.  Spring is finally here and I have already started my daily claritin!  While sick visits can be a good challenge and are enjoyable for me, the "sore throat patient" can seem a bit methodical.  So, I reminded myself to keep an eye out for rare "zebras."  You know, a diagnosis that seems simple but turns into something crazier than usual.  That's when I remembered learning about epiglottitis.  Since I have never diagnosed an epiglottitis in my practice, I decided to look it up again and why not write about it on my blog to further seal it in my memory?

Epiglottitis is inflammation of the epiglottis, the flap at the base of the tongue that keeps food from going down the trachea and into the airway with swallowing.   It is most often caused by Haemophilus influenzae type b but may also be caused by other types of bacterial infection.  You may have heard of Hib, because it is the name of a great childhood vaccine.  Non-infectious etiologies of epiglottitis are rare but include thermal causes, crack cocaine or marijuana smoking, foreign body ingestion and head and neck chemotherapy.  Providers must be capable of diagnosing epiglottitis quickly.  While initial signs of epiglottitis can be mild, the condition progresses quickly and is life-threatening.

Case Presentation: A 19 year-old female presents to your clinic complaining or sore throat and a muffled voice.  She states that she has difficulty swallowing.  Her symptoms began upon waking a few hours earlier.  The patient is generally in good health with no significant medical history.  She has a fever with a temperature of 100.8 and is tachycardic with a pulse of 112.
On exam, you notice the patient is unable to swallow secretions and is spitting.  She is in no respiratory distress but states it is difficult for her to breathe.  Her pharynx appears normal but you note cervical lymphadenopathy on examining her neck.  Her lung sounds are clear.  Based on the patient's symptoms, you order an X-Ray of the soft tissues of her neck which shows a "thumb sign" indicating epiglottitis.

So, the diagnosis of epiglottitis is based on clinical presentation and coorelated with imaging.  While X-Ray has traditionally been used to diagnose epiglottitis, laryngoscopy is now the preferred method. And that is when I call the patient who is sitting in the xray lab and direct them to the ER immediately. The enlarged, inflamed epiglottis can cause airway obstruction making airway management of utmost importance in treatment.  Patients need to be closely monitored in the ICU and may need to be intubated if they become unstable.

Third generation cephalosporins such as Rocephin are first-line treatment for epiglottitis.  Corticosteroid use in epiglottitis is controversial and has not been shown to be effective.  Antipyretics such as acetaminophen should be used to treat fever as necessary. 

Ok, now I really need to start studying for my ACLS recertification class that is scheduled for next week!