Acute epiglottitis in children.

Abstract

Acute respiratory obstruction represents one of the most urgent and dramatic emergencies in the practice of medicine. In children, acute upper respiratory infection is a frequent etiologic agent in this condition. In the early part of this century, acute laryngeal obstruction from acute infectious “croup” was thought to be caused predominantly by laryngeal diphtheria. Later, other non diphtheritic infections causing acute edema of the glottic and subglottic regions were recognized and placed in the category of acute laryngotracheobronchitis (3). Recently, another entity has been gaining recognition in which acute inflammation and edema are localized to the supraglottic, arytenoid, and epiglottic regions, with resultant acute laryngeal obstruction. This has been termed acute supraglottitis, or acute epiglottitis, and, though it is receiving more attention in the literature of late, its radiological manifestations have been virtually ignored and on occasion have been said to be nonexistent (3). Acute epiglottitis usually runs a rapid course and without adequate treatment often terminates fatally, making early diagnosis and treatment of the greatest importance. Mortality rates in the literature are varied, ranging from 8 per cent (8) up to as high as 26 deaths in 29 cases reported by Jones and Camps (3). The disease can be recognized easily radiographically, and virtually all deaths are preventable. It has been emphasized that these children should be handled carefully. All unnecessary examinations and manipulations, particularly indirect and direct laryngoscopy, should be done only when the operator is prepared to do a tracheotomy (2). The purpose of this paper is to emphasize the ease and speed with which a radiologic diagnosis can be established, thus avoiding the steps which may precipitate even further edema and the need for a tracheostomy. Clinical Manifestations Acute epiglottitis is characteristically a disease of pre-school children, the average age ranging from two to five years. Briefly, the disease is of abrupt and unexpected onset, sometimes following one to three days of malaise and, occasionally, low-grade fever. The course is rapid and fulminating, with sore throat, high fever, prostration, varying degrees of cyanosis, and severe inspiratory obstruction usually manifest within four to five hours following the onset of symptoms. There is marked redness and swelling of the epiglottis, which may be eight to ten times its normal size (5), protruding posteriorly and inferiorly above the glottis, reducing its aperture and causing a typical inspiratory obstruction. In 50 per cent of cases, the epiglottis alone is involved, and in the remaining cases, there is similar but less marked involvement of the aryepiglottic folds and arytenoids. Of the latter cases, the false cords are edematous in 50 per cent. The pharynx, true cords, and subglottic areas are not involved (6).