Epiglottitis — Individualized management with steroids

Abstract

AbstractThree therapeutic modalities are available for the management of acute epiglottitis — medical, intubation, and tracheotomy. Helping the otolaryngologist discern the regimen of choice for a given situation is the format for this paper. The incidence of diagnosed epiglottitis is definitely increasing in our institution and in others; therefore, a rational individualized approach based on recent information is essential. Twelve cases formed the basis for the concepts presented.Our current management protocol for supraglottic infection is as follows: first, medical management for selected cases is given a two‐hour trial. Should this prove unsuccessful, intubation is effected. Tracheotomy will no longer be performed unless the internal lumen of the tube placed is so small that crusting becomes a problem; the patient cannot be extubated in 48‐72 hours; or in the very rare contingency that the patient could not be intubated.In this series, medical management alone sufficed in eight cases. Two cases received a tracheotomy. These were performed prior to the initiation of our current protocol. Two patients were intubated.The 12 cases were analyzed with regard to the parameters which might depict those cases that would not respond to medical management. The initial respiratory rate, pulse rate, and temperature elevation were not indicative. Rather, the potential and direction of change of the aforementioned recorded over a two‐hour period was very significant. A significant medical response as manifested by a decreased respiratory rate was seen in four cases in less than one hour and within two hours in the remaining four cases. It is of significance that in one of the eight cases steroids were withheld for the first two hours with a significant deterioration in the patient's condition. Steroids were then given, and within two hours there was a definite clinical improvement. It should be noted that the steroid response could not be correlated with the length of symptoms prior to admission; also, those patients whose initial difficulty was primarily dysphagia seemed to have a more benign general course. Medical management was therapeutic in all of these cases. Information from our later cases supports this contention as well.An analysis of the four initial cases requiring airway intervention revealed a syndrome of cyanosis, exhaustion, and severe sternal retraction to indicate an initially poor medical response. Patients with this triad should be intubated as soon as possible and given appropriate antibiotics and steroids.