Acute Epiglottitis Research Articles

Management Dilemma: A Case of Acute Epiglottitis Secondary to Group A Streptococcus (GAS)

SESSION TITLE: Shock SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: In adults, epiglottitis has a male preponderance with the potential for rapid airway obstruction. Risk factors include hypertension, diabetes mellitus (T2DM), substance abuse and immune deficiency. CASE PRESENTATION: A 52-year-old male with history of T2DM, obesity and alcohol abuse presented with shortness of breath and choking sensation. Intubation was attempted in the ER for respiratory distress using a size 6 endotracheal tube. Chest X-ray revealed poor tube position despite multiple attempts to advance it. Epinephrine and pulse steroids were administered. Emergent bronchoscopy showed swelling of the supraglottis and an emergent tracheostomy was performed. Labs revealed leukocytosis with bandemia. Neck CT scan confirmed acute epiglottitis with critical airway stenosis. Bronchoalveolar lavage and blood cultures grew GAS. Bacteremia cleared two days after admission with Ceftriaxone and Vancomycin. Patient had spiking fevers and was noted to be extremely agitated. He received steroids for five days after a second CT neck revealed no interval change in edema.(Image 2) Two weeks after persistent fevers and hemodynamic instability requiring pressors, antibiotics were switched to Penicillin (PCN) G and Clindamycin without resuming steroids. After 24 hours, patient had significant clinical improvement and was subsequently weaned off the ventilator. He was seen in the clinic after discharge with complete resolution of symptoms. DISCUSSION: Multiple retrospective studies have noted that epiglottitis in adults can be managed conservatively with airway support required in only 6.6 - 16% of patients. We encountered a severe case of acute epiglottitis in an adult male who failed to respond clinically after two weeks of appropriate antibiotic coverage and a trial of steroids but responded to the addition of Clindamycin. The loss of penicillin binding proteins in ‘stationary growth phase’ bacteria occurs in more invasive streptococcal infections rendering PCNs less effective. Clindamycin suppresses bacterial toxin production, enhances opsonization, decreases cytokine activation and has a post-antibiotic effect.1 A recent in-vivo and in-vitro study endorsed the addition of Clindamycin to PCN in severe streptococcal infections.2 CONCLUSIONS: GAS epiglottitis can present in adults with risk factors: male sex, diabetics and substance abuse. With poor clinical response, complications such as toxic shock syndrome should be considered. The addition of Clindamycin to PCN in severe streptococcal infections may be beneficial with its action on slow growing bacteria and ability to inhibit bacterial toxin production. Reference #1: 1.Russell NE, Pachorek RE. Clindamycin in the treatment of streptococcal and staphylococcal toxic shock syndromes. Ann Pharmacother. 2000;34(7-8):936-939. Reference #2: 2.Andreoni F, Zürcher C, Tarnutzer A, et al. Clindamycin Affects Group A Streptococcus Virulence Factors and Improves Clinical Outcome. J Infect Dis. 2016;1:jiw229. DISCLOSURE: The following authors have nothing to disclose: Hisham Hakeem, Marnie Aguasvivas, Lokesh Dayal, Killol Patel No Product/Research Disclosure Information

Spontaneous Respiration Using Intravenous Anesthesia and High-Flow Nasal Oxygen (STRIVE Hi) Management of Acute Adult Epiglottitis: A Case Report.

High-flow nasal oxygen (HFNO) is a potentially life-saving adjunct in the emergency management of the obstructed airway. HFNO has multiple beneficial applications in critical care and respiratory support, but its use in emergency-obstructed airway management has not been defined. This case report describes spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen to successfully manage acute adult epiglottitis with rapidly progressing airway obstruction. Oxygenation, carbon dioxide levels, and airway patency were maintained, which facilitated endotracheal intubation while the patient was spontaneously breathing during general anesthesia. The application of HFNO can be extended to emergency airway obstruction.

発症後 8 時間後に窒息に至った急性喉頭蓋炎の 1 例

発症後 8 時間後に窒息に至った急性喉頭蓋炎の 1 例

Clinical evaluation of intravenous ampicillin as empirical antimicrobial treatment of acute epiglottitis

Introduction: The significant pathogens in acute epiglottitis (AE) are poorly defined in the post Haemophilus influenza type b-vaccine era. Furthermore, there is a lack of clinical evaluations of antibiotic regimens in patients with AE. We aimed to evaluate the effectiveness of empiric intravenous ampicillin in the treatment of patients with AE.Materials & methods: All patients admitted with AE to the Ear-Nose-Throat Department, Aarhus University Hospital, Denmark, from 2001 to 2015 were included.Results: In total, 103 (51 males) patients were included in the study. The median duration of hospitalization was four days. There was no statistical significant difference between patients initially treated with intravenous ampicillin (n = 83) or other antibiotics (n = 20) (p = .26). The antibiotic regimen was altered during admission in 11% of patients, without significant difference between antibiotic groups (ampicillin 10% vs non-ampicillin 15%, p = .44). Complications potentially related to insufficient antibiotic treatment were observed in four (5%) patients initially treated with ampicillin, but in none of the patients initially treated with antibiotics other than ampicillin (p = 1.00). Throat swab cultures and blood cultures frequently yielded negative results.Conclusions: Intravenous ampicillin is efficient as empiric antibiotic therapy for AE patients, leading to a quick recovery and low complication rates.

Do we need a change in ED diagnostic strategy for adult acute epiglottitis?

ObjectivesTo retrospectively evaluate the diagnostic performance of qualitative and quantitative radiographic parameters for diagnosing adult acute epiglottitis, and identify the prevalence and risk factors of false-negative neck radiography-based diagnosis of acute epiglottitis. MethodsAn emergency physician and a radiologist independently reviewed neck radiographs of 91 patients with laryngoscopy-confirmed acute epiglottitis and 91 control subjects between March 2010 and June 2016 for qualitative and quantitative radiographic parameters of acute epiglottitis, and concluded a diagnosis. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance of radiographic parameters, while independent risk factors of false-negative diagnosis were determined by multivariate logistic regression analysis. Inter-observer agreement was also calculated. ResultsAll radiographic parameters showed good diagnostic performance with sensitivities and specificities of 33.0–80.2% and 64.8–100%, respectively. Epiglottis width (EW)>6.3mm showed the highest diagnostic performance (area under the ROC curve [AUC]: 0.867, sensitivity: 75.8%, specificity: 97.8%). Interobserver agreement for all radiographic parameters was excellent (range: 0.893–0.991). The lateral neck radiography-based false-negative diagnosis rate was 31.9%, and previous oral antibiotic usage was an independent risk factor of false-negative results. ConclusionEW>6.3mm showed the best diagnostic accuracy, facilitating a neck radiograph-based diagnosis of acute epiglottitis. However, false-negative results on neck radiograph are quite common and previous oral antibiotic usage is a risk factor. Based on the knowledge of the usefulness and risk factors of false-negative results of neck radiography, diagnostic process for acute epiglottitis using neck radiography need to be changed.

入院加療を要した急性喉頭蓋炎を主とした喉頭浮腫80例の検討

Laryngeal edema, which is mainly caused by acute epiglottitis, is often encountered by otolaryngologists. This disease sometimes leads to dyspnea as a result of airway stenosis. Especially in the poor symptoms of respiratory organization, laryngeal fiber findings sometimes gets severe to the contrary. In severe cases, otolaryngologists must decide whether special airway management, such as a tracheotomy, is needed. We retrospectively analyzed 80 cases of laryngeal edema (mainly caused by acute epiglottitis) that were hospitalized in our department between January 2010 and April 2015. Items such as patient age, sex, initial symptoms, smoking rates, underlying disease or airway management, and duration from first symptoms until consultation were included in the analysis. We divided the patients into Grades 1, 2, and 3 according to the laryngeal findings (degree of swelling of epiglottis or epiglottis arytenoid), and each of the above-mentioned items were analyzed for each grade.

HAEMOPHILUS INFLUENZAE INFECTION IN CHILDREN DURING SPORADIC MORBIDITY: CLINICAL CASES WITH DIFFERENT (FAVORABLE OR FATAL) OUTCOMES

Haemophilus influenzae infection in children is detected as sporadic cases and is characterized by polymorphism of clinical symptoms (rhinopharyngitis, purulent meningitis, acute epiglottitis, panniculitis, etc.), which complicates an early diagnosis and treatment of this pathology. In young children, Haemophilus influenzae infection (type b) often occurs in generalized forms and may result in death. The article presents literature data and the results of own clinical observations of Haemophilus influenzae cases that occurred with an aspect of purulent meningitis and panniculitis in young children. The tactics of a complex therapy and ways to prevent Haemophilus in fluenzae infection are discussed.

Acute epiglottitis in an older person

Acute epiglottitis in an older person

Two Cases of Bilateral Pneumothorax after Tracheostomy

Tracheostomy is one of the most commonly performed procedures in the clinical field. Despite its frequent use, the tracheostomy procedure is not free of severe, and, in some cases devastating, complications. In fact, severe adverse events, such as pneumomediastinum, pneumothorax, hemorrhage, infections, and, occasionally, death, have been described. We experienced two cases of bilateral pneumothorax after emergency tracheostomy for acute epiglottitis and airway narrowing due to suspected thyroid cancer invasion of the trachea. Intraoperative pain on breathing with violent coughing aggravated the pneumothorax in our two cases, and consequently the SpO2 value deteriorated. We cut the tracheal wall and cannula insertion was performed. After that we performed positive pressure ventilation. However, respiratory impairment and degradation of SpO2 levels persisted and subcutaneous emphysema was appeared. We confirmed the subcutaneous emphysema, mediastinal emphysema, bilateral pneumothorax radiographically. The mechanism underlying the pneumothorax was thought to be extreme negative intrathoracic pressure induced by labored breathing and forced ventilation drawing air into the mediastinum and thorax. It is important to consider the development of pneumothorax when respiratory impairment and degradation of SpO2 levels persist, and subcutaneous emphysema appears immediately after tracheostomy.

急性喉頭蓋炎の各科での対応と重症度スコア

急性喉頭蓋炎の各科での対応と重症度スコア

EPIGLOTTIS MICROFLORA OF ADULT PATIENTS WITH ACUTE EPIGLOTTITIS

Introduction. Nowadays acute infectious-inflammatory processes of upper respiratory tract, including acute epiglottitis retain a high proportion among human pathology. In the literature acute epiglottitis is allocated into an independent nosology as severe acute phlegmonous bacterial inflammation of the epiglottis and hypopharynx. There are currently no clear guidelines on how to classify an acute epiglottitis, as well as protocols for patients at various stages of the pathological process. According to common belief, Haemophilus influenzae type -B (Haemophilus influenza type b (Hib)) is the most common cause of epiglottitis. At present, the main etiological role in the genesis of acute epiglottitis in children belongs to haemophilus influenzae. In adults the causes of the disease are beta hemolytic streptococci groups A, B, pneumococcus, Klebsiella, Pseudomonas, Staphylococcus aureus, herpes simplex virus (type 1) and parainfluenza, and others.The aim of this work is to study: the mucosal microflora of the epiglottis in adult patients with acute epiglottitis and to study sensitivity of certain isolates to antimicrobial agents. Material & methods. 86 adult patients with acute epiglottitis were observed: 36 with abscess form of epiglottitis and 50 - with infiltrative. Microbiological analysis of mucosal swab samples taken from hypopharynx were conducted by the conventional technology: for seeding solid or liquid nutrient medium, followed by allocation of isolith and its microscopic, biochemical and serological identification. Microorganisms were classified according to schemes of Bergy. Antimicrobial susceptibility of each strain was determined in accordance with the guidelines. We used discs with antibacterial drugs. The availability of sensitive and resistant strains of microorganisms to antibiotics was assessed. A mucous membrane of the epiglottis was analyzed through microbiological investigation in 86 patients with acute epiglottitis. As a result, 169 strains of microorganisms were sowed from mucous membrane of epiglottis. Results & discussion. In patients with acute epiglottitis Streptococcus progenies dominated in 33 (23.7%) of cases, H. influenza was detected in 27 cases (19.4%), Streptococcus pneumonia strain was in 21 (12.4%) of cases, 4th place -. Staphylococcus aureus -9.3%. There are different types of: staphylococci strains -29, of Enterococcus spp - 11, gram-negative bacilli -41. Noteworthy fact is the high degree of microbial contamination of patients 107-109 CFU. Conclusion. Acute epiglottitis highest sensitivity was observed to the following medications as cephalosporin, namely cefotaxime while it is variable within the same group (1,2,3 cephalosporin’s generation). The isolated strains showed almost 99,4±1,2% sensitivity to fluoroquinolones, especially to levofloxacin and others (S. aureus, S. pyogenes, S. pneumoniae, H. Influenzae). There was a high sensitivity to lincosamides - clindamycin; fluoroquinolones- levofloxacin. In 50% of cases, a resistance to the antibiotic penicillin; and macrolide antibiotic, especially the last generations was observed. According to the obtained findings on the sensitivity of microflora to antibiotics cephalosporin’s II- III generation with moderate and severe degrees of severity in combination with fluoroquinolones (all administered parenterally) are used in acute epiglottitis. Use of fluoroquinolones (levofloxacin, ciprofloxacin, and others) is recommended in case of Cephalosporin intolerance, as well as lincosamides (clindamycin, dalatsin, lincomycin)

Sudden Death Due to Acute Epiglottitis in Adults: A Retrospective Review of 11 Postmortem Cases.

We report a retrospective review of fatal acute epiglottitis cases in adults in the province of Ontario, Canada, between 2001 and 2014. Information on demographics, clinical history, gross, microscopic, and laboratory findings were collected and analyzed. Eleven cases, predominantly male (73%), with a mean age of 50 years were identified. Common presenting symptoms included sore throat, dysphagia, and low-grade fever. The predominant postmortem findings included hyperemia and edema of the epiglottis and aryepiglottic folds. Histological features included vascular congestion, stromal edema, and acute inflammation. Five cases (45%) were positive for growth of various bacterial organisms on blood and/or tissue cultures. Acute epiglottitis should be in the differential diagnosis in fatalities presenting with symptoms of upper respiratory tract infection, followed by an episode of acute shortness of breath. History, thorough postmortem examination with close attention to the head and neck structures, histological examination of tissues, and sampling for microbiology will assist in differentiating epiglottitis from other cases of laryngeal swelling leading to death.

Adult Acute Epiglottitis: An Eight - Year Experience in A Philippine Tertiary Government Hospital

Objective: To review cases of adult acute epiglottitis in a tertiary government hospital and describe the clinical presentations, diagnostics performed, management and outcomes.
 Methods:
 Study Design: Retrospective Chart Review
 Setting: Tertiary Government Hospital
 Subjects: Records of patients admitted by or referred to the Department of Otolaryngology Head and Neck Surgery with a diagnosis of acute epiglottitis from January 2008 to August 2014 were identified from the department census and charts were retrieved from the Hospital Record Section and evaluated according to inclusion and exclusion criteria. Information regarding demographic data, clinical features, laboratory and other diagnostic examinations, medical management, and length of hospital stay were collected.
 Results: There were 20 cases in seven years and eight months. Most were male, 18 to 37-years-old, presenting with dysphagia, odynophagia and a swollen epiglottis on laryngoscopy. Abnormal soft-tissue lateral radiographs of the neck and leukocytosis were seen in 73 % and 83% respectively. Intravenous antibiotics and corticosteroids were administered in all cases, and mean hospital stay was 11.2 days.
 Conclusion: Adult acute epiglottitis should be highly suspected in patients presenting with dysphagia, odynophagia, and muffling of the voice even with a normal oropharyngeal examination. History of respiratory infection, co-morbidities, smoking and alcohol intake, concomitant laryngeal pathology and supraglottic structure insults contribute to development of the disease. Laryngoscopy is still the gold standard in diagnosis. Airway protection is mandatory but prophylactic intubation or tracheostomy are not advised. Intravenous antibiotics are necessary and corticosteroids may be of benefit. 
 Keywords: epiglottitis, supraglottitis, epiglottis, adult, Philippines

経過中に急性喉頭蓋炎を生じたベーチェット病不全型の 1 例

経過中に急性喉頭蓋炎を生じたベーチェット病不全型の 1 例

Diagnosing Epiglottitis with Radiographs: Can we be More Objective?

Objective The classical radiographic signs in acute epiglottitis are qualitative. The purpose of our study was to identify objective radiographic parameters to aid diagnosis of acute epiglottitis in Chinese adults. Methods A case-control study of Chinese adult patients attending the accident and emergency department (AED) who were subsequently diagnosed to have acute epiglottitis from 1st January 2009 to 31st December 2013 in a public hospital in Hong Kong. Controls were one-to-one age- and sex-matched patients who attended the AED during the study period for orthopaedic problems with cervical spine radiographs taken. Cases and controls were retrieved from the hospital computer system and their radiographs were interpreted by two specialist radiologists with various pharyngeal and laryngeal parameters, including the dimensions of the third cervical vertebral body, epiglottis, aryepiglottic fold, hypopharynx, retropharyngeal soft tissue and retrotracheal soft tissue, measured and analysed. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each of the parameters. Results Twenty-six patients and 26 age- and sex-matched controls were included in the study. Epiglottis width of 5.5 mm or more was found to be 96.2% sensitive and 100% specific in diagnosing acute epiglottitis. Positive and negative likelihood ratios were infinity and 0.04 respectively. Aryepiglottic fold width of 5.9 mm or more was 92.3% sensitive and 80.8% specific. Positive and negative likelihood ratios were 4.80 and 0.10 respectively. Conclusion The identified objective radiographic parameters should aid in the diagnosis of acute epiglottitis in Chinese adults. (Hong Kong j. emerg.med. 2016;23:168-175)

Diagnostic Approaches: Images in GIM Acute Infectious Epiglottitis

A 36-year-old man presented to the emergency department with 1 week of sore throat, odynophagia, change in voice and inability to swallow saliva. His oropharynx was unremarkable with no palpable cervical lymphadenopathy, but his anterior neck was tender to light palpation. Lateral cervical radiograph showed substantial epiglottal swelling manifesting as the ‘thumb sign’ (Figure 1). Bedside flexible nasal laryngoscopy revealed an erythematous edematous epiglottis, with preserved vocal cord structure and function. Acute infectious epiglottitis was diagnosed, and improved with intravenous antibiotics.

抗甲状腺薬による無顆粒球症に急性喉頭蓋炎，深頸部膿瘍を併発し，気道確保と頸部切開排膿を要した1例

バセドウ病に対して使用されたチアマゾールにより無顆粒球症を生じ，併発した急性喉頭蓋炎と深頸部膿瘍により気道確保と頸部外切開による排膿を要した症例を経験したので報告する。急性喉頭蓋炎に対しては，喉頭内視鏡をガイドとした気管挿管にて気道確保を行った。同手技は外科的気道確保を避けたい症例において有用と考えられた。深頸部膿瘍は好中球数が上昇した後に確認され，無顆粒球症症例では通常とは異なる時期の膿瘍形成に留意する必要があった。治療経過では肺塞栓症を併発し，バセドウ病に対しては甲状腺全摘術を行った。

救命センターにおける急性喉頭蓋炎62例の臨床的検討

救命センターにおける急性喉頭蓋炎62例の臨床的検討

当科における急性喉頭蓋炎54例の検討

2009年5月から2013年5月までの4年1か月間に入院加療が行われた急性喉頭蓋炎54例について，特に気道確保を要した症例を中心に検討した。気道確保を要した症例は54例中5例 (9.3%) で，喉頭所見はKatoriらの分類において III Bが4例， II Bが1例であった。気道確保法は，気管挿管後に気管切開を行ったものが2例で，その他の3例は挿管が困難かつ局麻下の気管切開が困難な状態であり，輪状甲状膜切開の施行後に気管切開を行った。緊急に気道確保を要する症例で気管挿管が困難な場合，輪状甲状膜切開を先行して行う必要があると再認識された。また初療の時点から救急科や麻酔科医師と連携し，救急部での小手術も施行可能な態勢を整えることが重要である。

Prescription of antibacterial agents for acute upper respiratory tract infections in Beijing, 2010-2012.

PurposeThe purpose of this study was to describe the prescription of antibacterial agents for acute upper respiratory tract infections (URIs) in Beijing.MethodsA total of 8,588,699 outpatient cases in tertiary hospitals with acute upper respiratory tract infections (URIs) were selected from the Beijing Medical Claim Data for Employees (BMCDE) from Oct 2010 to Sep 2012. Second-generation cephalosporins, third-generation cephalosporins, fourth-generation cephalosporins, fluoroquinolones, macrolides (except for erythromycin), combinations of penicillins (including β-lactamase inhibitors), and streptomycins were classified as broad-spectrum antibacterial agents. The rates for antibiotic prescriptions and broad-spectrum antibiotic use were calculated in all cases as well as in various URI diagnosis subgroups and age (18–44, 45–64, and ≥65 years) subgroups. The most frequently prescribed antibiotic classes were identified by calculating the proportions of the different agents in all prescribed antibiotic agents.ResultsOverall, the rate of antibiotic prescription is 39.0 %, and cases diagnosed with acute tonsillitis, sinusitis, and epiglottitis have the highest prescription rate (73.6 %), followed by acute laryngitis and bronchitis (52.3 %), acute pharyngitis (40.1 %), and acute nasopharyngitis (37.2 %). Broad-spectrum agents were chosen in 82.4 % of the cases that were prescribed antibiotics, ranging from 81.9 % of cases with naspharyngitis to 87.1 % of the cases with tonsillitis, sinusitis, and epiglottitis. Second-generation cephalosporins, macrolides, fluoroquinolones, third-generation cephalosporins, and combinations of penicillins were most frequently prescribed, accounting for more than 80 % of all prescribed antibacterials.ConclusionsAntibacterial drug prescription for outpatients with acute URIs is common in tertiary hospitals in Beijing, and the prescribed antibacterials are usually broad-spectrum agents.Electronic supplementary materialThe online version of this article (doi:10.1007/s00228-015-1997-6) contains supplementary material, which is available to authorized users.