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Booth AW, Pungsornruk K, Llewellyn S, Sturgess D, Vidhani K. Airway management of adult epiglottitis: a systematic review and meta-analysis. BJA OPEN 2024; 9:100250. [PMID: 38230383 PMCID: PMC10789606 DOI: 10.1016/j.bjao.2023.100250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
Background Adult epiglottitis is a life-threatening airway emergency where airway protection is the immediate priority. Despite its importance, the optimal approach to airway management remains unclear. We performed a systematic review of the airway management for adult epiglottitis, including meta-analysis of trends over time. Methods We systematically searched PubMed, Ovid MEDLINE®, and Embase® for adult epiglottitis studies that described the airway management between 1980 and 2020. The primary outcome was the prevalence of airway intervention. Secondary outcomes were prevalence of tracheal intubation, tracheostomy, and failed intubation. A random-effects model meta-analysis was performed with subgroups defined by decade of study publication. Cases that described the specific method of airway intervention and severity of epiglottitis were included in a separate technique summary. Results Fifty-six studies with 10 630 patients were included in the meta-analysis. The overall rate of airway intervention was 15.6% (95% confidence interval [CI] 12.9-18.8%) but the rate decreased from 20% to 10% between 1980 and 2020. The overall rate of tracheal intubation was 10.2% (95% CI 7.1-13.6%) and that of failed intubation was 4.2% (95% CI 1.4-8.0%). The airway technique summary included 128 cases, of which 75 (58.6%) were performed awake and 53 (41.4%) involved general anaesthesia. We identified 32 cases of primary technique failure. Conclusion The rate of airway intervention for adult epiglottitis has decreased over four decades to a current level of 10%. Tracheal intubation is a high-risk scenario with a 1 in 25 failure rate. Specific technique selection is most likely influenced by contextual factors including the severity of epiglottitis.
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Affiliation(s)
- Anton W.G. Booth
- Department of Anaesthesia, Princess Alexandra Hospital – Southern Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Karla Pungsornruk
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia
| | - Stacey Llewellyn
- Statistics Unit, QIMR Berghofer Institute of Medical Research, Brisbane, Australia
| | - David Sturgess
- Department of Anaesthesia, Princess Alexandra Hospital – Southern Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- The University of Queensland (UQ) and Surgical Treatment and Rehabilitation Service (STARS), Brisbane, Australia
| | - Kim Vidhani
- Department of Anaesthesia, Princess Alexandra Hospital – Southern Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Sideris G, Papadimitriou N, Korres GF, Karaganis A, Maragkoudakis P, Nikolopoulos T, Delides A. Clinical and Microbiological Factors Associated With Abscess Formation in Adult Acute Epiglottitis. Ann Otol Rhinol Laryngol 2021; 131:1194-1201. [PMID: 34841913 DOI: 10.1177/00034894211051817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate clinical and microbiological findings that are correlated with abscess formation in adult acute epiglottitis (AE). METHODS We reviewed 140 cases of adult AE. Demographic, clinical, imaging, and microbiological findings are analyzed for all patients with AE in comparison to those with epiglottic abscess (EA). RESULTS A total of 113 patients presented with AE and 27 presented or progressed to EA (19.3%). Age, sex, seasonality, smoking, body mass index (BMI), and comorbidities were statistically insignificant between the 2 groups. Muffled voice (P < .013), respiratory distress (P < .001), and pre-existence of epiglottic cyst (P < .001) are symptoms and signs connected with abscess formation. A total of 120 patients were treated conservatively. Surgical treatment was performed on 20 patients with EA. About 72 out of 80 cultures revealed monomicrobial infection. Mixed flora was isolated in 8 patients with EA. Streptococcus was isolated in 51 out of 80 positive cultures (64%). Haemophilus Influenza (Hib) was not isolated in any sample. EA and mixed flora relates to a higher rate of airway intervention (P < .001). CONCLUSION A high level of suspicion for abscess formation is required if clinical examination reveals dyspnea, muffled voice, or an epiglottic cyst in adult with AE. The existence of EA doubles the duration of hospitalization. EA is typically found on the lingual surface of the epiglottis. Supraglottic or deep neck space expansion should be treated surgically. EA is associated with a mixed flora and a higher rate of airway obstruction. Streptococcus is discovered to be the most common pathogen.
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Affiliation(s)
- Giorgos Sideris
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Papadimitriou
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios F Korres
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Karaganis
- Department of Economic and Regional Development, Panteion University of Social and Political Sciences, Athens, Greece
| | - Pavlos Maragkoudakis
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Thomas Nikolopoulos
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Alexander Delides
- 2nd Otolaryngology Department, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
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Shaul C, Levin PD, Attal PD, Rafael A, Schwarz Y, Sichel JY. The management of acute supraglottitis patients at the intensive care unit. Eur Arch Otorhinolaryngol 2021; 279:1425-1429. [PMID: 34792627 DOI: 10.1007/s00405-021-07174-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis. METHODS A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam. RESULTS Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively. CONCLUSION Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.
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Affiliation(s)
- Chanan Shaul
- Departments of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 3235, 91031, Jerusalem, Israel.
| | - Phillip D Levin
- Intensive Care Unit, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Pierre D Attal
- Departments of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 3235, 91031, Jerusalem, Israel
| | - Allon Rafael
- Departments of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 3235, 91031, Jerusalem, Israel
| | - Yehuda Schwarz
- Departments of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 3235, 91031, Jerusalem, Israel
| | - Jean-Yves Sichel
- Departments of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 3235, 91031, Jerusalem, Israel
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Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives (1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification. Methods A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007. Results The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care. Conclusion A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.
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Chung CH. Case and Literature Review: Adult Acute Epiglottitis – Rising Incidence or Increasing Awareness? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790100800407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The prevalence of adult acute epiglottitis is probably more common than is generally appreciated. A retrospective case review in a district hospital and a medical literature search may provide baseline information to guide future strategies. Methods Cases of acute epiglottitis in a period of 3 years and 4 months were traced from the hospital computer systems. Medical records were reviewed. Medical literature on “adult acute epiglottitis” was searched through Medline and EMBASE. Relevant full text articles were retrieved through hospital library network. Results From February 1998 to June 2001, 11 cases of acute epiglottitis were identified. The age range was 34–78 (mean 47.5, median 41). There was no paediatric case. The male to female ratio was 9:2. Eight presented with fever, sore throat and dysphagia, one presented with dyspnoea and two presented as foreign body in throat. Nine were treated successfully conservatively. Two were intubated prophylactically. There was no case fatality. Conclusion Adult acute epiglottitis has become much commoner than its paediatric counterpart. Acute epiglottitis should be suspected in all patients with a sore throat and dysphagia, especially if symptoms are out of proportion to the pharyngeal inflammation.
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Affiliation(s)
- CH Chung
- North District Hospital, Accident &Emergency Department, 9 Po Kin Road, Sheung Shui, New Territories, Hong Kong
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Wong YK, Pan NY, Chu CY, Chan TN. Diagnosing Epiglottitis with Radiographs: Can we be More Objective? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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)
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Affiliation(s)
| | - NY Pan
- Princess Margaret Hospital, Department of Radiology, 2-10 Princess Margaret Hospital Road, Kwai Chung, N.T., Hong Kong
| | - CY Chu
- Pamela Youde Nethersole Eastern Hospital, Department of Radiology, 3 Lok Man Road, Chai Wan, Hong Kong
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Moyko A, Ali NJ, Dubosh NM, Wong ML. Pasteurella multocida Epiglottitis. Clin Pract Cases Emerg Med 2017; 1:22-24. [PMID: 29849414 PMCID: PMC5965432 DOI: 10.5811/cpcem.2016.11.32294] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/08/2016] [Accepted: 11/04/2016] [Indexed: 12/03/2022] Open
Abstract
Epiglottitis is an uncommon but life-threatening disease. While the most common infectious causes are the typical respiratory pathogens, Pasteurella multocida is a rare causative organism. We present a case of P. multocida epiglottitis diagnosed by blood culture. The patient required intubation but was successfully treated medically. P. multocida is a rare cause of epiglottitis; this is the ninth reported case in the literature. Most diagnoses are made from blood culture and patients usually have an exposure to animals.
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Affiliation(s)
- Andrey Moyko
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Nissa J Ali
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Nicole M Dubosh
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Matthew L Wong
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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Chang YL, Lo SH, Wang PC, Shu YH. Adult acute epiglottitis: Experiences in a Taiwanese setting. Otolaryngol Head Neck Surg 2016; 132:689-93. [PMID: 15886619 DOI: 10.1016/j.otohns.2005.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE: Acute epiglottitis is a potentially disastrous disease seen occasionally in otolaryngology emergency service. This study reports our experiences in managing adult patients with acute epiglottitis in a Taiwanese setting. STUDY DESIGN: Admission medical records from 46 adult patients with acute epiglottitis over a period of 8 years in a tertiary referral otolaryngology service were retrospectively reviewed. RESULTS: No mortality was reported; 4 (8.7%) patients were supported by artificial airway. A total of 16 (34.8%) patients had comorbid conditions; hypertension and diabetes mellitus were the most common systemic diseases. Patients who needed artificial airway support tended to have more systemic comorbidities ( P = 0.001) and a higher level of hyperglycemia ( P = 0.004) than those who did not need airway support. The incidences of drooling, stridor/dyspnea, and muffled voice were significantly higher in the airway-supported group ( P < 0.05). Stridor/dyspnea is a reliable clinical predictor of airway compromise (odds ratio 2.94; P = 0.0277). CONCLUSION: Dyspnea is a warning sign of impending airway collapse during an episode of acute epiglottitis. Adult patients with more systemic comorbidities might bear higher risk of airway compromise; the role of diabetes mellitus can't be overlooked. (Otolaryngol Head Neck Surg 2005;132:689-693.)
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Affiliation(s)
- Yen-Liang Chang
- Department of Otolaryngology, Cathay General Hospital, 280 Sec. 4 Jen-Ai Road, 106, Taipei, Taiwan
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Suzuki S, Yasunaga H, Matsui H, Fushimi K, Yamasoba T. Factors associated with severe epiglottitis in adults: Analysis of a Japanese inpatient database. Laryngoscope 2014; 125:2072-8. [DOI: 10.1002/lary.25114] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/14/2014] [Accepted: 12/01/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Sayaka Suzuki
- Department of Clinical Epidemiology and Health Economics; School of Public Health, The University of Tokyo; Tokyo Japan
- Department of Otolaryngology and Head and Neck Surgery; Faculty of Medicine, The University of Tokyo; Tokyo Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics; School of Public Health, The University of Tokyo; Tokyo Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics; School of Public Health, The University of Tokyo; Tokyo Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics; Tokyo Medical and Dental University Graduate School of Medicine; Tokyo Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology and Head and Neck Surgery; Faculty of Medicine, The University of Tokyo; Tokyo Japan
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Comorbidities and complications influence the diagnosis and management of geriatric supraglottitis. Am J Emerg Med 2014; 32:1334-8. [DOI: 10.1016/j.ajem.2014.08.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/01/2014] [Accepted: 08/12/2014] [Indexed: 11/17/2022] Open
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Bizaki AJ, Numminen J, Vasama JP, Laranne J, Rautiainen M. Acute supraglottitis in adults in Finland: Review and analysis of 308 cases. Laryngoscope 2011; 121:2107-13. [DOI: 10.1002/lary.22147] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/24/2011] [Indexed: 11/10/2022]
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Shah RK, Stocks C. Epiglottitis in the United States: National trends, variances, prognosis, and management. Laryngoscope 2010; 120:1256-62. [DOI: 10.1002/lary.20921] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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López Erausquin N, Bengoetxea Uriarte UX, Gorostiaga Casas A, Aguilera Celorrio L. [Two cases of acute epiglottis in adults requiring admission to the recovery unit]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:253-254. [PMID: 20499808 DOI: 10.1016/s0034-9356(10)70217-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Yoon T, Choi J, Lim S, Lee J. The incidence of epiglottic cysts in a cohort of adults with acute epiglottitis. Clin Otolaryngol 2010; 35:18-24. [DOI: 10.1111/j.1749-4486.2009.02069.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fuentes Cano S, Sánchez García D, Vega Cuadri A, Fuentes Cano M. [Fiberoptic bronchoscopic guidance for lower airway management in an adult with epiglottitis]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:448-449. [PMID: 18853686 DOI: 10.1016/s0034-9356(08)70619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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[Pseudomembranous supraglottitis with airway compromise in a patient with recurrent tonsillar carcinoma]. Can J Anaesth 2008; 55:42-6. [PMID: 18166747 DOI: 10.1007/bf03017596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE In this report, we discuss a patient with acute pseudomembranous supraglottitis complicating recurrent tonsillar carcinoma and describe the ramifications of these disorders on perioperative management. CLINICAL FEATURES The patient was an acutely ill man with a history of right tonsillar carcinoma originally treated with chemoradiation therapy and a radical neck dissection who presented with a brief history of fever, dyspnea, and stridor. The soft tissue of his neck was very stiff, his neck mobility was limited, and his mouth opening was restricted by pain and radiation-induced fibrosis. A nasal flexible fibreoptic laryngoscopy revealed a very large, indurated epiglottis almost completely obstructing the glottis. The aryepiglottic folds and false cords were edematous, and a gray pseudomembranous exudate was observed on the glottic surface, epiglottis, and true vocal cords. An elective tracheostomy was performed in the operating room using local anesthesia, and conscious sedation was avoided because of the potential for complete airway obstruction. General anesthesia was induced after the airway was secured, but trismus and tissue edema resulting from the acute infection made the glottis and surrounding structures nearly impossible to visualize during direct laryngoscopy. The patient was treated with intravenous antibiotics, and a subsequent direct laryngoscopy demonstrated tumour recurrence. CONCLUSIONS The case emphasizes that the perioperative management of imminent airway obstruction by acute supraglottitis complicating recurrent oropharyngeal cancer may optimally be approached by establishing a surgical airway under controlled operating conditions.
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Abstract
Epiglottitis is supraglottic inflammation of the oropharynx caused by infective, thermal, or caustic insult. Rapid swelling of the epiglottis results in airway obstruction and asphyxia. Widespread use of HiB vaccination in children has resulted in a reduction in childhood cases of epiglottitis. The majority of adults have not received vaccination, and remain susceptible. Peak incidence is in the 35- to 39-year-old age group with an annual incidence of 0.97-1.8/100,000, approximately 2.5 times the incidence in children (Sack and Brock, 2002; Carey, 1996; Fontanarosa et al., 1989). We present three cases of adult epiglottitis presenting to a District Hospital Accident and Emergency (A&E) department in Yorkshire over a six-month period.
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Affiliation(s)
- Matt Shepherd
- A&E Medicine, St James' University Hospital, 16 Adel Vale, Leeds LS16 8LF, UK.
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Abstract
In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.
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Affiliation(s)
- Arvind Bansal
- Pulmonary and Critical Care Medicine, Beth Israel Medical Center, New York NY 10128, USA
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Sack JL, Brock CD. Identifying acute epiglottitis in adults. High degree of awareness, close monitoring are key. Postgrad Med 2002; 112:81-2, 85-6. [PMID: 12146095 DOI: 10.3810/pgm.2002.07.1258] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epiglottitis can be a rapidly fatal condition in adults. Important clues that should raise clinical suspicion include the tripod sign, fever, stridor, sore throat, odynophagia, shortness of breath, and drooling. These features must be differentiated from those associated with common viral infections. The most helpful diagnostic studies are radiography of the neck and direct laryngoscopy. The patient's airway should be monitored during evaluation to avoid obstruction. Successful management requires teamwork between the primary care physician and personnel skilled in intubation as well as timely consultation with an otolaryngologist. Laryngoscopy and intubation always should be performed by the most skilled personnel because repeated attempts may increase periepiglottal swelling and the risk of airway obstruction. Racemic epinephrine should be avoided because of the rebound effect. Awareness of the possibility of epiglottitis in adults and close monitoring of the airway are the keys to management of this potentially life-threatening condition.
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Affiliation(s)
- Jonathan L Sack
- Department of Family Medicine, Medical University of South Carolina College of Medicine, 9298 Medical Plaza Dr, Charleston, SC 29406, USA.
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Abstract
A 53 year old man presented with the chief complaint of having a fish bone stuck in the throat for about 1 h. There was no dysphagia or respiratory symptoms. Plain lateral neck X-ray, direct laryngoscopy and oesophagogastroduodenoscopy showed a grossly swollen epiglottis with narrowing of the laryngeal lumen. No foreign body was found. His condition improved rapidly with intravenous antibiotic therapy. As acute epiglottitis may be a sudden life-threatening condition, a high index of suspicion should be maintained for patients who present with alleged foreign bodies in the throat.
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Affiliation(s)
- C H Chung
- Accident and Emergency Department, North District Hospital, 9 Po Kin Road, Sheung Shui, New Territories, Hong Kong SAR, China
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Abstract
BACKGROUND To examine the common presentations and management of acute epiglottitis in adults. METHOD Retrospective clinical study of 17 consecutive adult patients who presented to the Royal Melbourne Hospital between January 1988 and December 2000 was undertaken. RESULTS The mean patient age was 47 years (range 20-87 years) and the male-to-female ratio was 1.8 : 1.0. Peak incidence occurred in September during early spring. All patients presented with sore throat and dysphagia; however, respiratory distress was only noted in 65%. The most common signs were temperature and tachycardia. Four patients (23%) required endotracheal intubation, which was performed electively in three and as an emergency in one. Three of 14 blood cultures were positive, two yielded Haemophilus influenzae type b and one yielded Streptococcus mitis. One of the four throat cultures was positive for Haemophilus influenzae type b. Twelve patients underwent awake flexible laryngoscopy under topical anaesthetic as part of their initial assessment, and there were no complications associated with this procedure. There was no mortality. CONCLUSIONS The diagnosis of acute epiglottitis in the adult population is difficult as respiratory distress may be absent. Patients who have a significant sore throat with no obvious aetiology should have direct visualization of their larynx by flexible laryngoscopy. Lateral X-ray of neck is of limited value. Once diagnosed, these patients should be hospitalized and monitored as airway obstruction may develop rapidly.
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Affiliation(s)
- E Y Wong
- Royal Melbourne Hospital, Parkville, Victoria, Australia
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