Acute epiglottitis, sevoflurane and HIB vaccination

Infections of the airway

Infections of the airway in children may present to the anesthetist as an emergency in several locations: the Emergency Department, the Operating Department or on Intensive Care. In all of these locations, relevant and up to date knowledge of presentations, diagnoses, potential complications and clinical management will help the anesthetist and the surgical team, not only with the performance of their interventions, but also in buying time before these are undertaken, avoiding complications and altering the eventual outcome for the child. Diseases such as epiglottitis and diphtheria may show diminished incidence but they have not gone away and their clinical features and essential management remain unchanged. Paradoxically, perhaps, some conditions such as Lemierre's syndrome appear to be making a comeback. In these instances, clinicians need to be alert to these less common conditions, not only in regard to the disease itself but also to potentially serious complications. This article describes those infections of the airway that are most likely to present to the anesthetist, their attendant complications and recommendations for treatment.

Epiglottitis in the Hemophilus influenzae Type B Vaccine Era: Changing Trends

OBJECTIVE

To describe the epidemiology, natural history, and treatment of epiglottitis in the Hemophilus influenzae type B (Hib) vaccine era.

DESIGN

Ten-year retrospective study.

SETTING

Tertiary-care children's hospital.

PATIENTS

Nineteen patients with a discharge diagnosis of epiglottitis.

INTERVENTION

As indicated by the presentation of the patient, including direct laryngoscopy, intubation, intravenous antibiotics, and steroids.

MAIN OUTCOME MEASURES

Presentation, management, and microbiology.

RESULTS

Presenting symptoms included fever, drooling, and hot potato voice. Patients' ages ranged from 15.8 months to 17.5 (mean 8.9) years. From 1992 to 1997, the mean age was 5.8 years; from 1998 to 2002, the mean age was 11.6 years. Sixty-eight percent of patients were transferred from an outside hospital. A lateral neck radiograph was recorded in 84% of patients. Mean leukocyte count was 16600. Direct laryngoscopy with intubation was performed in 79%; intubation was for an average of 3.5 days. H. influenzae was cultured in six patients, five of which had up-to-date immunizations. The most commonly administered antibiotics were ampicillin/sulbactam and ceftriaxone. Steroids were administered to 63% of patients. Complications included deep neck space infection (2), seizure (1), recurrent illness (1), and vocal granuloma (1). There were no deaths.

CONCLUSION

The demographics, causative organisms, and natural history of epiglottitis have changed substantially in the Hib vaccination era. The clinician evaluating and treating patients with epiglottitis should be aware of current trends.