Epiglottitis

Epiglottitis is an infection of the epiglottis, a leaf-like piece of cartilage extending upwards from the larynx, which can lead to severe airway obstruction. When air is breathed in (inspired), it passes through the nose and the nasopharynx or through the mouth and the oropharynx. These are both connectedto the larynx. The air continues down the larynx to the trachea. The tracheathen splits into two branches, the left and right bronchi (bronchial tubes).These bronchi branch into smaller air tubes which run within the lungs, leading to the small air sacs of the lungs (alveoli). Food, liquid, or air may betaken in through the mouth. While air goes into the larynx and the respiratory system, food and liquid are directed into the tube leading to the stomach, the esophagus. Because food or liquid in the bronchial tubes or lungscould cause a blockage or lead to an infection, the airway is protected by the epiglottis. In epiglottitis, the epiglottis may swell considerably and there is a danger that the airway will be blocked off by the very structure designed to protect it. Air is then unable to reach the lungs. Without medical care, epiglottitis can be fatal. It generally strikes two to seven-year-old children, although older children and adults can also get it. Boys are twice as likely as girls to develop this infection. Because epiglottitis involves swelling and infection of tissues which are all located at or above the level of the epiglottis, it is sometimes referred to as supraglottitis (supra, meaning above). About 25% of all children with this infection also have pneumonia.

The most common cause of epiglottitis is infection with the bacteria called Haemophilus influenzae type b. Other types of bacteria are also occasionally responsible, including some types of Streptococcus bacteria andthe bacteria responsible for causing diphtheria. A patient with epiglottitistypically experiences a sudden fever, and begins having severe throat and neck pain. Because the swollen epiglottis interferes significantly with air movement, every breath creates a loud, harsh, high-pitched sound referred to as stridor. Because the vocal cords are located in the larynx just below the areaof the epiglottis, the swollen epiglottis makes the patient's voice sound muffled and strained. Swallowing becomes difficult, and the patient may drool.The patient often leans forward and juts out his or her jaw, while strugglingfor breath. Epiglottitis strikes suddenly and progresses quickly. A child may begin complaining of a sore throat, and within a few hours be suffering from extremely severe airway obstruction.

Diagnosis begins with a high level of suspicion that a quickly progressing illness with fever, sore throat, and airway obstruction is very likely to be epiglottitis. If epiglottitis is suspected, no efforts should be made to look at the throat, or to swab the throat in order to obtain a culture for identification of the causative organism. These actions may cause the larynx to go into spasm (laryngospasm), completely closing the airway. These procedures should only be performed in a fully equipped operating room, so that if laryngospasm occurs, a breathing tube can be immediately placed in order to keep the airway open. An instrument called a laryngoscope is often used in the operating room to view the epiglottis, which will appear cherry-red and quite swollen. An x-ray picture taken from the side of the neck should also be obtained. The swollen epiglottis has a characteristic appearance, called the "thumb sign." Treatment almost always involves the immediate establishment of an artificial airway: inserting a breathing tube into the throat (intubation); or making a tiny opening toward the base of the neck and putting a breathing tube into the trachea (tracheostomy). Because epiglottitis is caused by a bacteria, antibiotics such as cefotaxime, ceftriaxone, or ampicillin with sulbactam should be given through a needle placed in a vein (intravenously). This preventsthe bacteria which are circulating throughout the bloodstream from causing infection elsewhere in the body. With treatment, only about 1% of children withepiglottitis die. Without the artificial airway, this figure jumps to 6%. Most patients recover from the infection, and can have the breathing tube removed (extubation) within a few days. Prevention involves the use of a vaccine against influenzae type b (called the Hib vaccine). It is given to babies at two, four, six, and 15 months. Use of this vaccine has made epiglottitis rare.

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