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520 Clinical Medicine Epiglottitis-An Increasing Problem for Adults KHALID H. SHEIKH, MD, and STEVEN R. MOSTOW, MD, Denver In a 2-year period, 9 adults were admitted to hospital with acute epiglottitis confirmed by direct or lateral radiograph, or both. The mean age was 53 + 14 years, with acute epiglottitis occurring in 89% during the months of September to March. Intubation was required in 4 patients. The duration of symptoms was 7.8 + 2.4 hours for intubated patients versus 18.8 + 8.9 hours for those not intubated. For 6 patients an incorrect diagnosis was made on their first presentation. All 8 patients having laryngoscopy had typical findings, and none had respiratory obstruction precipitated by the procedure. In 5 patients blood cultures were positive, 4 for Hemophilus influenzae type b, and 1 for . In 2 patients the H influenzae was ampicillin-resistant. Al patients recovered after receiving parenteral steroid therapy and appropriate . (Sheikh KH, Mostow SR: Epiglottitis-An increasing problem for adults. West J Med 1989 Nov; 151:520-524)

Epiglottitis, a disease primarily of children, was first de- currence of symptoms and diagnosis in those patients re- scribed in an adult in 1936.1 Recent reports suggest an quiring intubation versus those not requiring intubation (7.8 increasing incidence in adult populations, but a large number + 2.4 hours versus 18.8 ± 8.9 hours; P <.05). Six of nine ofadult cases are misdiagnosed.2 6 Our experience with nine patients (67%) were initially seen by a physician and misdi- cases ofadult epiglottitis in 18 months prompts this report. agnosed, only to return on a subsequent visit with a progres- sion of symptoms. In two cases, intubation was required on Methods the second visit. Between September 1983 and December 1985, nine Diagnostic Procedures cases of epiglottitis in adults were seen at Rose Medical Center, a 400-bed teaching hospital in Denver. The diagnosis No patient had respiratory obstruction precipitated by was established by direct laryngoscopy or lateral neck soft flexible laryngoscopy or neck radiograph. In Figure 1 the tissue radiograph, or both. Pertinent clinical characteristics, characteristic laryngoscopic findings of supraglottic inflam- bacteriologic findings, and outcome were noted for each mation and airway narrowing are shown for patient 6. The patient. pretreatment lateral neck soft tissue radiograph from this A literature review identified additional case reports of patient is shown in Figure 2 and is notable for showing in- acute epiglottitis in adults between 1965 and 1985, and data flammation ofthe , aryepiglottic folds, and the ary- from these reports were grouped to determine incidence tenoid cartilage. The had resolved after three figures. weeks of treatment (Figure 3). All eight patients having lar- The t test was used for analyzing independent samples yngoscopy had characteristic findings. A falsely normal lat- and the x2 test for association; all tests were two-tailed. eral neck radiograph was noted in one ofnine cases. Etiology Results Blood cultures were done in all nine patients before anti- Epidemiology and Clinical Characteristics biotics were administered. Five cultures (56%) were posi- The clinical characteristics, bacteriologic findings, and tive, four for type b Hemophilus influenzae and one for Strep- outcome of our nine patients are shown in Table 1. The tococcus pneumoniae. Two of the four H influenzae isolates average age was 53 ± 14 years (range, 31 to 72); five were were ampicillin-resistant in vitro. Blood cultures in three of women. There was significant seasonality, with eight ofnine four patients requiring intubation grew pathogens. There patients being seen between September and March was a trend towards a shortening ofthe duration ofsymptoms (P < .01). All patients had both sore throat and on to the time of diagnosis in the five patients having positive presentation, and three (33 %) had temperatures greater than blood cultures compared with the four patients with no- 38.50C (101 0F). Five patients (56%) presented with respira- growth cultures (11.4 + 5.4 hours versus 17.0 + 11.8 tory symptoms-dyspnea, , drooling, the need to hours), but this was not statistically significant. maintain an upright position-and four of these required an endotracheal tube. The mean duration of symptoms from Complications their start to a correct diagnosis was 13.9 + 8.7 hours. There Four patients had extraepiglottic complications. These was a significant shortening in the interval between the oc- consisted of in three and empyema in two. In all

From the Department of Medicine, Rose Medical Center and University of Colorado Health Sciences Center, Denver. Reprint requests to Steven R. Mostow, MD, Department of Medicine, Rose Medical Center, 4567 E 9th Ave, Denver, CO 80220. THE WESTERN JOURNAL OF MEDICINE o NOVEMBER 1989 o 151 e 5 521

TABLE 1.-Adult Epiglottfitis, Rose Medcal Center Experience, Denve, S mber 1983 Through December 1985 rime to Missed Age, Abnormal Abnormal Neck Diagnosis, Diagnosis Patient Date yr Sex Laryngoscopy Radiga Result of od Culture Complications hours 1st Visit 1 ... 9/83 67 a Yes Not done Streptoc u pnwmoniae Pneumonia; intubated 8 Yes 2 ..... 9/83 64 9 Yes Yes Negative None 24 Yes 3 ... 11/83 72 9 Not done Yes Hemophius inblunzae Empyema 20 Yes 4 . 1/84 50 a Yes No Negative Intubated 6 No 5 ... 4/84 31 a Yes Yes H iuene (ampicilin resistant) None 12 Yes 6 ... 9/84 63 9 Yes Yes Negatve None 8 Yes 7 ... 9/84 42 9 Yes Yes H influenzae (ampicillin resistant) Pneumonia; ernupyema; intubated 6 No 8 ... 1/85 54 9 Yes Yes Negative None 30 No 9 ..... 12/85 38 ao Yes Yes Hinfunzae Intubated; pneumia 11 Yes

TABLE 2.-Case Reviews ofAdult Epiglo;t, 1965 Throh 1983 cases, Cases per Insthiton (Refrence Number) Number Sunvy Peri Years Yar University Hospital of Wales, Cardiff (7) .... :. :. 9 1966-1976 10.0 0.9 Wayne State University, Detroit (8) .4 1977-1980 4.0 1.0 Strong Memorial Hospital, Rochester, NY(5) .10 1966-1975 9.0 1.1 University of Southem Califomia, Los Angees (9) * . 17 1963-1973 10.0 1.7 University of Chicago (10) ...... 6 1979-1981 2.0 3.0 Gewtoffe Hospital, Helerup, Denmark (4) ...... 75 1965-1982 17.0 4.4 Michael Reese Hospital, Chicago (11) .3 1968 0.7 4.5 Harvard University, Boston (3) .75 19651981 16.0 4.7 Kaiser Medical Center, Denver (12) .5 1978 1.0 5.0 Institute of Medica Microbiology, GOteborg, Sweden (13) . . 10 1968-1969 1.5 6.7 Georgetown University, Washington, DC (14) .80 1975-1982 7.0 11.4 Northwestem Universiy, Chicago (15) .15 1978-1979 1.3 12.0 Lahey Cflinic, Boston (16) ...... 3 1983 0.2 15.0

patients with pneumonia or empyema, or both, blood or 24 to 48 hours. All patients survived. The average duration pleural fluid cultures were positive for pathogens. of hospital stay was 5.3 days. The longest hospital stay was 18 days in patient 7, in whom H influenzae empyema Treatment developed. Requiring intubation correlated with positive blood cul- Discussion tures, a rapid progression of symptoms, and the occurrence of symptoms. Intubation was done not pro- Incidence ofAdult Epiglotuitis phylactically but, rather, if a patient's condition appeared to Cases described between 1965 and 1983 are presented in be declining or if respiratory symptoms were progressing. Table 2.3-5 7-16 A substantial increase in the number of cases All patients received treatment with either chlor- has occurred since 1976. Between 1958 and 1976, there amphenicol or a ,B-lactamase-resistant cephalosporin. All pa- were 69 cases of epiglottitis reported in adults, and from tients also received parenteral (methylpredni- 1976 to 1983 a total of 203 adult cases were reported. An solone sodium succinate, 125 to 250 mg every 6 hours) for increased prevalence of other infectious illnesses caused by

rlrf < Cioss(4~~~~teral:r wi ,,' ~ .....

Figure 1.-The photograph taken with a flexible laryngoscope reveals an inflamed, swollen epiglottis (arrow) nearly obstructing the airway of patient 6. A drawing of the normal anatomyftXtol1gris shown for~~~~E,piglotliscomparison. 522 EPIGLOTTITIS IN ADULTS

H influenzae supports the proposal that the increased inci- within 12 hours after symptoms occur.23 In adults, the dura- dence ofH influenzae epiglottitis in adults is real rather than tion of symptoms can range from 2 hours to 10 days.8 Khi- the result ofincreased recognition.17- lanani and Khatib found that 58 % of adults presented within 24 hours,8 and Mustoe and Strome found 64% were seen Clinical Characteristics within 48 hours.3 The mean duration of symptoms in our The age ranges noted in our series are similar to those series was 13.9 + 8.7 hours, and only two patients sought in previous reports,231 5 and equivalent sex distributions medical care 24 hours or longer after symptoms began. exist.4 5'71 4 Although MayoSmith and colleagues found no The rapid appearance of respiratory symptoms in adults significant difference in the seasonal incidence of adult epi- indicates a more serious illness. The assumption of an up- glottitis,2 we and others have shown that more cases occur right posture and signs ofacute upper and during the winter months.21-24 drooling correlated with a high percentage of patients re- Most investigators report sore throat and dysphagia to be quiring airway intervention.14 In patients with symptoms of the most common symptoms,8'14'15 although has been less than eight hours' duration, evidence of airway compro- reported in as many as 80% of patients.2'3'8 Hoarseness, mise was found. In contrast, only 41 % ofpatients with symp- cervical adenopathy, neck tenderness, and have toms of longer than 12 hours' duration had airway compro- been noted in fewer than 30% .3,815 mise. Branefors-Helander and Jeppsson noted that all patients with symptoms of less than 24 hours' duration re- Unlike childhood epiglottitis, in which most children are quired intubation, but none required intubation if symptoms seen with respiratory symptoms, only five of our nine adult had been present for more than 24 hours. 13 Our most striking patients had such symptoms, consistent with the findings ofa observation was the frequency (67%) of missed diagnoses. previous report.23 In Khilanani and Khatib's review of 154 Schabel and co-workers and Procino found that 60% and cases, dyspnea occurred in 78 % ofpatients,8 but others have 75 % ofpatients in their series, respectively, were discharged reported respiratory symptoms in 20% to 33% of pa- with incorrect diagnoses on the initial visit.5'6 Lower, but still tients.3 4'14'15 The lower incidence of respiratory symptoms substantial rates of 38%, 32%, and 23% were reported by in adults may be related to the larger, more rigid structure of MayoSmith and colleagues, Mustoe and Strome, and An- the adult .3^4'8'4'16 dreassen and associates.24 The onset ofsymptoms tends to be more gradual in adults than in children. Most children with epiglottitis are seen Diagnosis The first approach to diagnosis is clinical and the second is microbiologic. The clinical diagnosis of epiglottitis is based on a patient's history and either abnormal findings on laryngoscopy or a confirmatory lateral neck soft tissue roent- genogram, or both. Awareness ofadult epiglottitis, however, is the most important step to diagnosis.

Figure 2.-The lateral neck radiographs depict the airway ob- structed by the inflamed, swollen epiglottis (arrow) of patient 6 before Figure 3.-The lateral neck radiograph done 3 weeks after suc- treatment. cessful therapy shows the normal epiglottis (arrow) of patient 6. * - THETHEWESTERNWESTERNJOURNAL OF MEDICINE * NOVEMBER 1989 151 * 5 523

Laryngoscopy, the most sensitive and specific test, rella multocida,3 ,34 Hemophilus should show inflammation of the epiglottis and supraglottic paraphrophilus,35 and Fusobacterium necrophorum. 36 structures. The laryngoscopist should be experienced and The large number of culture-negative cases may repre- able to establish an airway rapidly should the need arise. sent a viral or purely inflammatory cause.'5 Alternatively, in Although laryngoscopy has been reported to precipitate la- milder cases, the duration ofbacteremia may be self-limited. ryngeal in children with epiglottitis, we found no such In cases where H influenzae type b is identified as the reports in adults.424'25 pathogen, the disease is more severe.3"6 Two ofour patients Laryngeal visualization may be done either indirectly with cultures positive for H influenzae required intubation, using a laryngeal mirror or directly with a fiber-optic laryn- and in three of the four extraepiglottic complications devel- goscope or bronchoscope. Fiber-optic scopes have the added oped. In Mustoe and Strome's series, 70% of patients with advantage of facilitating by having the documented H influenzae had a leukocyte count endotracheal tube in position over the fiberscope before the greater than 15 x 109 per liter, 80% had temperatures procedure is begun.26' greater than 38.3°C (100.9°F), and 20% required a trach- The alternative to direct visualization is a soft tissue lat- eostomy.3 This was in contrast to 6% of patients without H eral neck roentgenogram. Its advantages are that it can be influenzae who required a tracheostomy. Also, the time from done without requiring the skills of an otolaryngologist or the occurrence of symptoms to hospital admission was re- pulmonologist and that there is no airway manipulation so duced compared with that in patients not infected with H the theoretic risk ofprovoking airway obstruction is not pres- influenzae. ent. It is, however, less sensitive and specific than direct visualization.9 In the only study comparing roentgenography Treatment with laryngoscopy, Schumaker and colleagues used quantita- Successful treatment requires an early recognition of tive measurements on a lateral neck radiograph and achieved epiglottitis in an adult. With 67% of patients misdiagnosed equal diagnostic yield.10 An epiglottic width of less than 8 on their initial presentation, many patients may not receive mm and an aryepiglottic fold width of less than 7 mm ruled appropriate therapy, sometimes with fatal consequences.37 out a diagnosis ofepiglottitis in adults, whereas an epiglottic Thus, a high level of suspicion and a low threshold for doing width ofmore than 14 mm and an aryepiglottic fold width of laryngoscopy or lateral neck roentgenograms, or both, are more than 10mm identified all cases ofepiglottitis confirmed necessary. by laryngoscopy. All diagnosed patients should be admitted to hospital and We suggest that laryngoscopy be done in all patients with carefully monitored, preferably in an . suspected epiglottitis. Ifthis is not possible, then lateral neck Although older series reported upper airway obstruction in soft tissue roentgenograms may either confirm or exclude the as many as half of adults, with a 50% mortality, and advo- diagnosis if the criteria noted earlier are used. If doubt still cated tracheostomy in all patients,4'5'925'38'39 more recent exists, however, then laryngoscopy should be done at the series' results indicate that no more than 10% to 30% of earliest opportunity. patients will require airway intervention.3'4'8"5 Prophylactic tracheostomy or intubation is recommended only for patients Etiology with rapidly progressive symptoms because most patients are Once a diagnosis of epiglottitis is established, therapy monitored carefully and can have airway support established should begin immediately. Determining the microbial cause if necessary. Recent cases of successful airway protection in is important to narrow the spectrum of antibiotic therapy, to acute epiglottitis by endotracheal and nasotracheal intuba- facilitate an assessment ofprognosis, and for epidemiologic tion have been reported.40'4' In McGovern and colleagues' surveys. Throat cultures and epiglottic swabs are not useful, series of 2,400 patients, endotracheal intubation carried a since organisms recovered may be normal flora. 17 Thus, con- mortality of less than 1 % versus a mortality of 3% for pa- firming the causative infectious agent requires a blood cul- tients having a tracheostomy.42'43 In a series of pediatric pa- ture or cultures ofaspirated material from abscess sites. tients consisting of 815 children with and 55 with Unlike childhood epiglottitis, in which more than 95 % of epiglottitis, the complication rate for intubation was 1.6%, children have a positive blood culture, most adult cases will whereas the mortality with tracheostomy was 3.6% .44 have no growth on cultures.28 In this series, five of nine Studies of smaller series ofadult patients arrived at the same patients (56%) had blood cultures positive for a pathogen. conclusions.45'46 The mean duration of airway support in This is higher than the 15% to 30% yield reported in most adult cases of epiglottitis has been reported at 40 to 60 other series.3"4'16 In the series of Deeb and associates, 86% hours.3'47 Intubation has been shown to decrease the duration had positive blood cultures if symptoms were of less than of hospital stays for epiglottitis patients as well, when com- eight hours' duration, but only 8% had positive cultures if pared with those having a tracheostomy.48 Tracheostomy symptoms were present for more than eight hours. 14 In addi- should be a maneuver oflast resort. tion, positive blood cultures are associated with the need for In patients with a more insidious onset of symptoms or airway intervention and with a poor outcome.2 without respiratory symptoms at presentation, careful obser- Type b Hemophilus influenzae, the most commonly cul- vation is recommended. Attention should be given to hydra- tured organism in both children and adults, is identified in tion and electrolyte and airway monitoring, as well as other 60% to 100% of all positive cultures.'0"12'28 In our series, associated extraepiglottic complications. There are anec- four of five positive blood cultures yielded H influenzae type dotal reports of benefits from the use of humidified oxygen, b. Streptococcus pneumoniae is the second most frequently inhaled vasoconstrictors (racemic epinephrine), and ste- cultured organism.8'29'30 Other orgamnsms reported include roids.49 Although there are no controlled trials of the use of hemolytic streptococcus (viridans, pyogenes),"I Staphylo- steroids in epiglottitis, it may be prudent to administer ste- coccus aureus, 16 Hemophilus parainfluenzae, 31'32 Pasteu- roids parenterally for a period of 24 to 48 hours. This will 524 EPIGLOTTITIS IN ADULTS

presumably decrease the inflammatory response, which 17. Hirschmann JV, Everett ED: infections in adults: Report of nine cases and a review of the literature. Medicine (Baltimore) 1979; may be more responsible for airway obstruction than the 58:80-94 . 18. Ward JI, Tsai TF, Filice GA, et al: Prevalence of ampicillin- and chloram- phenicol-resistant strains of Hemophilus influenzae causing meningitis and bacter- All patients should be started on antibiotic therapy once emia: National survey of hospital laboratories (News). J Infect Dis 1978; appropriate cultures are done. Initial treatment must be effec- 138:421-424 19. Chartrand SA, Marks MI, Roberts R, et al: Development of Hemophilus tive for resistant strains of H influenzae and S pneumoniae. influenzae meninigitis in patients treated with cefamandole. J Pediatr 1981; Ampicillin-resistant H influenzae was first reported in 98:1003-1005 20. Drapkin MS, Wilson ME, Shrager SM, et al: Bacteremic Hemophilus influ- 1974.50 By 1978 it represented 4.5 % ofcases"8 and by 1984, enzae type B cellulitis in the adult. Am J Med 1977; 63:449-452 14%.51 At our institution, 39% of H influenzae isolates are 21. Molteni RA: Epiglottitis: Incidence of extraepiglottic infection-Report of ampicillin-resistant. In our series two of four patients had H 72 cases and review ofthe literature. Pediatrics 1976; 58:526-531 22. Fearon BW, Bell RD: Acute epiglottitis: A potential killer. Can Med Assoc J influenzae bacteremia caused by ampicillin-resistant strains. 1975; 112:760-766 For these reasons, we recommend the use of chloram- 23. Johnson GK, Sullivan JL, Bishop LS: Acute epiglottitis-Review of55 cases phenicol or a fl-lactamase-resistant cephalosporin such as and suggested protocol. Arch Otolaryngol 1974; 100:333-337 24. Baxter JD: Acute epiglottitis in children. Laryngoscope 1967; 77:1358- cefuroxime52'53 or cefotaxime as initial antibiotic therapy. 1368 Treatment failures with cefamandole in children with H in- 25. Jones HM: Acute epiglottitis-A personal study over 20 years. Proc R Soc been noted. 19,54 The choice ofantibi- Med 1970; 63:706-712 fluenzae infections have 26. Phelan DM, Love JB: Adult epiglottitis-Is there a role for the fiberoptic otic can be changed once sensitivities have been determined. bronchoscope? Chest 1984; 86:783-784 A total seven- to ten-day course of antibiotics should be 27. Giudice JC, Komanski HJ: Acute epiglottitis-The use of the fiberoptic bronchoscope in diagnosis and therapy. Chest 1979; 75:211-212 administered. 28. Bottenfield GW, Archinue EL, Sarnaik A, et al: Diagnosis and management of acute epiglottitis: Report of 90 consecutive cases. Laryngoscope 1980; 90:822-825 Prognosis 29. Lederman MM, Lowder J, Lerner PI: Bacteremic pneumococcal epiglottitis In contrast to the earlier reported mortality rates ap- in adults with malignancy. Am Rev Respir Dis 1982; 125:117-118 30. Rose FB, Garman RF, Falkenberg KJ, et al: Adult epiglottitis, cellulitis and proaching 50%, most recent series report mortality at 0% to Streptococcuspneumoniae bacteremia. Scand J Infect Dis 1982; 14:301-303 20% I838'55In patients without respiratory symptoms on pre- 31. Oill PA, Chow AW, Guze LB: Adult bacteremic Haemophilus parainflu- is Khilanani and Khatib re- enzae infections. Arch Intern Med 1979; 139:985-988 sentation, mortality negligible.8 32. Schultes A, Agia GA: Acute Hemophilus parainfluenzae epiglottitis in an ported that patients with respiratory symptoms had a 21.7% adult. Postgrad Med 1984; 75:207-211 mortality and intubated patients a 14.3 % mortality.8 Patients 33. Johnson RH, Rumans LW: Unusual infections caused by Pasteurella multo- cida. JAMA 1977; 237:146-147 requiring an elective tracheostomy had a 4.9% mortality, 34. Berthiaume JT, Pien FP: Acute Klebsiella epiglottitis-Considerations for whereas those requiring emergency tracheostomy had a initial antibiotic coverage. Laryngoscope 1982; 92:799-800 In were no 35. Jones RN, Slepack J, Bigelow J: Ampicillin-resistant Haemophilus para- 45.5 % mortality. our series, there deaths. phrophilus laryngo-epiglottitis. J Clin Microbiol 1976; 4:405-407 Extraepiglottic infections have been reported, although 36. Lindquist JR, Franzen RE, Ossoff RH: Acute infectious supraglottitis in incidence figures are lacking. The most frequent infections adults. Ann Emerg Med 1980; 9:256-259 37. Strong M (Disct,ssant): Weekly clinicopathological exercises, In Scully RE, are pneumonia and empyema, as noted in our series. Other Galdabini JJ, Mcneely BU (Eds): Case Records of the Massachusetts General Hos- complications of acute epiglottitis are pericarditis,5" menin- pital. 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