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Epiglottitis-An Increasing Problem for Adults KHALID H

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Epiglottitis-An Increasing Problem for Adults KHALID H 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 laryngoscopy or lateral neck 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 Streptococcus pneumoniae. In 2 patients the H influenzae was ampicillin-resistant. Al patients recovered after receiving parenteral steroid therapy and appropriate antibiotics. (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 epiglottis, aryepiglottic folds, and the ary- from these reports were grouped to determine incidence tenoid cartilage. The inflammation 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 dysphagia 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, stridor, 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 pneumonia 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 respiratory tract 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 antibiotic 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 corticosteroids (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 airway obstruction 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 fever 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 pharyngitis have toms of longer than 12 hours' duration had airway compro- been noted in fewer than 30% .3,815 mise.
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