[CSF198] Epiglottitis: To intubate or not to intubate?

Carollo D, Whigham A, Abdallah C Children’s National Medical Center , Washington , DC, USA

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Introduction: Acute epiglottitis is a lifethreatening disorder with potential for laryngospasm and irrevocable loss of the airway. There are differences in trends, occurrences and management of acute epiglottitis between children and adults. Adolescent patients may present a challenge secondary to age categorization and management of acute epiglottitis. Case Presentation: A 16 years old presented to the emergency room complaining of severe sore throat, vocal changes and decrease oral intake. Vital signs were stable. Dysphagia was noted with no evidence of stridor or drooling. A lateral neck x-ray revealed the thumb sign (Fig1). A controlled intubation in the operating room after consultation and availability of an otorhinolaryngologist to create a surgical airway was planned. A deep plane of anesthesia was obtained with inhalation anesthesia (end tidal sevoflurane 4% in 100% O2) with the patient breathing spontaneously in a sitting position. Direct laryngoscopy showed a grade IV view secondary to an edematous epiglottis. The airway was secured with a 6.5 mm endotracheal tube using a Parsons Laryngoscope and a rigid bronchoscope. Anesthesia maintenance was achieved with a propofol infusion titrated to patients spontaneous ventilation. Trachea was extubated after two days of intravenous treatment with antiobiotics and corticosteroids. Patient was discharged home one day later. Blood and sputum culture showed no pathogens. Discussion: Epiglotittis in children is mostly due to haemophilus influenzae type b (Hib) and the incidence has been in decline due to vaccination against Hib. Acute epiglottitis in adults occurs from 0.97-3.1/ 100,000 with only 11% of sputum cultures and 31% of blood cultures revealing Hib etiology. There is an increase in the incidence of clinically less severe epiglottitis, with negative sputum cultures in adults (1). Difficulty in breathing and stridor are common signs of epiglottitis in children, but less frequent in adults. Selective airway intervention is possible in adults as those without severe airway compromise at presentation may recover well with medical treatment alone. Stridor in adults is regarded as a warning sign for occlusion of the upper airway. In this patient, despite the absence of stridor, a fast intervention by securing the airway under controlled conditions was justified considering hoarseness, dysphagia and a "thumb sign" on radiography. Conclusion: Criteria for selective airway intervention are not well defined in the adolescent patient with epiglottitis. Clinical signs may correlate with the level of inflammation. Significant predictors for imminent airway compromise may include drooling, stridor, shortness of breath or thumb-sign present in 79% of cases on X-rays of the neck. In the absence of a positive radiological finding, it is recommended to perform a flexible fiberoptic laryngoscopy for a reliable, timely diagnosis. References: 1. Neth J Med. 2008 Oct; 66(9):373-7.

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