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58 Clinical Quiz Volume 1 No. 1, 2003

CLINICAL QUIZ

How much do you know about ?

Casey Knight, BSc Alexandra Fraser, MSc

WHAT IS EPIGLOTTITIS? The is an elastic fibrocartilaginous valve that covers the superior aperture of the . During swal- lowing, the epiglottis functions to occlude the laryngeal opening and thus prevents material from entering the tra- chea. Epiglottitis, also known as supraglottitis, is an acute, severe and life-threatening of the upper airway. Epiglottitis occurs in both adult and pediatric populations. Since the introduction of a novel childhood vac- cine in the late 1980s, the pediatric incidence of this has significantly decreased. Considering the decreas- ing frequency and variable presentation of this infection, early recognition of this condition may become increas- ingly difficult. Failure to suspect and aggressively treat epiglottitis early contributes to its continuing mortality. The following quiz is designed to evaluate your knowledge of epiglottitis. Answers with explanations are located at the end of the quiz.

Question #1 Question #4 Which statement regarding epiglottitis in pediatric Anatomical structures affected by epiglottitis include all of populations is correct? the following EXCEPT: a) Highest incidence is between November and a) Aryepiglottic folds January. b) b) Prevalence is equal in both male and female c) Prevertebral soft tissues children. d) Arytenoids c) Worldwide incidence shows little geographic variance. d) Case fatality rates are extremely high with misdiagnosis. Question #5 Differential diagnosis for epiglottitis include all the following, EXCEPT: Question #2 a) (laryngotracheobronchitis) What childhood vaccination has significantly reduced the b) Retropharyngeal abscesses incidence of epiglottitis in children? c) Diphtheria a) Diphtheria d) b) H. influenzae type B c) Pertussis d) Varicella Question #6 Classic presentation of epiglottitis in the pediatric population includes: Question #3 a) , dyspnea and cough In North America, peak incidence of H. influenzae type b) Cough, fever and B epiglottitis is seen in the following age group: c) Stridor, drooling and fever a) 0-6 months d) Fever, cough and drooling b) 6-12 months c) 1-18 years d) 18 years + MUMJ Clinical Quiz59

Question #7 Question #10 When comparing adult and pediatric presentations of A characteristic radiographic finding of epiglottitis is the: epiglottitis, the following statement is INCORRECT: a) Thumb sign a) Adults exhibit more stridor b) Hourglass sign b) Adults are less likely to have dyspnea, fever or c) cough d) c) Adults are more likely to complain about painful swallowing d) Adults are likely to have tenderness Question #11 First line treatment of epiglottitis is: a) IV penicillin, amoxicillin or pivampicillin Question #8 b) IV chloramphenicol or levofloxacin The safest positioning of a patient with epiglottitis is: c) IV erythromycin a) Lying supine d) IV cefuroxime or b) Lying prone c) Patient’s position of choice d) Sitting in “tripod” position Question #12 Children with epiglottitis may subsequently develop: a) Meningitis Question #9 b) The most important step in the acute management of c) epiglottitis is: d) Ludwig’s angina a) Rapid administration of appropriate IV b) Protecting the airway c) Obtaining a lateral neck radiograph d) Direct visualization of the epiglottis

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ANSWERS

Question #1: D acute infectious process, epiglottitis mounts a systemic Without accurate diagnosis and rapid initiation of a immune response which often includes a febrile state on treatment plan that includes protection of the airway, presentation. mortality rises. Epiglottitis does not show seasonal vari- ation. Incidence varies widely with geographic location and there is a 60% predominance in males. Question #7: A In adults, epiglottitis often includes the supraglottic structures more extensively. Therefore, presenting com- Question #2: B plaints often focus on pharyngeal symptoms including H. influenzae type B vaccination has significantly severe pain and . These symptoms often reduced the incidence of epiglottitis in pediatric popula- occur before symptoms of respiratory distress. tions. However, HiB is still the leading cause of epiglot- Conversely, the initial presentation of epiglottitis in chil- titis in children. Other infectious causes include dren is more commonly focused around symptoms of , , respiratory distress. Candida albicans as well as several viruses. Traumatic epiglottitis can occur from direct trauma and thermal injury. Question #8: C Patients should be permitted to assume any position of comfort at all times, including sitting up during trans- Question #3: D port. Forcing children to assume specific positions, Peak incidence of epiglottitis has historically been in including removing them from parent’s lap, may cause children. However, with the introduction of the H. distress leading to complete obstruction. influenzae type B vaccine, epiglottitis in North American pediatric populations has virtually been eradicated. The highest incidence is now in adults who did not receive Question #9: B this vaccine as children or who develop the infection Due to the mortality and morbidity associated with com- from other etiological organisms. plete obstruction, airway control is the main priority in managing patients with suspected epiglottitis. Manipulation of the head for neck radiographs may Question #4: B result in complete obstruction of the airway. Direct visu- Epiglottitis can cause edema to numerous supraglottic alization of the epiglottis or irritation caused by starting structures including the aryepiglottic folds, the arytenoid an IV may also cause patient distress leading to airway cartilage and the prevertebral soft tissues of the neck. compromise. Therefore, all of the above are con- However, the vocal cords are spared. traindicated unless performed in a controlled setting with the support of physicians appropriately trained in otolaryngology or anesthesia. Question #5: D Croup, retropharyngeal abscesses and diphtheria can all cause and therefore can present Question #10: A like epiglottitis. Other differential diagnoses include: The thumb sign describes the thickened free edge of the foreign body aspiration, bacterial epiglottis, as seen on the lateral neck radiograph. The (pseudomembranous croup), peritonsillar abscesses, hourglass sign and steeple sign are both signs of croup, and thermal injuries. seen on the anteroposterior view of the neck. Both describe a widening of the hypopharynx with concomi- tant subglottic narrowing. The halo sign is a ring of air Question #6: C surrounding the heart on chest x-ray and is indicative of The most common presentation of epiglottis in children pneumopericardium. includes stridor, drooling and fever. Stridor results from the attempted movement of air past an enlarged, inflamed epiglottitis. Children who are unable to swal- low due to a narrowed, painful airway will drool. As an MUMJ Clinical Quiz61

following bacterial penetration of the mucosal barrier and invasion into the blood stream. This mechanism allows seeding of the epiglottis and surrounding tissues as well as infection of the meninges, skin, lungs, ears, and joints.

ACKNOWLEDGEMENTS The authors would like to thank Dr. J. Crossley, Emergency Medicine, Dr. R. Pennie, Pediatric Infectious Disease, and Dr. H. Stolberg, , all at Hamilton Health Sciences Corporation, for their assistance with this article. Figure 1. Normal lateral radiograph. With permission from the Department of Radiology, McMaster University. AUTHOR BIOGRAPHIES Casey Knight is completing her final year of medical school at McMaster University. Alexandra Fraser is in her second year of medical school at McMaster University.

REFERENCES 1. Altieri MF, Mayer TA. (1999). “Acute Respiratory Emergencies in Children: Croup, Epiglottitis, , .” In: Principles and Practice of Emergency Medicine 4ed. Schwartz MD et al. (eds.). Lippincott Williams & Wilkins: Philadelphia. Retrieved January 19, 2003 from the World Wide Web: http://online.statref.com/document.aspx?fxid=35&docid =1683. 2. Ames WA, Ward VMM, Tranter RMD, et al. (2000) Epiglottitis: an under- recognized, life-threatening condition. British Journal of Anaesthesia. 85: 795-797. 3. Carey MJ. (1996). “Epiglottitis in Adults.” American Journal of Emergency Medicine. 14: 421-424. 4. Ducic Y, Hebert PC, MacLachlan L, et al. (1997). “Description and evalu- ation of the vallecula sign: A new in the diagnosis of adult epiglottitis.” Annals of Emergency Medicine. 30: 1-6. Figure 2. Diffuse edema of the epiglottitis and aryepiglottic folds 5. Manno M. (2002). “Upper Airway Obstruction and Infection.” In: Rosen’s resulting in the thumb-like swelling. Emergency Medicine: Concepts and Clinical Practice, 5th ed. Marx JA et al (eds.) Mosby, Ind: St. Louis. 2245-2258 With permission from the Department of Radiology, McMaster University. 6. Mayo-Smith MF, Spinale JW, Donskey CJ et al. (1995). “Acute Epiglottitis: An 18-year experience in Rhode Island.” Chest. 108: 1640-1647. 7. Ogle JS, Anderson MS. (2003). “: Bacterial & Spirochetal.” In: Current Pediatric Diagnosis & Treatment, 16th ed. Hay, Jr. WW et. al. (eds.) McGraw-Hill Companies, Inc.: Philidelphia. Retrieved January 19, 2003 Question #11: D from the World Wide Web: http://online.statref.com/document.aspx?fxid= IV cefuroxime or ceftriaxone is first line treatment in 33&docid=601. epiglottitis. IV chloramphenicol or levofloxacin are sec- 8. Sack JL, Brock CD. (2002). “Identifying acute epiglottitis in adults: High degree of awareness, close monitoring are key.” Postgraduate Medicine. ond line treatment. Penicillin, amoxicillin and pivampi- 112: 81-86. cillin, and erythromycin are first and second line thera- 9. Stevenson MD, Gonzalez del Rey JA. (2002). “Upper Airway Obstruction: Infectious Cases.” Clinical Pediatrics Emergency Medicine. 3: 163-172. pies respectively for bacterial pharyngitis caused by 10. Stuart MJ. (1994). “Lesson of the Week: Adult epiglottitis: Prompt diag- group A streptococcus in adults. nosis saves lives.” British Medical Journal. 308: 329-330. 11. Tanner K, Fitzsimmons G, Carrol ED et al. (2002). “Haemophilus influen- zae type b epiglottitis as a cause of acute upper airway obstruction in chil- dren.” British Medical Journal. 325: 1099-1000. Question #12: A 12. Verghese ST, Hannallah RS. (2001). “Pediatric Otolaryngological Emergencies.” Anesthesiology Clinics of North America. 19: 237-256. Other foci of infection are possible during the bac- 13. Wurtele P. (1990). “Acute epiglottitis in children and adults: a large-scale teremic phase of epiglottitis. The most commonly incidence study.” Otolaryngology, Head and Neck Surgery. 103: 902-908. reported is pneumonia, followed by otitis media. Meningitis has also been reported. Bacteremia results