ADULT EPIGLOTTITIS
“George Washington at Princeton” by Charles Willson Peale (1741 - 1827) Oil on canvas, 1779
George Washington died on December 14 1799 of an acute upper respiratory tract infection, which caused an obstruction to his upper airway. There has been much speculation since as to what the actual disease was. Quinsy, diphtheria, Ludwig’s angina and epiglottitis have all been put forward as possibilities. The current “best guess” is that he died from “Adult Epiglottitis”. Three physicians attended him during his final illness and there was much debate as how best to treat him. Dr. Elisha Cullen Dick, the youngest of the three advocated a tracheostomy, a new technique he had seen done in England. His two elder colleagues, Dr. James Craik and Dr. Gustavus Richard Brown were skeptical of this new technique and they prevailed on their younger colleague to persevere with the current “standard practice”. Over the following 16 hours an incredible 5 pints of blood was “let” from their patient! This treatment no doubt contributed to the ultimate demise of America’s first president.
ADULT EPIGLOTTITIS
Introduction
With the introduction of childhood vaccination against H. Influenzae, epiglottitis is becoming rare in children. It is more commonly being seen it adults, although the condition remains rare even in adults
Organisms Responsible for Epiglottitis in Adults
● Haemophilus influenzae
● Haemophilus parainfluenzae
● Pneumococcus
● Staphylococcus aureus
In many cases no causative organism is found.
Clinical features
1. Severely sore throat, especially in association with an apparently normal looking throat on examination.
2. Fever
3. Dysphagia
4. Hoarse voice
5. Stridor is less a feature than in children, occurring in less than 20% of cases on presentation. Although upper airway obstruction is seen less commonly in adults than in children, it none the less remains a potential catastrophic complication.
6. Drooling
7. Anterior neck discomfort and tenderness.
Investigations
Blood tests
1. FBE
● Will show an elevated white cell count.
2. CRP
● Will be elevated.
3. Blood cultures.
Plain radiology
● Soft tissue lateral neck x-ray, may show evidence of a swollen epiglottis, however, it is not very sensitive or specific.
Micro and culture:
● Once the patient is intubated, then a swab may be taken directly from the epiglottis.
Laryngoscopy
● The definitive investigation is indirect laryngoscopy. In contrast to children, there have been no reports of acute airway obstruction due to this procedure.
Management
1. IV ceftriaxone given as soon as the condition is suspected.
2. If airway compromise is severe, nebulized adrenaline may be of temporary benefit, prior to intubation.
3. All patients with adult epiglottitis must be observed closely in ICU. In contrast to children were all cases must be intubated, adults may be closely watched in the first instance providing the airway is not significantly compromised.
4. If the patient does not rapidly respond to appropriate antibiotic therapy, the possibility of an epiglottic abscess needs to be considered.
5. Rifampicin should be given to close contacts of the patient.
References:
1. Carey M J Epiglottitis in Adults: Am J Emerg Med vol 14 (4) July 1996 p. 421.
Dr J. Hayes
Reviewed 2 November 2004