History

Fact Explanation
Acute onset high fever in an ill looking child aged 1-6 years. Acute epiglottitis is common in children aged 1-6. But can affect all age groups. [1]
Severe sore throat rapidly progressing to poor feeding, lack of activity and drooling of saliva. Edema occurs in the epiglottis and surrounding structures (Eg: arytenoids, aryepiglottic folds ) due to acute inflammation. [1],[2]
Soft stridor Stridor is produced by the rapid, turbulent flow of air through a narrowed or partially obstructed segment of the extra thoracic upper airway. The pitch of stridor helps to determine the level of obstruction. A low pitched, snoring type sound is generated at the level of oropharynx and supraglottis. Therefore, producing the soft stridor heard in epiglottitis. But in croup, the turbulence in airflow occurs at the level of Larynx and trachea, producing a high pitched harsh stridor. [3],[4]
Labored breathing Inflammation reduces the diameter of the upper airway; therefore, the resistance to the airflow is markedly increased. As a result of which the work of breathing increases. [4]
Non-immunization against Haemophilus influenzae type B (Hib) Acute epiglottitis is caused by H. influenzae type b. But the introduction of universal Hib immunization in infancy has led to a decrease by 99% in the incidence of epiglottitis and other invasive H. influenzae type b infections. [1],[4]
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. ABDALLAH Claude. Acute epiglottitis: Trends, diagnosis and management. Saudi journal of Anaesthesia. 2012 Jul-Sep; 6(3): 279–281. doi: 10.4103/1658-354X.101222
  3. BAILEY, B.J. CALHOUN, K.H. HEALY, G.B. eds. Head and neck surgery- otolaryngology. 3rd ed. Phildelphia: LIppincott, Williams & Wilkins, 2001.
  4. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.

Examination

Fact Explanation
Child is very ill with high fever. This is a severe bacterial infection caused by H. influenzae (type b). The thermostat in the hypothalamus is set at a higher point owing to cytokines produced in the inflammatory process, . [1],[2]
Child sitting up and leaning forward with an open mouth and extended neck. This position (Tripod position) optimises airway patency. [2]
Swollen and erythematous epiglottis. If Epiglottitis is suspected do not make attempts to examine the throat as this may further distress the child and cause laryngospasm; thus leading to airway obstruction. Examination is best done in the operating theater or in a similar setting with facilities for emergency procedures. ( Eg: Tracheostomy) [1],[3]
Tachypnea and dyspnea with marked intercostal and subcostal recessions. Hypoxia leads to the stimulation of respiration resulting in increased respiratory rate and effort. [1],[3]
Cyanosis Deoxygenated hemoglobin concentration of more than 5g/dl results in bluish discoloration. [1]
Deterioration of level of consciousness. Hypoxia reduces cerebral functions, resulting in decreased level of consciousness. This indicates impending respiratory arrest.[1]
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. ABDALLAH Claude. Acute epiglottitis: Trends, diagnosis and management. Saudi journal of Anaesthesia. 2012 Jul-Sep; 6(3): 279–281. doi: 10.4103/1658-354X.101222
  3. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.

Differential Diagnoses

Fact Explanation
Viral Croup Croup commonly affects children of 7-36 months of age. But may be seen in children of all age groups. The symptoms begin with upper respiratory tract symptoms and mild fever. Within 12 to 48 hours, a barking type cough and harsh inspiratory stridor may be apparent. Supraclavicular and subcostal recessions may noted. Symptoms are aggravated by crying and relieved by nebulized epinephrine. Most children appear only mildly ill. [1],[2],[3]
Inhaled foreign body A foreign body in either the trachea or esophagus produces stridor. Patient presents with sudden onset cough or respiratory distress with history of choking on food or on a small object. [1],[2]
Bacterial Tracheitis Caused by superinfection of the trachea that may follow viral croup; mostly caused by S. aureus. Affected patient generally appears very ill with high fever and loud harsh stridor. Relatively more common in older children. They usually do not respond to nebulized epinephrine. [2],[3]
Retro pharyngeal abscess Patient has fever, stridor, limitation of neck movement, agitation or lethargy. Physical examination may reveal midline fullness of the oropharynx. [3]
Inhalation of smoke or Thermal or caustic substance It may result in injury to airway and hypo pharynx. Symptoms of airway compromise may be delayed by as long as 6 hours. [2],[3]
Laryngomalacia Is the most common cause of congenital stridor and accounts for 75% of chronic stridor in children younger than 1 year. The stridor associated with laryngomalacia is positional; worsened by placing the infant in supine position. [2]
Other congenital airway abnormality There is a history of recurrent and continuous stridor since birth. Other congenital causes of stridor are laryngeal webs, laryngeal diverticuli, vocal cord paralysis, subglottic stenosis, tracheomalacia and vascular abnormality such as double aortic valve vascular sling. [3]
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.
  3. FLEISHER, Gary R. and LUDWIG Stephen. Textbook of Pediatric Emergency Medicine. 6th ed.Phildelphia: Lippincott Williams & Wilkins, 2010.

Investigations - for Diagnosis

Fact Explanation
Blood culture and Antibiogram Epiglottitis is a clinical diagnosis. But blood should be taken for culture and Antibiogram prior to administering empirical antibiotics. 50% of cultures Show H. influenzae (type b) growth. [1], [2]
Lateral neck x-ray The lateral radio graph reveals thickened and bulging epiglottis (Thumb sign) and swelling of aryepiglottic folds. [1], [2]
Direct observation under anesthesia or fiber optic larygoscopy The diagnosis of epiglottitis is confirmed by the inflamed and swollen supraglottic structures and swollen cherry red epiglottis. [2]
Full blood count This will show neutrophil leucocytosis. [1]
C-reactive protein (CRP) CRP is used mainly as a marker of inflammation (Normal concentration of C-reactive protein in healthy human serum is usually lower than 10 mg/L and may increase up to 40–200 mg/L in bacterial infections). CRP is a more sensitive and accurate reflection of the acute phase response than the ESR, as in the first 24 h, ESR may be normal although the CRP is usually elevated. The half-life of CRP is constant. Therefore, CRP level is mainly determined by the rate of production (and indicates the severity of the precipitating cause). [3]
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.
  3. KENNELLY, P. MURRAY, R.F. RODWELL V.W. BOTHAM, K.M. Harper's illustrated biochemistry. McGraw-Hill Medical, 2009.

Investigations - Followup

Fact Explanation
C-Reactive Protein. (CRP) Measuring CRP levels are useful in determining disease progression and the effectiveness of treatment. The half-life of CRP is constant. Therefore, CRP level is mainly determined by the rate of production (and indicates the severity of the precipitating cause). CRP returns to normal more quickly than ESR in response to therapy; therefore, CRP is a better predictor of recovery. [1]
References
  1. KENNELLY, P. MURRAY, R.F. RODWELL V.W. BOTHAM, K.M. Harper's illustrated biochemistry. McGraw-Hill Medical, 2009.

Management - General Measures

Fact Explanation
Admit the patient. It is a clinical diagnosis.The child needs urgent hospital admission owing to the impending risk of respiratory arrest due to laryngospasm.[1]
Keep the child calm. Keep the child in the most comfortable position with least disturbance (Ex: on mothers lap). Avoid irritating the child (Ex: cannulation or examining the throat with a spatula), due to the risk of laryngospasm. [1], [2],[3]
Oxygen Administer high flow humidified oxygen via face mask. Child needs respiratory support owing to the respiratory distress. Monitor via pulse oximetry to identify deterioration of the condition. [1], [3]
Get help Inform seniors, anesthetist, pediatrician and ENT surgeon and seek help immediately. Acute epiglottitis is a life-threatening disorder because of the impending risk of laryngospasm and subsequent obstruction of the airway. [1],[3]
Intubation Child should be intubated by the most competent person in order to ensure the maintenance of the airway. This is done under controlled conditions with general anesthesia. Tracheal tube can usually be removed after 24 hours. [1],[3]
Urgent tracheostomy If intubation fails, do urgent tracheostomy to maintain airway. [3]
Cricothyroidectomy In the absence of experts in above procedures, do cricothyroidectomy with a wide bore needle (G 16). It may be life saving in the event of sudden respiratory arrest. [3]
IV cannulation. Child needs IV antibiotics and IV fluids. [1],[2] Note that this is to be carried out after establishing the patency of the airway.
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.
  3. ABDALLAH Claude. Acute epiglottitis: Trends, diagnosis and management. Saudi journal of Anaesthesia. 2012 Jul-Sep; 6(3): 279–281. doi: 10.4103/1658-354X.101222

Management - Specific Treatments

Fact Explanation
IV antibiotics. Third generation cephalosporins are preferred over ampicillin and chloramphenicol, since 30% 0f H. influenzae are resistant to the latter drugs. 1) Ceftriaxone or cefotaxime are given for 7-10 days.They are the most active cephalosporins against strains of H. influenzae which are not susceptible to penicillin. 2) Chloramphenicol -When third generation cephalosporins are not available this is used as an alternative antibiotic. [1],[3]
Dexamethasone IV or budesonide aerosols They are anti inflammatiry agents which can be used to reduce pharyngeal edema and thereby reduce the airway resistance. [2]
Prophylaxis If there is a child under 4 years at home, who has not completed Hib vaccination, give Rifampicin 20mg/kg for 4 days to all household contacts including the index case to eradicate career state. [1],[3]
Immunization The introduction of universal Hib immunization in infancy has led to a decrease of 99% in the incidence of epiglottis and other invasive H. influenzae type b infections. [1],[4]
References
  1. LISSAUER Tom and CLAYDEN Graham. Illustrated text book of pediatrics. 3rd ed. Philadelphia: Elsevier, 2007.
  2. ABDALLAH Claude. Acute epiglottitis: Trends, diagnosis and management. Saudi journal of Anaesthesia. 2012 Jul-Sep; 6(3): 279–281. doi: 10.4103/1658-354X.101222
  3. BNF for children. BMJ publishing group LTd, Royal pharmaceutical society of great Britain, RCPCH Publication Ltd, 2005.
  4. KLIEGMAN, Robert M. MARCDANTE, Karen J. JENSON, Hal B. and BEHRMAN, Richard E. NELSON Essentials of pediatrics. 5th ed. Philadelphia: Elsevier, 2006.