Diagnostic work-up: laryngoscopy and x-rays
The diagnosis of epiglottitis is usually made clinically but can be confirmed by direct visualization with a laryngoscope under monitored conditions.3 This should be done by personnel trained in management of a difficult airway—ie, anesthesiol-ogists and otolaryngologists—and a cricothyrotomy tray should be readily available in the event that the patient’s airway becomes compromised.
Lateral soft-tissue x-rays of the neck can be obtained if the patient is stable. However, the interpretation of these films can be difficult in equivocal cases. For this reason, a negative lateral soft-tissue view should not exclude the diagnosis of epiglottitis if clinical suspicion is high.
Once the diagnosis of epiglottitis is confirmed and the patient is stabilized, blood cultures and throat cultures may be obtained; however, their utility is questionable. More often than not, a causative agent will not be identified. Regardless of the laboratory results, current recommendations call for broad-spectrum antibiotic coverage, since many of these infections can be polymicrobial.
Management: Monitor the airway, administer antibiotics
Airway management is crucial in patients with epiglottitis. There is a debate in the literature as to whether or not these patients require immediate intubation due the danger of quickly losing an airway with little warning. Though most authors believe children with epiglottitis require a definitive airway at the time of presentation, adults can be closely monitored and treated conservatively4 —ie, hospital admission to a medical intensive care unit in a facility that has immediate access to anesthesiology and otolaryngology support.
Medical management consists of broad-spectrum antibiotic coverage with a third-generation cephalosporin.5 The use of steroids to reduce airway inflammation and potentially avoid the need for intubation is controversial, since the literature fails to show a direct benefit regarding the need for intubation, the length of intubation, or duration of hospital stay.6 Despite the lack of supporting evidence, steroids are often used as adjuvant treatment for epiglottitis.
Patient follow-up
The patient in this case was admitted to the hospital for close airway monitoring. He was treated conservatively with intravenous ceftriaxone, clindamycin, and Decadron, and his symptoms were significantly reduced by the second day in the hospital. He was discharged to home in stable condition on day 3. The patient fully recovered after a 10-day outpatient course of clindamycin and cefpodoxime.
DISCLAIMER
The views expressed in this material are those of the authors, and do not reflect the official policy or position of the US government, the Department of Defense, or the Department of the Air Force.
CORRESPONDING AUTHOR
William T. O’Brien, Sr, DO, Department of Radiology, David Grant US Air Force Medical Center, Travis Air Force Base, CA. E-mail: William.obrien@travis.af.mil