Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13)

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Clinical Manifestations and Diagnosis Epiglottitis typically presents more acutely in young children than in adolescents or adults.

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Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13) Clinical Manifestations and Diagnosis Epiglottitis typically presents more acutely in young children than in adolescents or adults. On presentation, most children have had symptoms for
on clinical grounds, although direct fiberoptic laryngoscopy is frequently performed in a controlled environment (e.g., an operating room) in order to visualize and culture the typical edematous "cherry-red" epiglottis and to facilitate placement of an endotracheal tube. Direct visualization in an examination room (e.g., with a tongue blade and indirect laryngoscopy) is not recommended because of the risk of immediate laryngospasm and complete airway obstruction. Lateral neck radiographs and laboratory tests can assist in the diagnosis but may delay the critical securing of the airway and cause the patient to be moved or repositioned more than is necessary, thereby increasing the risk of further airway compromise. Neck radiographs typically reveal an enlarged edematous epiglottis (the "thumbprint sign," Fig. 31-2), usually with a dilated hypopharynx and normal subglottic structures. Laboratory tests characteristically document mild to moderate leukocytosis with a predominance of neutrophils. Blood cultures are positive in a significant proportion of cases. Figure 31-2
Acute epiglottitis. In this lateral soft tissue radiograph of the neck, the arrow indicates the enlarged edematous epiglottis (the "thumbprint sign"). Epiglottitis: Treatment Security of the airway is always of primary concern in acute epiglottitis, even if the diagnosis is only suspected. Mere observation for signs of impending airway obstruction is not routinely recommended, particularly in children. Many adults have been managed with observation only since the illness is perceived to be milder in this age group, but some data suggest that this approach may be risky and probably should be reserved only for adult patients who have yet to develop dyspnea or stridor. Once the airway has been secured and specimens of blood and
epiglottis tissue have been obtained for culture, treatment with IV antibiotics should be given to cover the most likely organisms, particularly H. influenzae. Because rates of ampicillin resistance in this organism have risen significantly in recent years, therapy with a β-lactam/β-lactamase inhibitor combination or a second- or third-generation cephalosporin is recommended. Typically, ampicillin/sulbactam, cefuroxime, cefotaxime, or ceftriaxone is given, with clindamycin and TMP-SMX reserved for patients allergic to β-lactams. Antibiotic therapy should be continued for 7–10 days and should be tailored, if necessary, to the organism recovered in culture. If the household contacts of a patient with H. influenzae epiglottitis include an unvaccinated child under the age of 4, all members of the household (including the patient) should receive prophylactic rifampin for 4 days to eradicate carriage of H. influenzae. Infections of the Deep Neck Structures Deep neck infections are usually extensions of infection from other primary sites, most often within the pharynx or oral cavity. Many of these infections are life-threatening but are difficult to detect at early stages when they may be more easily managed. Three of the most clinically relevant spaces in the neck are the submandibular (and sublingual) space, the lateral pharyngeal (or parapharyngeal) space, and the retropharyngeal space. These spaces communicate with one another and with other important structures in the head, neck, and thorax, providing pathogens with easy access to areas including the mediastinum, carotid sheath,
skull base, and meninges. Once infection reaches these sensitive areas, mortality rates can be as high as 20–50%.