Case Study of the Week: Epiglottitis

Have you seen any good zebras lately?  You know, a diagnoses that seem simple but turn into something crazier than usual.  Well, the other day I saw my second ever case of epiglottitis in a patient with a chief complaint of seemingly straightforward "sore throat" and thought the topic would be perfect for this week's case study.  

Epiglottitis is inflammation of the epiglottis, the flap at the base of the tongue that keeps food from going down the trachea and into the airway with swallowing.   It is most often cause by Haemophilus influenzae type b but may also be caused by other types of bacterial infection.  Non-infectious etiologies of epiglottitis include thermal causes, most often throat burns related to crack cocaine or marijuana smoking, ingestion of caustic substances, foreign body ingestion and head and neck chemotherapy.  Providers must be capable of diagnosing epiglottitis quickly.  While initial signs of epiglottitis can be mild, the condition progresses quickly and is life-threatening.

Case Presentation

A 32 year-old female presents to your clinic complaining or sore throat and a muffled voice.  She states that she has difficulty swallowing.  Her symptoms began upon waking a few hours earlier.  The patient is generally in good health with no significant medical history.  She has a fever with a temperature of 100.8 and is tachycardic with a pulse of 112.  

On exam, you notice the patient is unable to swallow secretions and is spitting into a cup.  She is in no respiratory distress but speaks with a muffled voice and states it is difficult for her to breathe.  Her pharynx appears normal but you note cervical lymphadenopathy on examining her neck.  Her lung sounds are clear.  Based on the patient's symptoms, you order an X-Ray of the soft tissues of her neck which shows a "thumb sign" indicating epiglottitis.  The patient then begins to experience increased difficulty breathing and is intubated by a physician. 

Management and Outcome

The enlarged, inflamed epiglottis can cause airway obstruction making airway management of utmost importance in treating epiglottitis.  Patients who are unstable, for example those with stridor, those who are sitting in the tripod position (on hands with tongue out and head forward) and those with respiratory distress require immediate airway attention.  These patients should be intubated.  If intubation is unsuccessful as a result of swelling of the epiglottis tracheostomy or cricothyrotomy may be necessary.  Stable patients without symptoms of airway compromise may be managed with close monitoring in the ICU.  

Third generation cephalosporins such as Rocephin are first-line treatment for epiglottitis.  Corticosteroid use in epiglottitis is controversial and has not been shown to be effective.  Antipyretics such as acetaminophen should be used to treat fever as necessary.  While X-Ray has traditionally been used to diagnose epiglottitis, laryngoscopy is now the preferred method.  

Although epiglottitis is a life-threatening emergency, outcome is usually very good with prompt treatment.

Discussion

Epiglottitis occurs in children and adults of any age.  Is it imperative that nurse practitioners recognize epiglottitis as it is a life-threatening emergency and must be treated promptly.  NPs should involve a physician in managing these patients as immediate intubation and advanced airway management is often necessary. 

 

Fun Fact: Did you know George Washington probably died of epiglottitis in 1799?