Infections of the Upper Pediatric Airway: Epiglottitis

00:00 Let's switch to another infection, a little bit lower down in the throat now which is Epiglottitis.

00:07 Remember the epiglottis is that flap of tissue that closes over the trachea and prevents us from aspirating liquids when we drink. Historically, epiglottitis was much more common than it is now. It seems to be persisting more on multiple choice tests than it does in real life. So I see epiglottitis very rarely and this is because of the remarkable efficacy of the <i>Haemophilus influenza</i> B vaccine. This is a fantastic vaccine that has dramatically improved the quality and the extent of children's lives. So, epiglottitis because there's really no more H. flu type B in the United States, is now very rare. Causative organisms outside of the United States can still be absolutely H. flu or perhaps unimmunized children within the United States but there are other bacteria that can cause it such as <i>Streptococcus</i> or <i>Staph aureus</i>. So, what you should know about this is the clinical presentation of epiglottitis. This is a rapid onset disease. These patients are in grave distress. They have a high fever, they'll have a sore throat and they will be toxic-appearing.

01:26 They're really terrified about their breathing and their breathing is remarkably tenuous. These patients will be sitting forward and almost leaning forward in a tripod position because they're trying to keep that airway open. They'll have a hot potato voice. What that means is if you put hot potatoes in your mouth "har har her her har har ka" like that. That's a hot potato voice and that's what they'll sound like because they're trying to keep that airway open. They may also have stridor, the noise we typically see in patients with a narrowed upper airway. If you suspect epiglottitis this is a dramatic emergency. Patients can easily die from epiglottitis. You have to examine them remarkably carefully because there are reports of patients going in respiratory arrest simply due to the exam, that leaning forward is what's keeping them alive. So leave the child in their most comfortable position. Lab testing doesn't help you with this diagnosis. Patients may get the stress from a blood draw which then causes them to go into arrest so no labs are indicated. Diagnosis may be made by getting a lateral neck x-ray and seeing this here. It's called a thumbprint sign. That's because that epiglottitis has caused an inflammation of the epiglottis which makes it rounded, almost like you would imagine a thumbprint right there. You see that thumbprint? That's a thumbprint sign. Now it's gone, now it's there. So we manage this through emergent involvement of the pediatric airway specialist. We need to call an ear, nose, and throat doctor or an anesthesiologist, somebody who's capable of doing perhaps even fibroscopic intubation. We're going to control that airway first and we're going to have to intubate that patient and we may, in rare circumstances, need to put in a tracheostomy because this airway is so intense and we're unable to intubate after the child has coded. Typically, we will obtain epiglottal cultures and then provide broad-spectrum antibiotics to try and reduce the airway inflammation.