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Epiglottitis diagnosis and treatment

Created by Ian Mannarino.

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Video transcript

- [Voiceover] Diagnosis of epiglottitis starts with a clinical impression. A patient will come in with difficulty breathing, perhaps difficulty swallowing. Patients will commonly be drooling because they can't swallow. They'll have a very muffled voice, like very hoarse and deep because they don't want to vibrate their epiglottis, because their epiglottis is swollen. That's epiglottitis. They have difficulty breathing because all of the swelling of their epiglottis causes narrowing of the airway, and difficulty getting air into the lungs. This narrowing also causes what's known as stridor. As a patient breathes in oxygen, it has to pass through this very narrow airway now. When it's narrowed, it can make this very musical sound. That musical sound is called stridor. A lot of times, it's referred to as inspiratory stridor. On inspiration, they have this musical sound. It kind of sounds like (heavy wheezing), trying to (high-pitched wheezing), trying to breathe and get air into the lungs with a narrow airway. (high-pitched wheezing) Makes that sound. Right along with fever, they've got fever. Other signs of infection, they might have chills. It might be severe enough for that. They look very toxic. They have this difficulty breathing, and this drooling going on. One thing of note, there are actually no cough receptors in the epiglottis, so patients won't have a cough. That's a point I will come back to in a little bit. Again, this musical sound, I'll go ahead and write it over here, is known as stridor. Another sign that these patients may have is commonly known as the tripod sign. First of all, patients will try to keep their mouth open. They'll actually extend their neck and chin forward, because that actually relieves some of this narrowing of the airway. It helps them breathe a little bit. It also decreases the pain, because if the epiglottis touches something, it can be painful. They're trying to pull that epiglottis back by opening their airway up. To illustrate the tripod position, I'm going to use a little stick figure. A patient may actually be sitting up, and leaning forward. When they lean forward, they put their hands forward, too, possibly on their knees or on the bed in front of them. This gives them a characteristic tripod position, where they're leaning forward, and they're using their hands to prop themself forward. This also relieves the airway obstruction, or the pressure on their throat, by going forward. You'll notice, they'll prefer the sitting-up position. A patient cannot actually lean back, lying flat on the back. If patients do that, then their airway will close up. The swelling will press further on their airway, and make it difficult for air to pass through. Those are some clinical signs that a health practitioner can use to help them diagnose epiglottitis. Diagnosis itself comes by direct visualization of the swollen epiglottis. Epiglottitis also includes swollen aryepiglottic folds, as well as the arytenoid cartilage. Just looking at this little diagram right here, you can see the epiglottis is this flap that goes up. The aryepiglottic folds go down from the epiglottis. The arytenoid cartilage is right here. Really, anything around here swollen would be diagnosed as epiglottitis. Direct visualization of swelling is how you can diagnose epiglottitis. But, there are a couple other tricks in the bag. For that, I'll go ahead and scroll down here to show some x-rays. Normally, what you would see without epiglottitis ... The normal epiglottis is going to be right here. This will be the normal epiglottis. There's some other pathology I'll show here in a second, but you can see the normal epiglottis is really tiny. It's right here. It's actually very thin. I'll color it in. It's this very thin flap that sits over the voice box that's able to close down when you swallow to protect the airway. The larynx would actually be right here. This is where the vocal cords are. Let's get rid of some of that. Again, the epiglottis is right here, this very thin flap. Over here, these two are cases of epiglottitis. Right here, you can see the epiglottis, in this lateral view, looks about like that. You can see that. I'll color it in again. It's a little more swollen. Really, anything over eight millimeters thick, with a lateral view, a lateral radiological view of the neck, would be considered epiglottitis. Over here, in this picture, you can actually see very severe epiglottitis. This whole thing, right here, is the epiglottis. It's completely swollen over, really big. We actually call that the thumb sign, because it appears like a big thumb just kind of smudged on there. Whereas, before ... Here's the normal epiglottis again. It's this very thin flap, as I keep saying. But here, it's really swollen. It can get really bad. You can see how that can close up the airway. Radiology may be used to assist in the diagnosis of epiglottitis. Other things that can be used are throat cultures. That's when a physician takes a piece of cotton, or a Q-tip, and just swabs the back of the throat, right back here, past the uvula, which is the little dangling thing in the back of your throat. That can help identify the bacterial organism that's causing epiglottitis. Back in the day, the most common organism that would cause epiglottitis is Haemophilus influenza, also known as H. flu. Influenza, it's not actually the flu virus. It's a bacteria. Haemophilus influenza is a bacteria. It's somewhat of a misleading name. This used to be the major cause of epiglottitis in the United States, and really in the world. In fact, very specifically, it was Haemophilus influenza type B. It's this specific type of H. flu that caused epiglottitis. Thanks to modern medicine, we have a vaccine, called H-i-b, Haemophilus influenza-b vaccine. That has helped decrease the incidents of epiglottitis. Some other bugs that have known to cause epiglottitis, but not as severely as H. flu, are the staph and strep bugs. Strep pneumoniae, strep pyogenes, and staph aureus. All of this, you can use to help you diagnose and lead to the treatment of epiglottitis. Before we talk about treatment, I want to go down here, and talk about the clinical picture, the clinical symptoms, again. There's actually another illness that is very similar to epiglottitis, called croup. Croup is also known as tracheolaryngitis. It's inflammation of the trachea, the throat. Let me just do a rough sketch of the airway again. We'll put the larynx in this circle right here. It's a very rough sketch. Croup is tracheolaryngitis. It includes the larynx, which is where the voice box is, and the trachea, which is the windpipe just below the larynx. Whereas, epiglottitis ... is really only swelling of the epiglottis, and the aryepiglottics, and arytenoids, everything above the larynx. With croup, it's swelling of the larynx and the trachea. So, you'll still get stridor, because you have a narrowing of this airway right here. You'll still get that musical noise of air trying to force its way into the lungs. You'll also see that, of course, with epiglottitis. With croup, a major difference is you won't see any drooling. Patients can swallow a little bit better, so they don't have as much drooling. Whereas, of course, epiglottitis, you do see drooling. Another major difference is, in epiglottitis, patients have the tripod sign. They're sitting up straight. They can't lie down, whereas croup, they can actually lie down without any issues. Finally, a major difference is, in epiglottitis, there's no cough because there are no cough receptors being stimulated. The epiglottis doesn't have any cough receptors. Whereas, when you touch the larynx or the trachea, it can very strongly stimulate cough. In fact, you actually get what's known as a barking cough. I keep moving us around, but I want to move back up here for a couple last points. This, right here, is actually a radiographic image of croup, tracheolaryngitis. You can see all this swollen tissue is closing up the airway, but that's below the epiglottis. Here, we don't have an issue. In fact, over here, you can't really see it at all. You have a very clear airway. That's a major difference, in a radiographic image, that you can see between croup and epiglottitis. Let's go ahead and finish off with the treatment of epiglottitis. First of all, this is a very major point. You want to protect the airway. This is the number-one treatment of epiglottitis, because it can close up so rapidly. In fact, one-to-two hours after getting a fever, patients can actually start to swell up and have trouble breathing. Airway protection is number one. A little side note, if you at all suspect epiglottitis, do not use a tongue blade. This is actually very critical because that can cause more swelling. You only want to examine the airway, to diagnose epiglottitis, when all the tools to establish airway protection, to be able to put a tube into the throat, are at hand to allow oxygen delivery to the lungs. Airway protection is critical. Number two, antibiotics should be given to the patient right away. The course is generally agreed to be about seven-to-ten days of treatment. However, around two-to-three days, some resolution of the symptoms can start to be seen. A patient should be observed in the hospital until their symptoms start to resolve. Antibiotics should be given for the full treatment. If a patient doesn't take antibiotics for the full seven-to-ten days, then epiglottitis may actually recur. Patients must be reminded to take the full treatment, the full course, of antibiotics. Last of all, prevention is through the H-i-b vaccine, the Hib vaccine. Of course, you'd also want to follow some precautions, like don't share any personal items. Make sure to wash hands thoroughly after encountering a patient with epiglottitis, and so on, and so forth.