Pediatric thermal epiglottitis: insights from a tertiary center experience.

Thermal epiglottitis, a non-infectious cause of epiglottitis, is a rare entity that shares some clinical features with infectious epiglottitis. This study presents 16 years of experience in diagnosing and managing thermal epiglottitis. A retrospective descriptive study in a tertiary center in southern Israel included confirmed cases of thermal epiglottitis in children (0-18 years) between 2004 and 2020 by endoscopy. Of approximately 600,000 pediatric ER admissions between 2004 and 2020, seven children were diagnosed by endoscopy with thermal epiglottitis (mean age 24 months, 71% males). Clinical presentation included stridor, respiratory distress, and drooling. Four children had fever and elevated inflammatory markers at presentation and were treated with systemic antibiotics. All were treated with systemic steroids. The median length of stay in the PICU was five days, and four patients required intubations. All fully recovered without experiencing any sequelae.  Conclusion: Thermal epiglottitis stands as a potential contributor to acute upper airway obstruction. Although it's rarity, it should be discussed in any child with acute upper airway obstruction. It is essential to inquire directly about the accidental intake of hot beverages, particularly in cases lacking fever or elevated inflammatory markers. What is Known: • Thermal epiglottitis is a rare, non-infectious condition sharing clinical features with infectious epiglottitis. • Common presentations include stridor, respiratory distress, and drooling. What is New: • Thermal epiglottitis is a potential contributor to acute upper airway obstruction, urging consideration even in the absence of fever or elevated markers. • Direct inquiry about hot beverage intake for diagnosis is essential for diagnosis.

High risk and low prevalence diseases: Adult epiglottitis.

INTRODUCTION: Adult epiglottitis is a serious condition that carries with it a high rate of morbidity and even mortality due to airway occlusion. OBJECTIVE: This review highlights the pearls and pitfalls of epiglottitis in adult patients, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence. DISCUSSION: Epiglottitis is a life-threatening emergency that occurs more commonly in adults in the current medical era with vaccinations. Children present more commonly with acute respiratory distress and fever, while adults present most commonly with severe dysphagia in a subacute manner. Other symptoms may include drooling, muffled voice, and dyspnea. Streptococcus and Staphylococcus bacteria are the most common etiologies, but others include viral, fungal, caustic, thermal injuries, and autoimmune. Lateral neck radiographs assist in diagnosis, but they may be falsely negative. Visualization of the epiglottis is the key to diagnosis. Airway assessment and management are paramount, which has transitioned from direct laryngoscopy to flexible intubating endoscopy and video laryngoscopy with assistance from anesthesia and/or otolaryngology if available. Along with airway assessment, antibiotics should be administered. Corticosteroids and nebulized epinephrine are controversial but should be considered. Patients should be admitted to the intensive care setting for close airway observation or ventilatory management if intubated. CONCLUSIONS: An understanding of epiglottitis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Acute epiglottitis in a COVID-19 positive patient.

There have been more than 178 million global cases of COVID-19, the disease caused by the SARS-CoV-2 virus, with more than 3.8 million deaths worldwide [1]. COVID-19 can present with a wide variety of symptoms, and one rare manifestation that has been reported in the literature is acute epiglottitis. To date, there have been two reported cases of acute epiglottitis in COVID-19 positive patients [2, 3]. We present a case of a 49-year-old male presenting to a community emergency department with the chief complaint of dysphagia and sore throat, confirmed as acute epiglottitis, in the presence of a positive rapid COVID-19 PCR test.

Infective Uvulitis in a Child.

ABSTRACT: Infective uvulitis is a rare condition in children. In this report, we describe the case of a 4-year old-patient who presented a group A Streptococcus pharyngitis with uvulitis. No signs of epiglottitis were detected at nasal fibroscopy. She recovered rapidly with intravenous antibiotic therapy and 2 days of corticosteroid. Uvulitis is usually caused by group A Streptococcus or Haemophilus influentiae, but also other bacteria can be detected. Uvulitis can be isolated, or it can occur with epiglottitis and become an emergency.

Tonsillar hypertrophy and prolapse in a child - is epiglottitis a predisposing factor for sudden unexpected death?

BACKGROUND: Tonsillitis, with associated tonsillar hypertrophy, is a common disease of childhood, yet it is rarely associated with sudden death due to airway obstruction. Lethal complications involving the inflamed tonsils include haemorrhage, retropharyngeal abscess and disseminated sepsis. CASE PRESENTATION: We report on a case of sudden and unexpected death in an 8-year-old female who was diagnosed with and treated for tonsillitis. The child was diagnosed with acute tonsillitis 2 days prior to her collapse and was placed on a course of oral antibiotics. There were no signs of upper or lower airway obstruction. She was found to be unresponsive by her caregiver and gasping for air in her bed in the early hours of the second morning after the start of treatment. Autopsy showed massive and symmetrically enlarged palatine tonsils. The tonsils filled the pharynx almost completely. The epiglottis and laryngeal mucosa at the base of the epiglottis in the vicinity of the aryepiglottic membrane and the superior aspect of the larynx displayed red-purple discoloration, with mucosal swelling and edema. Histological examination of the palatine tonsils revealed prominent lymphoid hyperplasia, but no evidence of acute inflammation. CONCLUSION: Palatine tonsillar hypertrophy in infants is a common feature of both viral and bacterial tonsillitis and has been postulated as a possible risk factor for Sudden and Unexplained Death in Infancy (SUDI), based on the theory of mechanical impediment of breathing by narrowing of the upper airway. The rounded shape of the tonsils may facilitate some airflow past the enlarged structures and hence protect against asphyxial death when the enlarged tonsils fill the laryngo-pharynx. Epiglottal and proximal laryngeal edema may play a more significant role in asphyxial unexpected deaths in cases of tonsillitis with tonsillar hypertrophy than previously suspected. This focusses the importance of careful examination of the epiglottis and proximal laryngeal mucosa, as part of a thorough examination of the laryngo-pharynx in cases of sudden death associated with tonsillar hypertrophy.

A Rare Case of Candida Epiglottitis in an Immunocompetent Child.

We present a case of acute Candida epiglottitis in an otherwise healthy and Haemophilus influenzae type B-immunized 4-year-old child. A query of the literature reveals this disease to be commonly found in patients who are immunocompromised by problems including human immunodeficiency virus disease and lymphoma and leukemia. However, there are no published reports of acute Candida epiglottitis in immunocompetent and vaccinated patients. Our case should emphasize to the emergency physician the need to remain vigilant for subtle and atypical presentations of airway-destabilizing diseases.

Beware of thermal epiglottis! A case report describing 'teapot syndrome'.

BACKGROUND: The type of scalding injury known as 'teapot syndrome', where hot liquid is grabbed by the child with the aim of ingestion and falls over a child causing burns on the face, upper thorax and arms, is known to cause peri-oral and facial oedema. Thermal epiglottitis following scalds to face, neck and thorax is rare and can occur even in absence of ingestion of a damaging agent or intraoral burns, Awareness of the possibility of thermal epiglottitis, also in scald burns, is imperative to ensure prompt airway protection. CASE PRESENTATION: We report the case of a child with thermal epiglottitis after a scalding burn from boiling milk resulting in mixed deep burns of the face, neck and chest, but no history of ingestion. Upon presentation there was a progressive stridor and signs of respiratory distress requiring intubation. Laryngoscopy revealed epiglottis oedema, confirming the diagnosis of thermal epiglottitis. Final extubation took place 5 days after initial burn. CONCLUSIONS: Thermal epiglottitis following scalds to face, neck and thorax is rare and can occur even in absence of ingestion and intra-oral damage. Burns to the peri-oral area should raise suspicion of additional damage to oral cavity and supraglottic structures, even in absence of intra-oral injury or initial respiratory distress. Awareness of the occurrence of thermal epiglottitis in absence of intra-oral injury is important to diagnose impending upper airway obstruction requiring intubation.

Necrotizing epiglottitis treated with early surgical debridement: A case report.

OBJECTIVE: Necrotizing supraglottitis is a rare but potentially morbid infection most often seen in immunocompromised patients. All reported cases have utilized intravenous antibiotic therapy as the mainstay of treatment and many have had associated morbidities. METHODS: We describe a case of a 50-year-old previously healthy female who presented with necrotizing epiglottis and was treated with immediate surgical debridement followed by directed antibiotic therapy. RESULTS: Our patient rapidly recovered with no further invasive interventions. On follow up she had no further complications or functional deficits. CONCLUSIONS: Although uncommon, providers should be aware of the potential benefits of early debridement when treating patients with similar pathology. Early surgical intervention should be considered to avoid local tissue loss, airway interventions, and long-term sequelae.

Case Report of a 5-Year-Old With Epiglottitis: An Atypical Presentation of an Uncommon Disease.

Epiglottitis is a rarely encountered infection in pediatrics since the advent of the conjugate Haemophilus influenzae type b vaccine first introduced in the United States in 1985. However, the disease remains a much feared infection in pediatrics. The literature reiterates the importance of early recognition, avoidance of agitating the patient, and the need for securing the airway in the operating room as key and essential features to a good outcome. However, with only 1 case per 200,000 children reported in the United States in 2006, most practitioners have never encountered this infection. The following is a case of a previously healthy and immunized child who presented to our emergency department and whose condition was ultimately diagnosed as epiglottitis.

Do we need a change in ED diagnostic strategy for adult acute epiglottitis?

OBJECTIVES: To retrospectively evaluate the diagnostic performance of qualitative and quantitative radiographic parameters for diagnosing adult acute epiglottitis, and identify the prevalence and risk factors of false-negative neck radiography-based diagnosis of acute epiglottitis. METHODS: An emergency physician and a radiologist independently reviewed neck radiographs of 91 patients with laryngoscopy-confirmed acute epiglottitis and 91 control subjects between March 2010 and June 2016 for qualitative and quantitative radiographic parameters of acute epiglottitis, and concluded a diagnosis. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance of radiographic parameters, while independent risk factors of false-negative diagnosis were determined by multivariate logistic regression analysis. Inter-observer agreement was also calculated. RESULTS: All radiographic parameters showed good diagnostic performance with sensitivities and specificities of 33.0-80.2% and 64.8-100%, respectively. Epiglottis width (EW)>6.3mm showed the highest diagnostic performance (area under the ROC curve [AUC]: 0.867, sensitivity: 75.8%, specificity: 97.8%). Interobserver agreement for all radiographic parameters was excellent (range: 0.893-0.991). The lateral neck radiography-based false-negative diagnosis rate was 31.9%, and previous oral antibiotic usage was an independent risk factor of false-negative results. CONCLUSION: EW>6.3mm showed the best diagnostic accuracy, facilitating a neck radiograph-based diagnosis of acute epiglottitis. However, false-negative results on neck radiograph are quite common and previous oral antibiotic usage is a risk factor. Based on the knowledge of the usefulness and risk factors of false-negative results of neck radiography, diagnostic process for acute epiglottitis using neck radiography need to be changed.

[A Clinical Study of Acute Epiglottitis].

We carried out a retrospective review of 285 cases of acute epiglottitis (180 males, 105 females, mean age 49.6 years) that required inpatients hospital care between 1998 and 2014. All the patients complained of sore throat, and 62 patients complained of respiratory discomfort; 17 patients had severe dyspnea, and 27 patients required airway management (tracheotomy in 25, cricothyroidotomy in 2 patients). All the patients survived. As acute epiglottitis can cause rapidly progressive airway obstruction and death, emergent airway management should be undertaken in patients with dyspnea. However, it is difficult to determine the indications for prophylactic respiratory management in patients without dyspnea. Therefore, the disease severity of the epiglottitis was evaluated on a five-grade scale according to the degree of swelling of both the epiglottis and the arytenoids. Although prospective evaluation is necessary, this scoring system may be beneficial to determine the indication for airway management, because all of the patients who complained of severe dyspnea or underwent airway management had grade 4 or 5 disease, while none of the patients with grade 1-3 disease required tracheotomy or cricothyroidotomy. Moreover, we compared the white blood cell count, body temperature, serum CRP and the interval from the onset between the group that required airway management and the group that did not require airway management. The white blood-cell count and body temperature were significantly higher, and the interval from the onset was significantly shorter in the group that required airway management than in the group that did not require airway management; however, the serum CRP level did not differ between the two groups.

[Epiglottitis and necrotizing mediastinitis in a middle-aged man]. / Keski-ikäisen miehen epiglottiitti ja nekrotisoiva mediastiniitti.

Acute epiglottitis is nowadays a rare bacterial infection. Airway management and promptly started antimicrobial medication are essential in the treatment. Descending necrotizing mediastinitis is a life-threatening bacterial infection that typically spreads from an odontogenic, pharyngeal or neck infection. Despite the vagueness of symptoms, diagnosis must be made quickly. Owing to the high mortality rate, aggressive surgical treatment is indicated.