Predictors of airway intervention in acute supraglottitis (AS), a recent 7- year experience.

AIMS: Acute supraglottitis (AS) can be a life threatening infection that may lead to sudden airway obstruction. Thankfully, paediatric instances have decreased with public health vaccination programmes. Owing to the nature of the location of pathology, this time sensitive emergency requires astute clinical acumen and awareness of early warning signs. This study aimed to i) determine if the incidence of AS has changed over time; ii) investigate geographical and seasonal variation of infection; iii) identify features of presentation which may predict airway intervention; iv) assess efficacy of treatment and make recommendations for management. MATERIALS AND METHOD: All adult patients admitted to a tertiary hospital with the diagnosis of acute supraglottitis between 2013 and 2021 were included. Diagnosis was confirmed with flexible nasendoscopy and consultant review. Demographics, management and outcomes were recorded. Statistical analysis was performed by calculating means and standard deviation for descriptive purposes. Fischer's exact test and two tailed t-test for categorical and continuous variables respectively. Results were deemed significant if P values of less than or equal to 0.05 were calculated. RESULTS: Forty-three adults were identified. Five patients (11.6%) required airway intervention. Stridor, respiratory distress and CRP of >100 mg/L were noted to be significant predictive factors for airway intervention. Intubated patients had a significantly longer hospital stay. Regions with a higher population density were noted to have a higher incidence but this did not prove to be significant. CONCLUSION: This is the largest study of AS in Ireland to date. There is a trend towards increasing incidence of acute supraglottitis in adults. Factors such as stridor, respiratory distress and elevated CRP should alert the clinician to the possible need for airway intervention. Acute supraglottitis is more common in higher density populated regions.

Non-infective supraglottitis: two cases of unusual aetiology.

Supraglottitis is an ear, nose and throat emergency where swelling of the laryngeal structures can threaten to fatally obstruct the airway. Most cases of supraglottitis are of infective origin but other rarer causes have been documented. We present two patients who presented with stridor and were found to have supraglottic oedema on fibreoptic nasolaryngoscopy. Both patients presented with odynophagia and progressive dyspnoea and were initially medically managed to stabilise their airway. This included intravenous steroids, nebulised epinephrine and intravenous antibiotics. After this initial treatment they both required investigation and optimisation of their underlying medical conditions (rheumatoid arthritis with possible systemic lupus erythematosus and nephrotic syndrome) as more definitive management.

When Specialty Care Is Unavailable to Rural Families.

We present the case of a 2-year-old boy with epidermolysis bullosa and supraglottic stenosis whose parents refuse an elective tracheostomy because of the significant care the tracheostomy would require. The patient's family lives in a rural area with few health care resources and his parents are already handling hours of daily skin care for his epidermolysis bullosa. In an attempt to convince the parents to pursue the intervention, the medical team recommends that the family move to an area with additional resources to assist in the child's care. The parents refuse to move, citing the many benefits their home environment provides for their son. The medical team calls an ethics consultation, questioning whether this decision constitutes medical neglect. This case raises important questions about medical decision-making in pediatrics. First, is a parent's refusal of a recommended medical intervention because it would require moving their family to a new environment a reasonable decision? Second, how broadly can parents define their child's best interest? Should only physical interests be included when making medical decisions? Is there a limit to what can be considered a relevant interest? Third, can parents only consider the interests of the individual child, or can they consider the interests of other members of the family? Finally, what is the threshold for overruling a parental decision? Is it whenever the parent's definition of a patient's best interest is different from the medical team's, or do other criteria have to be met?

Pediatric supraglottic airway devices in clinical practice: A prospective observational study.

BACKGROUND: Supraglottic airway devices (SGA) are commonly used in pediatric anesthesia and serve as primary or back-up devices for difficult airway management. Most SGA are marketed without proper clinical evaluation. The purpose of this study was to evaluate the performance of the pediatric LMA Supreme™, Air-Q® and Ambu® Aura-i™. METHODS: This prospective observational study was performed at Bern University Hospital, Switzerland. With ethics committee approval and a waiver for written informed consent 240 children undergoing elective surgery with an ASA class I-III and a weight of 5-30 kg were included. Three different pediatric supraglottic airway devices were assessed: The LMA Supreme™, Air-Q® and Ambu® Aura-i™. Primary outcome parameter was airway leak pressure. Secondary outcome parameters included first attempt and overall success rate, insertion time, fiberoptic view through the SGA, and adverse events. The primary hypothesis was that the mean airway leak pressure of each tested SGA was 20 cmH2O ± 10%. RESULTS: None of the SGA showed a mean airway leak pressure of 20 cmH2O ± 10%, but mean airway leak pressures differed significantly between devices [LMA Supreme™ 18.0 (3.4) cmH2O, Air-Q® 15.9 (3.2) cmH2O, Ambu® Aura-i™ 17.3 (3.7) cmH2O, p < 0.001]. First attempt success rates (LMA Supreme™ 100%, Air-Q® 90%, Ambu® Aura-i™ 91%, p = 0.02) and overall success rates (LMA Supreme™ 100%, Air-Q® 91%, Ambu® Aura-i™ 95%, p = 0.02) also differed significantly. Insertion times ranged from 20 (7) seconds (Air-Q®) to 24 (6) seconds (LMA Supreme™,

Feasibility of a Supraglottic Airway Device for Transbronchial Lung Cryobiopsy-A Retrospective Analysis.

OBJECTIVES: To determine the feasibility of a supraglottic airway device for transbronchial cryobiopsy in adults. DESIGN: Retrospective analysis of anesthetic and pulmonary records between March 2015 and August 2016. SETTING: Single university medical center. PARTICIPANTS: One hundred thirty-two patients who underwent transbronchial cryobiopsy procedures performed under general anesthesia. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Failure-free use of a supraglottic airway device was 96.8%. Failure of supraglottic airway device insertion was 3.1% because of impossible placement (n = 1), high oropharyngeal leakage (n = 1), massive bleeding requiring bronchial blocker (n = 1), and acute right heart failure with cardiac arrest requiring resuscitation (n = 1). No serious adverse events due to the supraglottic airway device were observed. CONCLUSION: The data demonstrated that transbronchial cryobiopsy under general anesthesia and airway management with a supraglottic airway device was a feasible technique.

Infections and edema.

Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.

Adult supraglottitis: changing trends.

There is no clinical dynamic staging system which scores according to severity all the anatomical regions in adult supraglottitis. The objective of the study was to describe the demographics, clinical presentation, interventions and outcomes of adult patients diagnosed with acute supraglottitis (AS), and to study the correlation of a new AS classification with the need for airway intervention, in comparison with the current classification. This was a retrospective, cohort study conducted at a secondary medical care center. Adults diagnosed with AS from the years 1990-2013 were identified. Data were extracted for demographic and clinical information and there was no intervention. The main outcome and measures were the need for airway intervention. 288 eligible patients were enrolled. AS incidence rate was 4.3/100,000 patients/year. The mean age was 50 ± 16 years. Sore throat (94 %) and dysphagia (88 %) were the most common presenting symptoms. Patients were hospitalized either in the Otolaryngology Department (n = 255, 89 %) or in the Intensive Care Unit (n = 33, 11 %). Of the latter, 19 (58 %) had an airway securing intervention procedure. Our suggested classification was more sensitive than the current one for predicting the need for intubation (p = 0.03). Signs and symptoms of AS in adults are different from those in children. Adult patients presenting with oropharyngeal complaints should be suspected for AS and treated appropriately.

Supraglottitis due to group B streptococcus in an adult with IgG4 and C2 deficiency: a case report and review of the literature.

Acute supraglottitis is a medical emergency as it can rapidly lead to airway compromise. With routine pediatric immunization for Hemophilus influenzae serotype b, supraglottitis is now more prevalent in adults, with a shift in the causative organisms and a change in the natural history of this disease. Here, we present a case of supraglottitis due to group B streptococcus that occurred in an adult with previously undetected immunoglobulin 4 (IgG4) and complement protein C2 deficiency.

Diagnostic accuracy of lateral neck radiography in ruling out supraglottitis: a prospective observational study.

OBJECTIVE: To assess the diagnostic accuracy of lateral neck radiographs (LNR) for acute supraglottitis in adults. DESIGN: A single centre prospective observational study. SETTING: Emergency department at Kurashiki Central Hospital, Japan. PARTICIPANTS: Adult patients who underwent LNR to detect supraglottitis. MAIN OUTCOME MEASURES: Presence of supraglottitis, based on nasopharyngeal laryngoscopy or a follow-up telephone call, 7-30 days after the visit. RESULTS: 140 patients had LNR during the study period. 35 patients were excluded from further analysis because of lack of consent. Of the 105 eligible patients, 21 patients (20%) were given the diagnosis of supraglottitis: 17 of 29 with a radiographic abnormality, and 4 of 76 patients without a radiographic abnormality. Three of the four cases where LNR was negative was grade 1, and all cases of grade 3 or higher had abnormal LNR. Sensitivity and specificity (95% CI) of LNR for supraglottitis were 81.0% (64.2 to 97.7) and 85.7% (78.2 to 93.2), respectively. The positive predictive value of LNR was 58.6% (40.7 to 76.5) and the negative predictive value was 94.7% (89.7 to 99.8). The positive likelihood ratio of LNR was 5.67 (3.27 to 9.82) and the negative likelihood ratio was 0.22 (0.10 to 0.51). CONCLUSIONS: LNR showed only moderate sensitivity and specificity for supraglottitis and would miss some cases of supraglottitis if the pre-test probability is high. LNR was very sensitive for grade 3 or higher supraglottitis, but would miss milder cases. TRIAL REGISTRATION: UMIN000011928.

Comorbidities and complications influence the diagnosis and management of geriatric supraglottitis.

INTRODUCTION: This study aimed to assess the differences in the clinical characteristics, management, and outcomes of supraglottitis between geriatric and nongeriatric adults over a 30-month period. METHODS: All adult patients admitted to the emergency department with suspected supraglottitis and who underwent laryngoscopy for confirmation were included. We collected the clinical characteristics, management, and outcomes of these patients and compared geriatric (≥60 years old) and nongeriatric (12-59 years old) groups in terms of these data. RESULTS: Eighty-one geriatric patients and 205 nongeriatric patients were reviewed during the study period. The accuracies of the clinical suspicions of supraglottitis were lower in the geriatric group (geriatric vs nongeriatric, 29.4% vs 47.3%, P = .008). The geriatric group constituted 19.8% of all supraglottitis patients. Comorbidities were discovered in 74.1% of the geriatric group and 25.4% of the nongeriatric group (P = .000). The complication rate in the geriatric patients was almost twice that of the nongeriatric patients (20.8% vs 10.8%). Additionally, the geriatric patients exhibited tendencies toward longer periods of intubation, hospitalization, and stay in the intensive care unit. CONCLUSIONS: The clinical characteristics and management were similar between the geriatric and nongeriatric supraglottitis patients. Nevertheless, the comorbidities altered the clinical presentations of the geriatric patients and resulted in lower diagnostic accuracy. Additionally, the elevated complication rates of the geriatric patient might have negatively affected their outcomes.

Neonatal herpes simplex 2 infection presenting with supraglottitis.

Herpes simplex virus (HSV) is a double stranded DNA virus capable of causing primary and recurrent infection. We describe an unusual case of neonatal HSV-2 infection presenting with supraglottitis. Despite a 2 month course of intravenous aciclovir followed by 2 months of oral valaciclovir, the infant subsequently developed HSV-2 encephalitis which responded to further antiviral treatment. The subsequent diagnosis of encephalitis highlights the importance of testing CSF for HSV to establish the presence of CNS infection in neonates and thus the potential benefit of longer term suppressive antiviral therapy.

An unusual presentation of an infected vallecular cyst presenting as supraglottitis.

A 50-year-old gentleman presented to the emergency department with a 24 h history of stridor, dysphonia, dysphagia and vomiting. On examination, the patient had fever and tachycardic. There was no palpable cervical lymphadenopathy. Flexible nasendoscopy and lateral neck x-ray revealed soft tissue swelling around the epiglottis. The swelling subsided with conservative management of intravenous antibiotics and steroids, only to later reveal a vallecular cyst, which was confirmed on microlaryngoscopy. The cyst was subsequently deroofed and sent for biopsy. Histological examination revealed an infected, benign vallecular cyst consisting of a squamous epithelium with underlying lymphoid tissue. In adults, vallecular cysts are usually asymptomatic, but can become infected and initiate acute supraglottitis, potentially leading to life-threatening airway obstruction. The case described here, although rare, highlights how early definitive diagnosis and management of vallecular cysts can lead to significantly improved patient outcomes.

Chronic non-granulomatous supraglottitis: a rare and difficult disease.

OBJECTIVES: To examine chronic non-granulomatous supraglottitis, a rare disorder of uncertain aetiology with few reported cases in the literature. CASE REPORTS: We describe two cases of chronic non-granulomatous supraglottitis that led to persistent respiratory compromise. Patients underwent extensive investigation that failed to reveal a definitive diagnosis. CONCLUSION: In patients suffering from chronic inflammation of the supraglottic larynx without evidence of infection, neoplasm or granulomatous disease, many disorders must be ruled out in order to diagnose chronic non-granulomatous supraglottitis, which is a diagnosis of exclusion. We review the literature on this rare entity, discuss current management strategies, and suggest an algorithm for diagnostic investigation.

A new era in supraglottitis? An isolated UK case of supraglottitis secondary to Neisseria meningitidis.

OBJECTIVE: We report the first UK case of supraglottitis secondary to Neisseria meningitidis. METHOD: Case report with review of the current literature on supraglottitis and its aetiology. RESULTS: An 89-year-old woman was referred with worsening symptoms of dysphagia, hoarseness and neck discomfort. After nasopharyngoscopy and neck X-ray, supraglottitis was diagnosed. Prompt treatment comprised nebulised adrenaline, oxygen therapy and intravenous antibiotics. Microbiology samples grew N meningitidis, a notifiable disease in the UK. Public health officials were informed, and full precautions and prophylactic treatment initiated for those at risk. The patient made excellent progress and was discharged several days later. DISCUSSION AND CONCLUSION: Supraglottitis occurs in <4 per 100 000 population. Following a successful UK childhood immunisation programme, most cases occur in adults. Supraglottitis secondary to N meningitidis is exceptionally rare, with only seven other reported cases worldwide. Morbidity is exceptionally high; over 60 per cent of patients require airway intervention. To our knowledge, this is the first reported UK case of supraglottitis secondary to N meningitidis. This case highlights the important clinical, diagnostic and therapeutic interventions required to prevent complications associated with this potentially fatal condition.