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.

Using Transfer Learning of Convolutional Neural Network on Neck Radiographs to Identify Acute Epiglottitis.

Acute epiglottitis (AE) is a life-threatening condition and needs to be recognized timely. Diagnosis of AE with a lateral neck radiograph yields poor reliability and sensitivity. Convolutional neural networks (CNN) are powerful tools to assist the analysis of medical images. This study aimed to develop an artificial intelligence model using CNN-based transfer learning to identify AE in lateral neck radiographs. All cases in this study are from two hospitals, a medical center, and a local teaching hospital in Taiwan. In this retrospective study, we collected 251 lateral neck radiographs of patients with AE and 936 individuals without AE. Neck radiographs obtained from patients without and with AE were used as the input for model transfer learning in a pre-trained CNN including Inception V3, Densenet201, Resnet101, VGG19, and Inception V2 to select the optimal model. We used five-fold cross-validation to estimate the performance of the selected model. The confusion matrix of the final model was analyzed. We found that Inception V3 yielded the best results as the optimal model among all pre-train models. Based on the average value of the fivefold cross-validation, the confusion metrics were obtained: accuracy = 0.92, precision = 0.94, recall = 0.90, and area under the curve (AUC) = 0.96. Using the Inception V3-based model can provide an excellent performance to identify AE based on radiographic images. We suggest using the CNN-based model which can offer a non-invasive, accurate, and fast diagnostic method for AE in the future.

Acute odynophagia: A new symptom of COVID-19 during the SARS-CoV-2 Omicron variant wave in Sweden.

OBJECTIVE: The objective of this study is to present a novel clinical manifestation of infection with the Omicron variant of the SARS-CoV-2 virus affecting mainly young, vaccinated, and healthy adults. We describe a new group of COVID-19 patients seeking emergency care with symptoms similar to the life-threatening condition epiglottitis. Here, we present a case series and discuss management. METHODS: We performed a retrospective single-center case study of patients diagnosed with COVID-19 who were referred to the Ear, Nose, and Throat Emergency Department (ENT ED) between January 1 and January 23, 2022 with clinical symptoms such as acute odynophagia, severe sore throat, and fever. Ethical approval was obtained from the Swedish Ethical Review Authority (2020-02579). Informed consent was obtained from all patients included in the study. RESULTS: Twenty patients meeting inclusion criteria were identified. Fifteen patients were fully vaccinated against COVID-19. Four patients needed a short hospitalization for their symptoms. The most common diagnoses were COVID-19-associated acute viral laryngotracheitis and/or viral pharyngitis. Six patients presented with signs of secondary bacterial infection and were put on antibiotics. CONCLUSION: Previous variants of SARS-CoV-2 infection affected predominantly the lower respiratory tract and were associated with loss of smell and taste in many patients. The Omicron variant seems to affect predominantly the upper airways and cause acute laryngitis without olfactory dysfunction. In some patients, the clinical manifestation is similar to the symptoms of epiglottitis. In such a case, a prompt examination of the larynx is the gold standard to exclude inflammatory edema in the upper airways. None of the patients described in this study developed epiglottitis. In this study, we discuss the management of acute odynophagia in COVID-19 patients.

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.

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 infectious supraglottitis in adult population: epidemiology, management, outcomes and predictors of airway intervention.

PURPOSE: The purpose is to analyze the incidence of acute infectious supraglottitis in our center between 2010 and 2020, define the characteristics and trends of those patients and identify factors associated with the need of airway intervention. METHODS: A retrospective single-center observational study of a cohort of patients diagnosed with acute infectious supraglottitis between January 2010 and December 2020. Patients were stratified according to airway management. RESULTS: Eighty eight patients were included: 59 men (67%) and 29 women (33%). A significant upward trend of 9% in the annual incidence rate of supraglottitis was seen during 2010-2020, with an important increase in cases during 2019. Muffled voice (41%) and respiratory distress (38%) were the most common presenting symptoms; and the median duration of symptoms before hospital admission was 2 days [IQR 1; 3]. Airway intervention was performed in fifteen patients (17%). Nine patients (10%) were intubated and six required tracheotomy (7%). Comparing the patients who required airway intervention with those who received a conservative treatment, younger patients (p < 0.01) were more likely to need airway intervention. In logistic regression analysis, we found that epiglottic abscess (p = 0.015), hypersalivation (p = 0.027) and smoking (p = 0.036) were independent factors with a significant association with airway intervention. CONCLUSION: There was an important increase in cases and its severity in 2019, but due to COVID-19 pandemic, it was not possible to define if it was an isolate event or an upward trend. Epiglottic abscess, hypersalivation and smoking could be possible risk factors for airway intervention.

George Washington's Recurrent Health Problems and Fatal Infection Re-examined.

George Washington's medical history has been recounted so many times and with such consistency that it seems that nothing new remains to be said about the panoply of disorders that plagued him during his life. The same can be said for the particular one that carried him off at age 67. We know that he had small pox, dysentery, recurrent attacks of malaria, and a host of other infections during his long and spectacularly productive career. His teeth were a source of unrelenting distress despite his assiduous attention to dental hygiene; and terminally, he developed a rapidly progressive upper respiratory infection, which killed him in little more than a day and a half despite the best medical care available.

Cannabis induced thermal epiglottitis in a pediatric patient.

Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

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.

Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017.

PURPOSE: Evaluate trends in mortality due to acute epiglottitis before and after adoption of Haemophilus influenza Type b vaccination (Hib) in pediatric and adult populations. MATERIALS AND METHODS: Patients who died from acute epiglottis from 1979 to 2017 identified using National Vital Statistics System. Mortality rates calculated using age-adjusted US census data expressed in rate per 100,000 individuals. Trends analyzed using the National Cancer Institute Joinpoint Regression Program (version 4.7.0; Bethesda, Maryland). RESULTS: 1187 epiglottitis-related deaths were identified over thirty-nine years. Total deaths decreased from 65 in 1979 to 15 in 2017. Adult deaths accounted for 63.5% and decreased from 0.015 per 100,000 individuals (24 deaths) in 1979 to 0.006 per 100,000 individuals (14 deaths) in 2017. Best fitting log-liner regression model showed APC of -3.5% (95% CI, -4.2 to -2.7%) from 1979 to 2017. Pediatric and adolescent deaths accounted for 443 (37.3%) deaths, decreasing from 0.064 per 100,000 individuals (41 deaths) in 1979 to 0.001 per 100,000 individuals (1 death) in 2017. APC was -11.1% (95% CI, -13.8% to -8.3%) in 1979 to 1990; 46.5% (95% CI, -16.6% to 157.3%) in 1990 to 1993; -61.6% (95% CI, -88% to 23%) in 1993 to 1996; and 1.1% (95% CI, -2.4% to 4.7%) in 1996 to 2017. CONCLUSIONS: Mortality from acute epiglottitis decreased after widespread adoption of Hib vaccination in the US. Adults are now more likely than children to die of acute epiglottitis. Further research including multi-institutional cohort studies must be done to elucidate causative factors contributing to remaining cases of mortality.

Death related to epiglottitis.

Although death due to epiglottitis is well-reported in the medical literature, because of vaccines and antibiotics, deaths caused by epiglottitis are rare in the era of modern medicine. This report presents a case of epiglottitis-related death occurring in a middle-aged diabetic man. He initially presented to an emergency department with complaints of a sore throat and bilateral ear pain. Although a quick test for Strep pneumoniae was negative, the work-up was not extensive enough to exclude epiglottitis. He was discharged with a prescription for a decongestant and instructed to drink plenty of fluids. He subsequently collapsed in respiratory distress while waiting to fill his prescription at a pharmacy. He was admitted to the hospital and eventually diagnosed with anoxic brain injury, dying 4 days following his initial presentation. Autopsy disclosed gross and microscopic features of acute epiglottitis, which was considered the underlying cause of death. Awareness of epiglottitis and its risk factors is essential in identifying the proper diagnosis clinically. Characteristic findings at autopsy can confirm the diagnosis.

Using spectral reflectance to distinguish between tracheal and oesophageal tissue: applications for airway management.

Proper placement of the tracheal tube requires confirmation, and the predominant method in addition to clinical signs is the presence of end-tidal carbon dioxide. Such is the importance of confirmation that novel methods may also have a place. We previously demonstrated using ex-vivo swine tissue a unique spectral reflectance characteristic of tracheal tissue that differs from oesophageal tissue. We hypothesised that this characteristic would be present in living swine tissue and human cadavers. Reflectance spectra in the range 500-650 nm were captured using a customised fibreoptic probe, compact spectrometer and white light source from both the trachea and the oesophagus in anesthetised living swine and in human cadavers. A tracheal detection algorithm using ratio comparisons of reflectance was developed. The existence of the unique tracheal characteristic in both in-vivo swine and cadaver models was confirmed (p < 0.0001 for all comparisons between tracheal and oesophageal tissue at all target wavelengths in both species). Furthermore, our proposed tracheal detection algorithm exhibited a 100% positive predictive value in both models. This has potential utility for incorporation into airway management devices.

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.

A Lot to Choke on: Case of Adult Epiglottitis with Concurrent Peritonsillar Abscess in a Patient with a Sore Throat.

BACKGROUND: In the winter months, one often sees a large increase in the volume of patients presenting to emergency departments with acute pharyngitis. While most cases of acute pharyngitis are benign, a rare minority can be life threatening. CASE REPORT: We report a case of epiglottis with a concomitant peritonsillar abscess (PTA) in an adult who presented to the emergency department with a sore throat. Computed tomography (CT) scan showed epiglottitis with a developing left PTA. The patient was treated with broad-spectrum antibiotics, high-dose steroids, and underwent multiple laryngoscopies with eventual resolution of his epiglottic swelling. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case serves to highlight the importance of physical examination and CT imaging in identifying patients with pharyngitis who can benefit from additional interventions and monitoring. It is also an unusual example of the presence of two likely related upper respiratory pathologies presenting in the same patient.

Sudden death from acute epiglottitis in a toddler.

The bacterium Haemophilus influenzae type b (Hib) can cause severe and life-threatening infections such as epiglottitis and meningitis. The course of the disease can be very rapid, resulting in sudden death. The incidence of Hib-induced epiglottitis in children has declined since the introduction of vaccinations in countries where such vaccinations are routinely administered. We herein present a case involving a 2.5-year-old boy who died suddenly at home. He had developed acute-onset throat and abdominal pain and a high fever. Despite an emergency cricothyrotomy due to a complicated intubation because of a massively swollen epiglottis, the efforts to resuscitate the child were unsuccessful. He was a previously healthy toddler, but he had not yet been vaccinated. Microbiologic analysis revealed the pathogenic bacterium Hib. The main autopsy finding was acute epiglottitis with swelling and cherry-red coloring of the epiglottis. Postmortem cultures of the cerebrospinal fluid and heart blood also revealed Hib as the pathogenic agent. Acute pneumonia was also diagnosed microscopically. The present report describes a rare case of Hib-induced acute epiglottitis and presents the key findings of forensic investigations in this type of disease.

Emergence of Invasive Haemophilus influenzae Type A Disease in Italy.

We report on the first detection of 2 cases of invasive Haemophilus influenzae type a (Hia) disease in Italy. The cases were sustained by the same Hia "strain" belonging to the ST23 clone that has previously been reported only outside Europe. The emergence of invasive Hia disease is of concern.

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.

Epiglottitis Strikes Twice: A Case of Adult Recurrent Epiglottitis.

Epiglottitis is an uncommon condition in adults, and recurrent episodes are rare. We report a 58-year-old male who had a second episode of epiglottitis nine years after his first. Our patient's immunologic profile obtained during his hospitalization revealed a significantly low absolute cluster of differentiation 4+ (CD4+) T lymphocyte count of 77 cells/mcL and a low immunoglobulin G (IgG) level of 635 mg/dL. Our patient was successfully managed with broad-spectrum antibiotics and corticosteroids. Given the known ability of short-term corticosteroids and acute inflammation's effect on lymphocyte populations, the significance of these laboratory values remains unclear due to our patient's unwillingness to undergo further diagnostic testing following discharge from our facility. We have considered multiple underlying etiologies for our patient's predisposition to developing this rare, recurrent, infectious manifestation; however, the exact cause is yet to be fully elucidated.