Approach
Characteristic history and exam findings are often sufficient or pathognomonic to diagnose the condition.[19][20] During diagnosis, no action should be taken that could stimulate a child with suspected epiglottitis. Epiglottitis is a clinical diagnosis and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected. Stimulating actions include examination of the oral cavity, starting intravenous lines, blood draws, or even separation of a child from a parent. These actions should only be undertaken when the airway is secure. Similar caution is required in fulminant acute epiglottitis in adults. Flexible fiber-optic examination should only be performed with great caution in adults so as not to exacerbate airway compromise. In adults with less specific symptoms the condition can present a diagnostic challenge, so a high index of suspicion is important.
History
There is often a rapidly progressing sore throat with dysphagia, drooling, difficulty in breathing, markedly decreased oral intake, and difficulty in controlling secretions. An important risk factor is not being immunized against Haemophilus influenzae type B (Hib).
Adult patients tend to have a slower onset, fewer severe respiratory symptoms, and more pharyngeal symptoms than pediatric patients. Adults commonly present with a sore throat, odynophagia, and dysphagia to the extent of being unable to swallow their own saliva.[21]
Physical exam
Children appear "toxic", in acute distress, febrile, in the tripod position, and may be drooling. They also may have stridor caused by the obstructed airflow through the narrowed airway. Tripod positioning is where the child postures the neck and head anteriorly and places his/her hands on his/her knees. Anterior displacement of the mandible and neck allows the child to breathe much more easily as the hyoid and epiglottis are also moved anteriorly, which opens up the effective airway space for breathing.
Auscultation sounds: Stridor
Diagnostic tests
In most patients, the clinical presentation is highly suggestive of the diagnosis. This is confirmed by laryngoscopy, which, when combined with nasotracheal intubation, also acts as a therapeutic measure, since it will establish an airway. This should ideally be performed in a controlled operating room setting with appropriately trained personnel present so an emergency surgical airway can be obtained if endotracheal intubation is not possible. Cooperation between the otolaryngologist, intensivist, emergency department physician, anesthesiologist, and pediatrician (where relevant) is crucial. An erect lateral neck radiograph will show a markedly enlarged epiglottis, referred to as a "thumbprint sign". This should only be obtained with healthcare professionals capable of securing the airway with proper equipment available during the test. The patient should be kept in an upright position. It is usually safe to perform in adults who are not in extremis. Subsequent to the endoscopic and imaging test, a complete blood count may show leukocytosis with left shift. If possible and permissible without perturbing the patient and/or once the airway has been secured, obtaining cultures from the blood and directly from the epiglottis is crucial in identifying the infecting agent.[Figure caption and citation for the preceding image starts]: Lateral neck film demonstrating thumbprint sign (arrows)From the collection of Dr Petri [Citation ends].
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