PANCE Blueprint EENT (7%)

Epiglottitis

Patient will present as → a 3-year-old who is brought into the emergency room by her parents. The child has had a high fever, sore throat, and stridor. She has a muffled voice and is sitting up on the stretcher drooling while leaning forward with her neck extended. The patient's parents are adamantly against vaccinations, claiming that they are a "government conspiracy." You order a lateral neck x-ray, which shows a swollen epiglottis. The patient recovered following treatment with prednisone and ceftriaxone.

Infection of the upper airway with (most common cause) H. influenzae type B (Hib)

  • Presents with classic triad of drooling + dysphagia and distress
  • Patients sit with the neck hyperextended and chin protruding (sniffing dog position)

Diagnosis of epiglottitis, in a person who is stable and breathing comfortably, is done with an X-ray (lateral film) - Thumbprint sign

  • A CT scan would also show a narrow airway from tissue swelling - lying flat for a CT can be dangerous because it can make the epiglottis further obstruct the airway
  • An endoscope can be used to look directly at the epiglottis which typically appears swollen and cherry red in color from the inflammation

Secure airway - call anesthesiology and prepare to establish airway, transfer to OR to perform an exam, tracheostomy if necessary to maintain airway

  • Admit for observation, humidified O2, IV antibiotics (ceftriaxone + clindamycin), and IV corticosteroids

osmosis Osmosis
Picmonic
Epiglottitis and treatments

Epiglottitis is supraglottic inflammation/obstruction of the airway due to infection with Haemophilus influenzae. The Hib vaccine is available to protect against Haemophilus influenzae type b and should be given to infants in three to four divided doses starting at the age of two months. Signs and symptoms of epiglottitis include inspiratory stridor, restlessness, cough, dyspnea, fever, and drooling. It is important to note that the throat should not be examined if epiglottitis is suspected, as this could cause spasm and complete closure of the airway. Assessment of the throat should only be done when immediate endotracheal intubation is possible. Epiglottitis requires emergency treatment.

Epiglottitis assessment
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Epiglottitis interventions
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Haemophilus influenzae disease
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Third-generation cephalosporin
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Question 1
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?
A
Croupy cough and drooling
B
Thick gray, adherent exudate
Hint:
Thick gray adherent exudate is suggestive of diphtheria.
C
Beefy red uvula, palatal petechiae, white exudate
Hint:
Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.
D
Inflammation and medial protrusion of one tonsil
Hint:
Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Question 1 Explanation: 
A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
Question 2
Which of the following pathogens is the most common cause of epiglottitis in children?
A
Rhinovirus
Hint:
Causes upper respiratory infections but not a common cause of epiglottitis.
B
Streptococcus pneumoniae
Hint:
Can infect the respiratory tract but not a prime cause of epiglottitis.
C
Neisseria meningitidis
Hint:
Associated with meningitis more than epiglottitis.
D
Haemophilus influenzae type B
E
Group A Streptococcus
Hint:
Leads to pharyngitis and tonsillitis more often than epiglottitis.
Question 2 Explanation: 
Haemophilus influenzae type B was previously the most common cause of epiglottitis in the pediatric population. The introduction of the Hib vaccine has made this pathogen much less prevalent, but it remains the most commonly associated with pediatric epiglottitis. Streptococcus pneumoniae, Neisseria meningitidis, rhinovirus, and group A streptococcus are less likely culprits.
Question 3
A 3-year-old girl presents with high fever, drooling, stridor, and trouble swallowing liquids. Physical exam reveals a muffled voice and inspiratory retractions. Which of the following is the most appropriate diagnostic test?
A
Throat culture
Hint:
Difficult to obtain and does not provide specific information in this case.
B
Lateral neck X-ray
C
Complete blood count
Hint:
Not specific for diagnosing epiglottitis.
D
Monospot test
Hint:
Checks for EBV infection unrelated to this child's presentation.
E
Rapid streptococcal test
Hint:
Useful for pharyngitis but not epiglottitis.
Question 3 Explanation: 
Given this child's presentation concerning for epiglottitis, the most appropriate diagnostic test is a lateral neck X-ray, which can reveal enlargement of the epiglottis, known as a "thumbprint sign". A throat culture is not easily obtained and does not confirm the diagnosis. A CBC and Monospot test evaluate for other conditions. A rapid streptococcal test identifies group A strep pharyngitis.
Question 4
A 5-year-old boy is diagnosed with acute epiglottitis. He appears toxic and has stridor and severe respiratory distress. Which of the following is the most appropriate initial treatment?
A
Intravenous antibiotics
Hint:
Treat the underlying infection but do not address the airway obstruction.
B
Nebulized racemic epinephrine
Hint:
May transiently improve stridor but intubation is still required.
C
Intubation
D
Oral corticosteroids
Hint:
Do not improve the airway obstruction requiring intubation
E
Cool mist humidification
Hint:
May provide some symptomatic relief but does not address need for intubation.
Question 4 Explanation: 
Given this child's severe respiratory distress, the most appropriate initial intervention is to secure the airway by intubation. While intravenous antibiotics and steroids cover treatment of the underlying infection, intubation is required urgently to manage the airway obstruction until the swelling and inflammation improve. Nebulized epinephrine and humidification may provide temporary benefit but intubation is essential.
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References: Merck Manual · UpToDate

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