Adult epiglottitis: a five-year retrospective chart review in a major urban centre
Ira M. Price, MD;* Ian Preyra, MD, MBA;*†‡ Christopher M.B. Fernandes, MD;*‡ Karen Woolfrey, MD;*† Andrew Worster, MD, MSc*‡
*McMaster University, Hamilton, Ont.
†St. Joseph's Hospital, Hamilton, Ont.
‡Hamilton Health Sciences, Hamilton, Ont.
Objective: There is an increasing awareness of unvaccinated adults presenting with epiglottitis to the emergency department. This study examines the clinical presentations and outcomes of diagnosed cases of adult epiglottitis presenting to all emergency departments in Hamilton, Ont., between 1999 and 2003.
Methods: We employed explicit protocols with defined variables, trained abstractors and standardized abstraction forms, and reviewed all diagnosed cases of adult epiglottitis during a 5-year period. Inter-rater agreement was measured using a kappa statistic.
Results: Inter-rater reliability for data abstraction was κ = 1. From a total of 1 million emergency department admissions, 54 cases of epiglottitis were identified. The mean age was 49, and 69% of the patients were male. The 3 most frequently documented symptoms were sore throat (100%) odynophagia (94%) and inability to swallow secretions (63%). The 2 most frequently documented signs were swelling of the epiglottis/supraglottis (100%), and tachycardia (53%). Organisms were isolated from blood in 11% of the cases. There was a white blood cell count >20 × 109/L in 4 of the cases (7.4%). From the 54 cases, 9 of the patients were intubated and all patients were safely discharged from hospital.
Conclusion: Adults presenting with epiglottitis to the emergency department in Hamilton have good outcomes, with less airway management required than previously reported in children. Further study is needed to see if these conclusions are similar in other populations.
Objectif : On se rend compte de plus en plus des patients non vaccinés qui visitent le département d'urgence pour une épiglottite. La présente étude a examiné la présentation clinique et les résultats de cas diagnostiqués d'épiglottite chez des adultes ayant été reçus à tous les départements d'urgence à Hamilton, en Ontario entre 1999 et 2003.
Méthodes : Nous avons utilisé des protocoles explicites avec variables définies, des rédacteurs de sommaires qualifiés et des formulaires standardisés de sommaires pour examiner tous les cas d'épiglottite diagnostiqués chez des adultes au cours d'une période de cinq ans. L'accord interjuge pour le sommaire des données était κ = 1. Parmi 1 million d'admissions au département d'urgence, on a identifié 54 cas d'épiglottite. L'âge moyen était de 49 ans et 69 % des patients étaient des hommes. Les trois symptômes documentés les plus fréquents étaient le mal de gorge (100 %), l'odynophagie (94 %) et l'incapacité à avaler les sécrétions (63 %). Les deux signes les plus fréquemment documentés étaient l'œdème de l'épiglotte ou de l'étage supraglottique (100 %) et la tachycardie (53 %). Les organismes furent isolés dans le sang dans 11 % des cas. Dans quatre des cas (7,4 %), la numération des leucocytes était de >20 × 109/L. Parmi les 54 cas, neuf patients furent intubés et tous les patients reçurent leur congé de l'hôpital en toute sécurité.
Conclusion : Les adultes qui se présentent au département d'urgence pour une épiglottite à Hamilton ont de bons résultats, nécessitant moins de protection de la perméabilité des voies aériennes que ce qui avait précédemment été constaté chez les enfants. Des études plus poussées sont nécessaires pour vérifier si ces conclusions sont similaires chez d'autres populations.
Acute epiglottitis is a potentially life-threatening upper airway emergency that requires prompt diagnosis and management. Epiglottitis is defined as inflammation of the epiglottis, the fibro-cartilaginous flap that covers the superior aperture of the larynx.1,2 The most commonly cultured organism in pediatric cases has been Hemophilus influenzae type B (HIB).3,4 Since the introduction of the HIB conjugate vaccine to Canada in 1978, the number of pediatric patients with epiglottitis has steadily declined.2 As a result, there is increasing interest in epiglottitis in adults.
Adults with acute epiglottitis may not present in the same manner as children, owing in part to the anatomic differences between the adult and pediatric airway, and to the differing infectious etiologies.5,6 The differences in presenting features, natural history and bacterial etiology suggest a management strategy that is different than that used in the pediatric population.
This paper examines the diagnosed cases of all adult patients presenting with acute epiglottitis from 1999–2003 to Hamilton, Ont., emergency departments (EDs). The primary purpose is to delineate features of adult epiglottitis, as well as to define this disease with respect to demographics, diagnosis and management.
Hamilton Health Sciences and St. Joseph's Hospital provide emergency care for the city of Hamilton through 4 EDs and 1 urgent care site. All departments are staffed by full-time emergency physicians.
We conducted a comprehensive search for all diagnosed cases of adult (age >18 years) epiglottitis presenting to EDs in Hamilton, Ont., between 1999 and 2003. An unblinded researcher abstracted 100% of the cases, after which a second researcher independently abstracted a random selection of 40% of the selected cases. Both used study-specific data collection forms for this purpose with explicit variable definitions. Abstractor performance was monitored, and differences were planned for resolution by group consensus. Periodic meetings were also held to discuss any difficulties and provide abstractor performance feedback. Inter-rater reliability on data abstraction was measured and tested using a kappa statistic.
The case selection criterion was the final discharge diagnosis of epiglottitis. The diagnosis of epiglottitis or supraglottitis was confirmed by laryngoscopy.
From a total of 1 million ED visits over a 5-year period, we identified 54 cases of epiglottitis. The mean age was 49 with a range from 18 to 93 years; 37 (69%) of the patients were male. The 3 most frequently documented symptoms were sore throat, odynophagia and inability to swallow secretions (Table 1). The 2 most frequently documented signs were swelling of the epiglottis/supraglottis, and tachycardia. Organisms were isolated from blood in 11% of the cases. There was a white blood cell count >20 × 109/L in 4 of the cases. Nine of the 54 patients were intubated. Fifty-three patients were safely discharged from hospital within 72 hours, and 1 was managed as an outpatient. All patients underwent laryngoscopy. One patient required emergency intubation and surgical airway management, due to a facial abnormality. There were no other "crash" intubations. There were no adverse outcomes.
Inter-rater reliability (κ) for data abstraction was 1.
Rapid airway control with mandatory endotracheal intubation has been advocated for the management of patients with acute epiglottitis.7 This approach was developed from experience with epiglottitis in young children, primarily due to infection by HIB.8 Since the initiation of universal pediatric immunization against HIB, the microbiology and demographics of epiglottitis have changed. There has been an increased proportion of adults with the disease, and a decline in cases caused by HIB.2 As this study demonstrates, an aggressive airway management approach is unnecessary in the majority of adult cases.
|Variable||No. of patients
|Inability to swallow secretions||34 (63)|
|Sore throat||54 (100)|
|Muffled / “potato” voice†||26 (48)|
|Inability to lie down||15 (28)|
|Fever (>38°C)||15 (28)|
|Tachycardia (>100 beats/min)||29 (54)|
|Tachypnea (>24 breaths/min)||6 (11)|
|Swelling of epiglottis/supraglottis||54 (100)|
|Cervical lymph nodes||18 (33)|
|Documented stridor||5 (9.3)|
|White blood cell count (<3 or >20 × 109/L)||4 (7)|
|Organism isolated||6 (11)|
|Abnormal soft tissue visible in lateral neck x-ray||34 (63)|
|Mean age, yr (and SD)||49 (18–93)|
|*Unless otherwise specified. †”Potato” or “hot potato” voice is when the patient talks as if he had a hot potato in his mouth.|
Of the 9 cases in this study that underwent endotracheal intubation, 8 were elective: 1 was intubated for prevention of aspiration due to a congenital airway abnormality and only 1 patient was intubated for more than 48 hours. In contrast, intubation rates as high as 100% have been previously reported in the pediatric population.9 The adult airway is less prone to obstruction in acute epiglottitis. The epiglottis in children is relatively larger, U-shaped and less rigid, making it more likely to occlude the airway when inflamed. Furthermore, the pediatric airway is of smaller calibre, has more lymphoid tissue and has a relatively narrow supraglottis.
All patients in our series presented with sore throat, and 94% presented with odynophagia. Inability to swallow secretions, a hallmark of the disease in children, was present in only 63% of patients. Fever, respiratory distress and stridor were uncommon presenting signs. Overall, the presentation of epiglottitis in adults was less acute than has been reported in children, with a low incidence of symptoms of acute airway obstruction (stridor, respiratory distress, tachypnea) and systemic toxicity (fever, tachycardia).
Organisms were cultured from blood samples in 11% of cases, and no organisms were cultured from the epiglottis itself. This is in contrast to the high rates of bacteremia seen in pediatric epiglottitis caused by HIB.6 None of the cases in this series grew HIB. This appears to confirm the decreasing incidence of HIB and the different bacterial etiology of the disease in adults.10
This review implemented published strategies for medical record review studies to enhance overall validity, reproducibility and quality of the research.11,12
The limitations of this study are the method of case selection, which can allow for cases to be missed, and the unblinding of data abstractors.11,12
Possible weaknesses include this review's retrospective nature, dependency on deciphering medical records, and the small number of patients (n = 54). The use of only a single geographic site may be confounding, since epidemiological factors and local preferences may affect the presentation and management of disease.
Acute epiglottitis in adults presents differently from that previously reported in children. Differences in microbiology, epidemiology and anatomy probably contribute to a less severe illness. Prospective multi-centre evaluation would more clearly define the management strategy for acute epiglottitis in adults.
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Dr. Christopher M.B. Fernandes, Hamilton Health Sciences, 237 Barton St. E, Hamilton ON L8L 2X2