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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 119-123

Acute epiglottitis in elderly age group: Our experiences at a tertiary care teaching hospital in Eastern India


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Oral Pathology and Microbiology, IDS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
3 Central Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission12-Apr-2019
Date of Acceptance20-Aug-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and Sum Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_291_19

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  Abstract 

Background: Acute epiglottitis (AE) is a potentially life-threatening condition which can lead to airway obstruction. It is less commonly encountered in elderly persons but has more potential for poor outcome due to the indolent property of the clinical presentations.
Objective: The objective of this study is to assess the clinical presentations and management of the elderly patients who visited the outpatient department of otorhinolaryngology with AE.
Materials and Methods: This is a retrospective study done at a tertiary care teaching hospital from December 2014 to November 2019. We searched our electronic medical records for patient details with the diagnosis of AE. The patients of more than the age 50 years were included in this study.
Results: A total of 21 patients were included in this study. The age ranges were from 52 to 78 years, with the mean age of the patients was 59.21 years. The most common symptom was sore throat (n = 19, 90.47%), followed by odynophagia (n = 13, 61.90%), fever (n = 9, 42.85%), change in voice (n = 7, 33.33%), drooling of saliva (n = 4%, 19.04%), and dyspnea (n = 4, 19.04%). Seventeen patients were treated conservatively with the help of broad-spectrum antibiotics and steroids without the requirement of definite airway intervention. Two patients were intubated, one underwent tracheostomy and one underwent cricothyrotomy.
Conclusion: In elderly patients with AE, sore throat is the most common clinical symptom, but stridor is less common. Conservative management is commonly utilized for the management of AE in elderly patients. If AE left untreated, can progress to life-threatening airway obstruction and so the diagnosis not be missed.

Keywords: Acute epiglottitis, adult, elderly patients, supraglottitis


How to cite this article:
Swain SK, Shajahan N, Debta P, Das S, Padhy R. Acute epiglottitis in elderly age group: Our experiences at a tertiary care teaching hospital in Eastern India. Indian J Health Sci Biomed Res 2021;14:119-23

How to cite this URL:
Swain SK, Shajahan N, Debta P, Das S, Padhy R. Acute epiglottitis in elderly age group: Our experiences at a tertiary care teaching hospital in Eastern India. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Mar 2];14:119-23. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/119/308964




  Introduction Top


Acute epiglottitis (AE) is an inflammatory condition of the supraglottis, leading to fatal condition such as airway obstruction. AE in the pediatric age group is often marked by acute onset of fever, sore throat, and sudden onset of the respiratory distress. Approximately 85% of the pediatric patients of AE are asymptomatic for <24 h before attending the hospital.[1] Conversely, the adult or elderly patients of AE present with a prodrome like that of the upper respiratory tract infection over 1–2 days.[2] The elderly patients of AE often present with sore throat, dyspnea, dysphagia, change in voice, and stridor particularly in the supine position of the patient. Fever is uncommon and absent in up to around 50% cases of elderly patients with AE and may develop in the later stage of the disease.[3] The incidence of AE in the pediatric age group has been decreased due to vaccination for Haemophilus influenzae Type b.[4] There is an increased incidence of AE in the adult age group nowadays.[5] In adults, males and advanced ages are often affected with AE and associated with several comorbid conditions such as diabetes, hypertension, and immunocompromised persons.[6] Many patients of AE are ameliorated with conservative treatment only, so often it is difficult to decide the requirement and timing of the airway management. Herein, we retrospectively assessed the inpatients of AE those were managed in our department. The aim of this study is to assess the clinical presentations, diagnostic methods, treatment, and outcomes of the elderly patients with AE at a tertiary care teaching hospital in Eastern India.


  Materials and Methods Top


This is a retrospective observational study on elderly patients diagnosed with AE. We searched medical records for the diagnosis of AE between December 2014 and November 2019. This study was approved by the Institutional Ethical Committee, IMS&SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneswar with Ref no IEC/IMS/SOA31/2014 dated 21.08.2014. Detailed retrospective chart review of the selected patients of AE was done. Detailed patient's profile such as clinical, laryngoscopic findings, radiological, and therapeutic data were recovered. There were 21 patients whose final diagnosis confirmed with AE enrolled in this study. The diagnosis of AE was defined as hyperemia and edema of the epiglottis, which documented in the laryngoscopic findings by otolaryngologists and thumb sign in the lateral view of the X-ray of soft tissue of the neck. We collected details of clinical data with respect to age, gender, underlying comorbid conditions, and clinical presentations such as sore throat, dyspnea, fever, and duration of symptoms. Laryngoscopic examinations of the larynx with AE were done in all cases with the help of fiber-optic nasopharyngolaryngoscopy. Respiratory rate, body temperature, and white blood cell (WBC) counts were analyzed in all patients. Before starting antibiotics, blood culture was done in 13 cases. Throat cultures were not taken in any patients of this study for anticipating the irritation of the airway and aggravating to airway obstruction. We also collected the outcome of the treatment with respect to conservative treatment and airway intervention.


  Results Top


A total of 21 patients were included in this study. The age ranges of the patients participating in this study were from 52 to 78 years. The mean age of the patient was 59.21 years. There were 14 males and 7 females in the ratio of 2:1. The most common symptom was sore throat/throat pain (n = 19; 90.47%), followed by odynophagia (n = 13; 61.90%), fever (n = 9; 42.85%), change in voice (n = 7; 33.33%), drooling of saliva (n = 4; 19.04%), and dyspnea (n = 4; 19.04%) [Table 1]. There eight patients had a comorbid disease such as six patients of hypertension (28.57%), five patients had diabetes mellitus (23.80%), one patient had acquired immunodeficiency syndrome (4.76%), and one had tongue cancer (4.76%) [Table 2]. The most common symptom was sore throat, followed by odynophagia and fever. The mean duration of the symptom from onset to the time of the consultation was 2.8 days. X-ray of the neck (lateral view) was done in all 21 cases where 18 cases showed classical swelling of the epiglottis (thumb sign) [Figure 1]. In five cases of AE, contrast computed tomography (CT) scan was done. The diagnosis of AE was confirmed by fiber-optic nasopharyngolaryngoscopy performed by senior authors in all patients where larynx shows hyperemic edematous epiglottis [Figure 2] except one case. Four patients of AE showed breathing difficulties required airway interventions. The diagnoses of intubated patients were confirmed by contrast CT scan. Laboratory test such as WBC count was done in all cases and shows leukocytosis. Before starting antibiotics, blood culture was done in 13 cases, but there was no growth seen. Out of 21 patients, 17 patients were treated conservatively, whereas 4 were admitted in the medical intensive care unit (ICU) with ventilator. Four patients underwent airway interventions where two had intubations, one had tracheostomy, and one had cricothyrotomy at the emergency room. The patient was discharged from the ICU after 3 days [Table 3]. All the patients were treated with intravenous antibiotics. The most commonly used antibiotic was cefotaxime 1.5 g twice daily. Steroids such as methylprednisolone or dexamethasone were administered to all patients.
Table 1: Clinical symptoms of acute epiglottitis patients

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Table 2: Patients profile of comorbid diseases

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Figure 1: X-ray of the soft tissue of neck (lateral view) showing classical thumb sign in acute epiglottitis

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Figure 2: Laryngoscopic picture of acute epiglottitis showing hyperemic swollen epiglottis

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Table 3: Requirement of airway interventions

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  Discussion Top


AE is a life-threatening infective condition which can lead to fatal airway obstruction. Previously, it has been thought to be primarily a pediatric disease, but it is increasing in adults and the elderly age group due to some associated comorbid conditions. H. influenzae Type b is the most common etiology for AE in children, but a more diverse range of microbiological agents is recognized in adults and elderly persons. Staphylococcus aureus, Streptococcus species, viruses, and fungi are common microbiological agents, which are common etiology for AE in adults and elderly persons although frequently no organisms isolated.[7] Around 20%–25% of the AE in adults and elderly patients have positive blood or laryngeal culture for H. influenzae Type b.[8] In this study, before starting antibiotics, blood culture was done in 13 cases, but there was no growth seen. The structures involved in the AE supraglottic region and specifically epiglottis and sometimes surrounding structures such as oropharynx, vallecula, arytenoids, and aryepiglottic folds.[9] Because of loose and vascular nature of the mucosa surrounding the epiglottic area, it is vulnerable to injury by irritation, inflammation, and allergic reactions. This is why, the term supraglottis is a better term for epiglottitis.[9] However, the etiology for elderly AE may also be nonbacterial in origin.[10] Trauma to the epiglottis by either foreign body, chemical injury, or due to reaction of chemotherapy can lead to AE in adult or elderly people.[11] In adults, the epiglottis is smaller and rigid, so making the epiglottis to less severe form of epiglottis due to lesser clogging of the airway by inflammation.[12] The incidence of AE in the pediatric age group has reduced from 4.9 to 0.02 cases/100,000/year due to vaccination with H. influenzae Type b.[13] Diabetes mellitus, hypertension, bronchial asthma, and malignancy are considered predisposing concomitant diagnosis for AE.[14] However, in this study, diabetes, hypertension, and head-and-neck cancers are predisposing factors associated with AE. Head-and-neck malignancy is prevalent in patients of AE than in patients without AE, because the patients of head-and-neck cancers who underwent surgery and radiotherapy are vulnerable to infections of the larynx. The risk factors for AE include elderly age, male sex, obesity, impaired host immunity, and infected epiglottic cyst.[15] Several studies demonstrated AE to occur predominantly in male (54%–88%).[16],[17] In the present study, the AE is associated with more male groups than females (2:1).

Clinical presentations of AE in elderly persons differ from children. AE in the elderly typically is a less severe, nonbacteremic infection and usually associated with longer duration and with predominant of sore throat.[12] In this study, the clinical presentations were sore throat, odynophagia, muffled voice, and dyspnea. Stridor is uncommon in the elderly and adult age group. Sudden onset of fever and dyspnea are often associated with AE in pediatric patients.[1] Redundant and mobile epiglottic tissue along with narrow trachea of the children makes a higher risk for the rapid progression of the AE to complete airway obstruction. Although many authors have stated that elderly or adult patients with AE have less likely for sudden airway obstruction compared to pediatric patients, mortality is still documented, and proper airway management is still vital for clinicians. There are four predictors for impending airway obstructions such as drooling, history of diabetes mellitus, rapid onset of clinical symptoms, and abscess formation. In this study, four patients were presenting with breathing difficulties (19.04%). As the subglottis is the narrowest portion of the pediatric airway, so prone to inflammation.[18],[19] This is why the children are more prone to airway intervention in AE. The differential diagnosis of AE includes bacterial tracheitis, heat-induced epiglottitis (due to scald burn smoke or hot beverages), angioneurotic edema of the epiglottis, peritonsillar or retropharyngeal abscess, uvulitis, and diphtheria.

The diagnosis of AE in elderly people is made by taking a proper history, clinical presentations, physical examinations, simple X-ray of the neck, and laryngoscopy. The diagnosis of the AE is based on the clinical presentations of the patient and direct visualization of the inflamed epiglottis or supraglottic tissues.[20] The diagnosis of AE is done by indirect laryngoscopy, direct laryngoscopy, or flexible laryngoscopic examination. In pediatric patients of AE, indirect laryngoscopy can trigger laryngeal spasm and acute respiratory distress. However, adults or elderly patients can easily tolerate this examination. Laryngeal examination can be done safely in adults and the elderly unlike the children.[21] Lateral view of the X-ray neck shows thumb-shaped epiglottis, called as thumb sign.[22] Direct laryngoscopic examination of the larynx confirms the diagnosis of AE where hyperemic and edematous epiglottis is visualized. Laryngeal examination needs extreme caution for avoiding airway manipulation and airway obstruction.[23] In this study, the diagnosis of AE was confirmed by fiber-optic nasopharyngolaryngoscopy performed in all patients where larynx shows hyperemic edematous epiglottis except one case. Contrast CT scan of the neck is sometimes dangerous particularly in supine patients and so not required to make the diagnosis of AE. However, it can be done in case of patients where laryngoscopic examination is not performed. In case of intubated patients with AE, CT scan is also helpful for diagnosis. In this study, thumb sign in X-ray of the neck (lateral view) confirmed the diagnosis of AE in 18 cases (85.71%). Patients with AE show leukocytosis with a higher WBC count with comparison to patient without AE. Hence, WBC count may serve as an effective screening parameter for the diagnosis of AE. In our study, WBC count was done in all cases and shows leukocytosis. Raised WBC count (leukocytosis) and positive soft-tissue lateral radiography of the neck will support the clinical diagnosis and warrant for the requirement of laryngoscopic examination for confirmation. Blood culture report of 13 cases showed no growth of the micro-organisms. This may be due to early administration antibiotics before attending our hospital. Throat cultures were not taken in any patients of this study for anticipating the irritation of the airway and aggravating to airway obstruction.

The treatment of AE usually consists of intravenous antibiotics, hydration with normal saline and steroids, or reducing the local inflammatory condition of the supraglottis. The treatment of AE is usually centered on the airway management. One study revealed that 13.2% of the patients with AE needed intubation, and 3.6% needed tracheostomy.[1] Airway intervention is an important part of the management of AE. Kim et al. performed tracheostomy in 4 out of 13 patients with AE.[24] In this study, airway interventions were required in four cases (19.04%). We performed intubation in two patients, tracheostomy in one patient and cricothyrotomy in one patient of the study group. Patients are often shifted to the ICU after securing the airway. Early treatment and administration of broad-spectrum antibiotics might attribute to reduce the requirement of intubation or tracheostomy in AE patients. Antibiotics are the mainstay of the early treatment along with steroids. Third-generation cephalosporin usually recommended medications in the treatment of AE.[25] Corticosteroids are often administered for decreasing the edema and inflammation of the epiglottis and supraglottis and so airway obstruction. It also reduces the duration of the hospital stay.

Arterial oxygen saturation of the patient is continuously monitored by finger pulse oxymetry. According to the treatment protocol of the AE, the glottic and supraglottic airway should be assessed by an otolaryngologist with a flexible fiber-optic laryngoscopy and find out whether the airway is patent or compromised. The decision for securing the airway is based on the basis of the symptoms and airway appearance. In case of respiratory difficulties such as stridor, oxygen desaturation, cyanosis, and sitting erect, airway intervention is required immediately?. In some situations, patients lack symptoms and signs of airway obstruction. The the narrow airway should have at least 50% of the airway diameter to perform the fiber-optic laryngoscopy for intervention. The causes for latter protocol are due to the fickle nature of the disease, which can land on imminent respiratory distress in any time. When feasible, patients of AE are shifted to the operating room for endotracheal intubation for maintaining airway. If endotracheal intubations fail after repeated attempt, tracheostomy or cricothyrotomy is performed. After securing the airway, patients are usually transferred to the ICU. It is often advocated that patients of AE are admitted to ICU for close monitoring. However, patients may be admitted in the ward provided that they should be with adequate airway, antibiotics, and corticosteroids. The elderly patients of AE with patent laryngeal airway are admitted in ward with closely supervised by an otolaryngologist and trained staff nurse. The clinicians equipped with the ability for intubating or performing tracheostomy must be available. Repeated attempts for intubation may lead to injury and periepiglottic swelling leading to more morbidity.[26],[27] The complications of AE are epiglottic abscess and systemic bacteremia. It also may be complicated by a retropharyngeal abscess, cervical necrotizing fasciitis, negative pressure pulmonary edema, sepsis, and sudden airway obstruction, leading to respiratory arrest.[28],[29] In this study, no such complications were not documented.


  Conclusion Top


AE is a life-threatening clinical entity and requires timely diagnosis and intervention. It is a true airway emergency. AE has the potential for causing abrupt and complete airway obstruction. Clinicians must maintain a high suspicion as presentencing symptoms are often variable along with unreliable physical examination. Delayed diagnosis can lead to catastrophic consequences. It requires prompt diagnosis and careful management of the airway. Although it is less common in elderly people, it has more potential for poor outcome due to the indolent property of the clinical presentations.

Limitation of the study

The limitations of this study are small sample size because of the low prevalence or rarity of the AE in the elderly age group, retrospective study design, and performing study at a single medical center. Further studies may cover basic research, multicentric, and prospective studies with the assessment of the different characteristics of the elderly age group with AE for overcoming these limitations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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