Clinical features of patients with acute epiglottitis in the emergency department

Introduction

Acute epiglottitis (AE) is an inflammation of the epiglottis and adjacent supraglottic structures. Historically, AE was described as a disease of adults; however, it was subsequently reported more frequently in children and considered primarily a paediatric disease from the 1960s onwards. ¹ However, the recent widespread use of the haemophilus vaccination has produced a drastic decline in the number of children with epiglottitis, and the disease is once again more common in adults.^2,3

AE in adults seems to differ from that observed in children. Most adult patients with AE have a concomitant underlying medical condition at diagnosis. In contrast to the swelling observed in AE in children, the swelling in adults with AE often occurs not only in the epiglottis but also in the surrounding supraglottic area. ⁴

Prompt diagnosis of AE is vital to prevent a subsequent life-threatening airway obstruction. Currently, AE is diagnosed through direct visualisation of an inflamed epiglottis. Therefore, early diagnosis of AE is challenging for physicians when an otolaryngology consultation or flexible laryngoscopy is unavailable.

Previous studies have investigated patients with a confirmed AE diagnosis to identify the risk factors and clinical features. However, the diagnostic validity of the clinical parameters for identifying patients with definite AE is rarely discussed. Therefore, we investigated patients suspected of having AE in the emergency department (ED) to assess the clinical differences between patients with AE and those without.

Methods

Results

We collected data on 291 consecutive patients suspected of having AE during the study period. Of the patients, 108 were confirmed as having AE after flexible laryngoscopy. Among the patients with AE, 67 were men and 41 were women, representing a male-to-female ratio of 1.6:1. The median age was 44 years.

A total of 34 patients with AE had concomitant medical conditions at diagnosis, among which diabetes mellitus, cardiovascular diseases (including hypertension, coronary artery disease, congestive heart failure and peripheral arterial occlusive disease) and head and neck tumours were the three commonest. By contrast, 77 patients without AE had concomitant diseases. We compared the systemic comorbidities between the patients with and those without AE (Figure 1) and determined that patients with AE had a higher prevalence of head and neck tumours (AE vs non-AE: 10% vs 3%, p = 0.015). By contrast, more patients without AE had concomitant cardiovascular disease (AE vs non-AE: 11% vs 21%, p = 0.035), dementia or stroke (AE vs non-AE: 3% vs 9%, p = 0.034), or asthma or chronic pulmonary obstructive disease (AE vs non-AE: 0% vs 7%, p = 0.007).

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Figure 1.

Systemic comorbidities in patients with and without AE.

The mean duration of symptoms before arrival at the ED was 2 days. Sore throat was the commonest symptom (81.5%), followed by odynophagia (49.1%). However, compared with the non-AE group, only odynophagia was statistically significantly more common in patients with AE (AE vs non-AE: 49% vs 37%, p = 0.037). Conversely, patients without AE had higher rates of fever (23% vs 37%, p < 0.001), cough (15% vs 36%, p < 0.001) and rhinorrhoea (5% vs 12%, p = 0.048).

The neck radiographs were positive for epiglottitis in 61 of the 103 patients with AE and 46 of the 177 patients without AE, yielding a sensitivity of 59%, specificity of 74%, positive predictive value of 57% and negative predictive value of 76%.

The patients with AE had a higher prevalence of leucocytosis (AE vs non-AE: 72% vs 43%, p < 0.001) and a higher WBC count (12,200 vs 9500/μL, p < 0.001) than did the patients without AE, but the prevalence of elevated CRP levels was similar between the two groups (Table 1).

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Table 1.

Comparison of clinical manifestations in patients with and without AE.

	AE	Non-AE	p
Male-to-female ratio	1.6:1	1:1	0.077
Median age (years)	44 ± 18	27 ± 6	0.131
No. of patients with comorbidities	34	77
Duration of subjective symptoms before arrival	2 ± 6	2 ± 4	0.704
Sore throat	82%	78%	0.431
Odynophagia	49%	37%	0.037
Fever	23%	37%	<0.001
Dyspnoea	19%	21%	0.787
Cough	15%	36%	<0.001
Hoarseness	10%	12%	0.734
Neck pain	8%	4%	0.164
Drooling	7%	6%	0.641
Rhinorrhoea	5%	12%	0.048
FB sensation	3%	0%	0.051
Stridor	2%	3%	1.000
Nausea/vomiting	1%	3%	0.418
Choking	1%	2%	1.000
Vital signs at arrival
Tachycardia	35%	37%	0.807
Heart rate	94 ± 17	93 ± 20	0.347
SAP	141 ± 24	141 ± 25	0.944
DAP	86 ± 13	89 ± 15	0.628
Fever	7%	11%	0.325
Temperature	37 ± 1	37 ± 1	0.514
Tachypnoea	6%	11%	0.121
RR	18 ± 2	18 ± 3	0.326
Desaturation	1%	2%	0.301
SaO2	97 ± 3	97 ± 3	0.435
Positive neck x-ray findings	61/103	46/177	<0.001
Laboratory results
Leucocytosis a	72%	43%	<0.001
WBC count (×1000/μL)	12 ± 6	10 ± 4	<0.001
CRP > 3	78%	86%	0.127
CRP level (mg/dL)	18 ± 47	24 ± 37	0.988

AE: acute epiglottitis; FB: foreign body; SAP: systolic arterial pressure; DAP: diastolic arterial pressure; RR: respiratory rate; SaO₂: oxygen saturation; WBC: white blood cell; CRP: C-reactive protein.

a

Defined as WBC >10,000/μL. Bold values indicated the p value < 0.05.

Of the patients diagnosed with AE, 99% were administered antibiotics. Amoxicillin with clavulanic acid was the commonest empiric regimen, prescribed for 83.3% of the patients; 93% of them underwent corticosteroid therapy. Two patients had already undergone tracheostomies at diagnosis, and 30 of the remaining 106 patients required urgent airway interventions, including 9 orotracheal intubations, 20 nasotracheal intubations and 1 emergent tracheostomy. The median intubation period was 5 days. The outcome and dispositions of the patients with AE are shown in Figure 2.

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Figure 2.

The outcome and dispositions of the AE patients.

Two patients were discharged against medical advice, and two patients were transferred to another hospital. Of the remaining 104 patients, 20 were discharged from the ED with uneventful outcomes, 50 were admitted to the ward and 34 required ICU admission. Complications were documented in 14 patients, including 6 deep neck infections, 3 pulmonary abnormalities (pneumonia, pneumothorax and pulmonary embolism), 2 epiglottic abscesses, 1 bleeding tumour, 1 oesophageal laceration and 1 cerebral infarction. Two patients expired: one with concomitant buccal cancer developed tumour bleeding and a deep neck infection and the other patient had a history of thyroid cancer and developed pneumothorax and a deep neck infection. Of those who had complications but could be discharged, the mean hospital stay was 13.6 (standard deviation (SD) = 6.92) days. Patients without complications had a mean hospital stay of 6.3 (SD = 2.66) days.

Because two of the patients with AE had pre-existing tracheostomies, we divided the remaining 106 patients with AE into two groups: those who received airway intervention and those who did not. Comparing the clinical characteristics of the two groups revealed that patients with AE who required artificial airways had a higher prevalence of cardiovascular diseases and diabetes mellitus (Figure 3). In addition, patients who required artificial airways had a higher prevalence of sore throat, drooling, tachypnoea and leucocytosis as well as higher WBC counts and higher CRP levels (Table 2).

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Figure 3.

Comorbidity prevalence by artificial airway creation.

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Table 2.

Comparisons between patients with AE who received an artificial airway and those who did not.

	Artificial airway	Non-artificial airway	p
Gender (F)	23%	43%	0.055
Median age (years)	46 ± 13	43 ± 21	0.054
Duration of subjective symptoms before arrival	2 ± 11	2 ± 2	0.354
Sore throat	70%	87%	0.042
Odynophagia	50.%	50%	1.000
Fever at home	17%	25%	0.356
Dyspnoea	27%	16%	0.197
Cough	10%	17%	0.357
Hoarseness	10%	11%	0.936
Neck pain	17%	5%	0.058
Drooling	17%	4%	0.026
Rhinorrhoea	3%	5%	0.673
FB sensation	3%	3%	0.844
Stridor	3%	1%	0.492
Nausea/vomiting	3%	0%	0.110
Choking	3%	0%	0.110
Vital signs at arrival
Tachycardia	33%	36%	0.831
Heart rate	101 ± 18	93 ± 17	0.920
SAP	140 ± 32	141 ± 20	0.348
DAP	85 ± 15	86 ± 12	0.879
Fever	7%	9%	0.672
Temperature	37 ± 1	37 ± 1	0.626
Tachypnoea	13%	1%	0.009
Desaturation	4%	0%	0.166
SaO2	97 ± 4	97 ± 2	0.526
Positive neck radiograph findings	20/28	39/73	0.100
Laboratory results
Leucocystosis a	93%	63%	0.002
WBC count (×1000/μL)	15 ± 5	12 ± 5	0.001
CRP > 3	84%	76%	0.397
CRP level (mg/dL)	37 ± 67	13 ± 33	0.005

AE: acute epiglottitis; SAP: systolic arterial pressure; DAP: diastolic arterial pressure; RR: respiratory rate; SaO₂: oxygen saturation; WBC: white blood cell; CRP: C-reactive protein.

a

Defined as WBC >10,000/μL. Bold values indicated the p value < 0.05

Discussion

The patient characteristics of our patients with AE were similar to those reported in other studies, that is, middle-aged and slightly predominantly male.^4–7

Hypertension, diabetes mellitus, malignancy and asthma have been considered possible predisposing concomitant diagnoses for AE. ⁴ However, our study revealed that although cardiovascular diseases, diabetes mellitus and head and neck tumours were the three commonest comorbidities in patients with AE, only head and neck tumours were significantly more prevalent in the AE group than in the patients without AE, probably because the patients with head and neck tumours had typically undergone surgery or radiotherapy for their tumours, rendering the involved regions vulnerable and susceptible to infection or inflammation. In addition, cardiovascular diseases, diabetes mellitus, asthma or chronic obstructive pulmonary disease, and dementia or old stroke were even more common in patients with conditions mimicking AE.

A history of dementia and stroke impaired patients’ ability to express their symptoms and resulted in more patients being inaccurately diagnosed with AE. Patients with cardiovascular diseases, asthma or chronic obstructive pulmonary disease typically presented to the ED with dyspnoea, cough or tachypnoea. When combined with sore throat or odynophagia, these clinical presentations may indicate AE.

Several studies have revealed that sore throat was the commonest presenting complaint.^4,6–11 However, this complaint was nonspecific and commonly expressed by patients with other disease entities. By contrast, odynophagia was more specific to patients with AE and was less often reported in the non-AE group. Rhinorrhoea and cough were typically caused by inflammation involving the extra laryngopharyngeal region and therefore usually resulted from conditions other than AE.

Previous studies have reported a sensitivity of 38%–77% and a specificity of 76% for diagnosing epiglottitis through radiography of the lateral soft tissues of the neck.^7,10 Although lateral neck radiography is not a sensitive diagnostic tool, clinical physicians should clinically suspect AE when radiologic features indicative of a swollen epiglottis are present.

We determined that more patients with AE exhibited leucocytosis with a higher WBC count compared with patients without AE. However, neither elevated CRP prevalence nor the CRP level differed between the two groups. Therefore, WBC count may serve as a more effective screening parameter for diagnosing epiglottitis than CRP.

Airway management is essential in managing epiglottitis. No consensus has emerged on the optimal timing for establishing an artificial airway, whereas clinicians agree that patients presenting with an acute airway obstruction should undergo immediate airway management. Although concomitant underlying diseases interfered with AE diagnosis, their presence may decrease the immunity and physiologic reserve of patients with AE, thereby increasing the risk of airway obstruction. Our study found that patients with AE who required airway management had a higher prevalence of cardiovascular disease and diabetes mellitus, drooling, tachypnoea and leucocytosis. In addition, they had higher WBC counts and CRP levels, which served as surrogate markers of their greater disease severity. All patients with AE received similar medical treatment, but more patients with emergent airway management developed subsequent complications and had longer hospital stays.

Conclusion

We found that of the patients presenting with AE, those with definite AE were associated with head and neck tumours, odynophagia, positive neck radiography findings, leucocytosis and a high WBC count, but the aforementioned parameters were insufficient for formulating a clinical diagnostic tool. Therefore, for patients suspected of having AE, early referral for flexible laryngoscopy remains necessary. Furthermore, once a patient is confirmed as having AE, coexisting diabetes mellitus, cardiovascular diseases, drooling, tachypnoea, leucocytosis, a high WBC count and a high CRP level may indicate a higher risk of developing airway compromise.