Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13)

Clinical Manifestations and Diagnosis Epiglottitis typically presents more acutely in young children than in adolescents or adults.
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Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13) Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13) Clinical Manifestations and Diagnosis Epiglottitis typically presents more acutely in young children than inadolescents or adults. On presentation, most children have had symptoms for on clinical grounds, although direct fiberoptic laryngoscopy is frequentlyperformed in a controlled environment (e.g., an operating room) in order tovisualize and culture the typical edematous cherry-red epiglottis and to facilitateplacement of an endotracheal tube. Direct visualization in an examination room(e.g., with a tongue blade and indirect laryngoscopy) is not recommended becauseof the risk of immediate laryngospasm and complete airway obstruction. Lateralneck radiographs and laboratory tests can assist in the diagnosis but may delay thecritical securing of the airway and cause the patient to be moved or repositionedmore than is necessary, thereby increasing the risk of further airway compromise.Neck radiographs typically reveal an enlarged edematous epiglottis (thethumbprint sign, Fig. 31-2), usually with a dilated hypopharynx and normalsubglottic structures. Laboratory tests characteristically document mild tomoderate leukocytosis with a predominance of neutrophils. Blood cultures arepositive in a significant proportion of cases. Figure 31-2 Acute epiglottitis. In this lateral soft tissue radiograph of the neck, thearrow indicates the enlarged edematous epiglottis (the thumbprint sign). Epiglottitis: Treatment Security of the airway is always of primary concern in acute epiglottitis,even if the diagnosis is only suspected. Mere observation for signs of impendingairway obstruction is not routinely recommended, particularly in children. Manyadults have been managed with observation only since the illness is perceived tobe milder in this age group, but some data suggest that this approach may be riskyand probably should be reserved only for adult patients who have yet to developdyspnea or stridor. Once the airway has been secured and specimens of blood andepiglottis tissue have been obtained for culture, treatment with IV antibioticsshould be given to cover the most likely organisms, particularly H. influenzae.Because rates of ampicillin resistance in this organism have risen significantly inrecent years, therapy with a β-lactam/β-lactamase inhibitor combination or asecond- or third-generation cephalosporin is recommended. Typically,ampicillin/sulbactam, cefuroxime, cefotaxime, or ceftriaxone is given, withclindamycin and TMP-SMX reserved for patients allergic to β-lactams. Antibiotictherapy should be continued for 7–10 days and should be tailored, if necessary, tothe organism recovered in culture. If the household contacts of a patient with H.influenzae epiglottitis include an unvaccinated child under the age of 4, allmembers of the household (including the patient) should receive prophylacticrifampin for 4 days to eradicate carriage of H. influenzae. Infections of the Deep Neck Structures Deep neck infections are usually extensions of infection from other primarysites, most often within the pharynx or oral cavity. Many of these infections arelife-threatening but are difficult to detect at early stages when they may be moreeasily managed. Three of the most clinically relevant spaces in the neck are thesubmandibular (and sublingual) space, the lateral pharyngeal (or parapharyngeal)space, and the retropharyngeal space. These spaces communicate with one anotherand with other important structures in the head, neck, and thorax, providingpathogens with easy access to areas including the mediastinum, carotid sheath,skull base, and meninges. Once infection reaches these sensitive areas, mortalityrates can be as high as 20–50%.