Acute epiglottitis is a serious life-threatening infectious disease disease that may cause death by asphyxiation. It is more prevalent in males. It can occur in both adults and children, but is more severe in pediatric patients. The disease can occur throughout the year, mostly in the winter and spring.
Etiology
1. Infection is the most common cause of the disease. It is generally believed to occur after a cold or flu, existing viral invasion, followed by bacterial infection. Lower body resistance, laryngeal trauma, the elderly and frail are prone to bacterial infection and morbidity. The disease is most common with Haemophilus influenzae type B. Other common pathogenic bacteria include Staphylococcus aureus, Streptococcus, Diplococcus pneumoniae, Neisseria catarrhalis, Diphtheria-like bacilli, etc. The infection can also be mixed with respiratory syncytial virus, rhinovirus and influenza A virus. Various pathogenic bacteria can be inhaled from the respiratory tract, can also be infected by bloodstream, or spread by neighboring organs.
2, allergic reaction to a kind of allergens, causing inflammation of the epiglottis, can be secondary to bacterial, viral infections and morbidity. Acute epiglottitis can also be caused by metaplasia alone, some scholars will be a separate disease, type I metaplasia, the allergens are mostly drugs, serum, biological products or food, mostly in adults, often recurrent, the chance of laryngeal obstruction is much higher than the acute epiglottitis caused by infection.
3, the spread of adjacent foci such as acute tonsillitis, pharyngitis, stomatitis, rhinitis and other spread and invasion of the upper mucosa of the voice. It can also be secondary to acute infectious diseases.
4.Other factors such as trauma, foreign body, irritating food, inhalation of harmful gas, radiation injury, infection such as epiglottis cyst can cause this disease.
Pathology】 The pathological histological changes can be divided into 3 types.
1, acute khat type Acute khat inflammation occurs in the epiglottis, with diffuse mucosal congestion and edema. There is mononuclear and polymorphonuclear cell infiltration. Because the lingual surface of the epiglottis is more relaxed, so the swelling is more obvious and can be thickened to 6-10 times the normal.
2.Acute edema type If metaplastic inflammation occurs in the epiglottis, the mucosa and submucosa are highly edematous, the mucosa is pale and thickened, and the epiglottis is significantly enlarged like a round ball. The eosinophilic infiltrate, the basement membrane is destroyed, and the eosinophils and mast cells are increased. This type is very likely to have caused laryngeal obstruction.
The pathological changes are that the bacteria often invade the submucosa and glandular tissue, and septicemia and ulceration may occur. If the blood vessel wall is eroded, it can cause erosion and bleeding.
Clinical manifestations
1. Systemic symptoms The disease starts rapidly and often occurs suddenly at night. Most patients fall asleep in a normal fashion, but wake up in the middle of the night with a sudden pain in the throat or difficulty in breathing. Patients may have chills and fever, with body temperature ranging from 37.5℃ to 39.5℃, and a few may reach above 40℃. Patients may be irritable, depressed, pale, and weak. The symptoms are relatively more severe in the elderly and children. Severe patients may experience fainting or shock within a short period of time, manifesting as difficulty in breathing, depression, weakness, cold limbs, pale face, fast and thin pulse, decreased blood pressure, etc.
2. Pain in the throat is the main symptom, and the pain increases when swallowing.
3.Difficulty in swallowing Swallowing can lead to pain in the throat, salivation and refusal to eat. The pain can be radiated to the jaw, neck, ear or back. Dysphagia can occur when the mucosa at the epiglottis and arytenoid cartilage is extremely swollen.
4, dyspnea Due to the swelling of the mucosa of the epiglottis, the mucosa of the arytenoid cartilage, the arytenoid fold and the posterior wall of the pharynx are also edematous, so that the entrance to the larynx is significantly reduced, blocking the vocal cords and causing inspiratory dyspnea. If the condition continues to deteriorate, asphyxia may occur. Although the patient has dyspnea, hoarseness rarely occurs, and the patient’s speech is slurred.
5. Swollen cervical lymph nodes Swollen and painful deep cervical lymph nodes on one or both sides.
Examination
The patient has an acute appearance and often has dyspnea. Although the patient has obvious throat pain, the mucosa of the oropharynx often has no obvious changes, which should be noted. Indirect laryngoscopy reveals diffuse congestion and swelling of the lingual surface of the epiglottis, which is as heavy as a sphere; if there is abscess formation, it is often swollen on one side of the lingual surface of the epiglottis, which is acutely congested and has yellow pus spots on the surface. The mucosa of the ventricular zone and arytenoid process is congested and swollen. Due to the obvious swelling of the epiglottis, the vocal cords and vocal folds cannot be seen.
Children are often unable to cooperate with indirect laryngoscopy. Taking a lateral X-ray of the larynx, which shows an enlarged epiglottis, is helpful for diagnosis.
Diagnosis】 For acute sore throat, pain that worsens when swallowing, no obvious abnormalities in oropharyngeal examination, or inflammation in the oropharynx but not enough to explain the symptoms, acute epiglottitis should be considered, and indirect laryngoscopy should be performed promptly. The diagnosis of acute epiglottitis can be made when the epiglottis is congested and enlarged under indirect laryngoscopy.
Differential diagnosis】 Acute epiglottitis must be differentiated from the following diseases
1, laryngeal foreign body often have a history of foreign body inhalation, larger foreign body can have loss of voice, severe cough, dyspnea, cyanosis, and even asphyxiation, serious cases can die of asphyxiation within minutes; smaller foreign body is often hoarse, laryngeal wheezing, paroxysmal violent cough. If the laryngeal mucosa is pierced by a sharp foreign body, there are symptoms such as sore throat, fever, painful swallowing or difficulty in breathing. Based on the history of laryngeal foreign body inhalation, laryngoscopy, anteroposterior and lateral laryngeal X-ray, and CT scan of larynx, the diagnosis can be confirmed and clarified.
2. Acute laryngotracheobronchitis is usually seen in infants and young children under 3 years of age, often with a mild cough followed by a croupy dry cough, wheezing, hoarseness and inspiratory dyspnea. Examination reveals congestion of the nasal, pharyngeal and vocal fold mucosa with normal epiglottis. Directly after the or bronchoscopy, diffuse congestion and swelling below the vocal fissure is seen.
3, laryngeal diphtheria The onset is slow, with heavy symptoms of systemic toxicity, violent cough, slow development of dyspnea, hoarseness or loss of voice. A grayish white film is formed in the throat, which cannot be easily removed and bleeds easily when forcibly peeled off. The lymph nodes in the neck are sometimes enlarged, and in severe cases, they are in the shape of a “bull’s neck”. Diphtheria bacilli can be found in the swab smear and culture of the pharynx.
4.Epiglottic cyst is slow, without systemic symptoms. Cystic masses can be seen in the epiglottis, mostly on the lingual surface of the epiglottis. When the epiglottis cyst is combined with infection, there is a local manifestation of pus cyst, it is appropriate to incise and drain pus treatment.
Treatment
Acute epiglottitis is more dangerous and can quickly lead to fatal laryngeal obstruction. Treatment is based on the principle of anti-infection and keeping the respiratory tract unobstructed. Close observation and preparation for resuscitation are necessary.
1, anti-infection systemic application of a sufficient amount of strong antibiotics and glucocorticoids. Cephalosporins and penicillin antibiotics can be used. Glucocorticosteroids are used such as dexamethasone. Dexamethasone and other glucocorticoids and antibiotics combined application, can get good results.
2, tracheotomy For those who have respiratory distress, intravenous use of antibiotics and glucocorticoids does not improve the emergency tracheotomy. Tracheotomy should be performed as soon as possible for those with acute onset, rapid progress, and laryngeal obstruction of degree II or above; those with serious disease, many secretions in the throat and swallowing disorder; those with high mucosal congestion and swelling at the epiglottis or arytenoid cartilage, whose condition does not improve after anti-inflammatory and oxygenation treatment; and those who are old and weak and have poor cough function. Emergency tracheotomy should be performed immediately in cases of irritability, cyanosis, four concave signs, disappearance of pulmonary breath sounds, fainting, shock, etc.
3.Other In case of abscess formation on the lingual surface of the epiglottis or poor drainage despite the rupture of the abscess, laryngoscopic incision and drainage of the abscess can be performed under the condition of keeping the airway unobstructed. Pay attention to maintaining the water-electrolyte acid-base balance, and use intravenous rehydration and other supportive treatment for those who have difficulty in eating.