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

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. On presentation, most children have had symptoms for <24
h, including high fever, severe sore throat, tachycardia, systemic toxicity, and (in
many cases) drooling while sitting forward. Symptoms and signs of respiratory
obstruction may also be present and may progress rapidly. The somewhat milder
illness in adolescents and adults often follows 1–2 days of severe sore throat and is
commonly accompanied by dyspnea, drooling, and stridor. Physical examination
of patients with acute epiglottitis may reveal moderate or severe respiratory
distress, with inspiratory stridor and retractions of the chest wall. These findings
diminish as the disease progresses and the patient tires. Conversely, oropharyngeal
examination reveals injection that is much less severe than would be predicted
from the symptoms—a finding that should alert the clinician to a cause of
symptoms and obstruction that lies beyond the tonsils. The diagnosis is often made
on clinical grounds, although direct fiberoptic laryngoscopy is frequently
performed in a controlled environment (e.g., an operating room) in order to
visualize and culture the typical edematous "cherry-red" epiglottis and to facilitate
placement of an endotracheal tube. Direct visualization in an examination room
(e.g., with a tongue blade and indirect laryngoscopy) is not recommended because
of the risk of immediate laryngospasm and complete airway obstruction. Lateral
neck radiographs and laboratory tests can assist in the diagnosis but may delay the
critical securing of the airway and cause the patient to be moved or repositioned
more than is necessary, thereby increasing the risk of further airway compromise.
Neck radiographs typically reveal an enlarged edematous epiglottis (the
"thumbprint sign," Fig. 31-2), usually with a dilated hypopharynx and normal
subglottic structures. Laboratory tests characteristically document mild to
moderate leukocytosis with a predominance of neutrophils. Blood cultures are

positive in a significant proportion of cases.
Figure 31-2

Acute epiglottitis. In this lateral soft tissue radiograph of the neck, the
arrow 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 impending
airway obstruction is not routinely recommended, particularly in children. Many
adults have been managed with observation only since the illness is perceived to
be milder in this age group, but some data suggest that this approach may be risky
and probably should be reserved only for adult patients who have yet to develop
dyspnea or stridor. Once the airway has been secured and specimens of blood and
epiglottis tissue have been obtained for culture, treatment with IV antibiotics
should be given to cover the most likely organisms, particularly H. influenzae.
Because rates of ampicillin resistance in this organism have risen significantly in
recent years, therapy with a β-lactam/β-lactamase inhibitor combination or a
second- or third-generation cephalosporin is recommended. Typically,
ampicillin/sulbactam, cefuroxime, cefotaxime, or ceftriaxone is given, with
clindamycin and TMP-SMX reserved for patients allergic to β-lactams. Antibiotic
therapy should be continued for 7–10 days and should be tailored, if necessary, to
the organism recovered in culture. If the household contacts of a patient with H.
influenzae epiglottitis include an unvaccinated child under the age of 4, all
members of the household (including the patient) should receive prophylactic
rifampin 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 primary
sites, most often within the pharynx or oral cavity. Many of these infections are
life-threatening but are difficult to detect at early stages when they may be more
easily managed. Three of the most clinically relevant spaces in the neck are the

submandibular (and sublingual) space, the lateral pharyngeal (or parapharyngeal)
space, and the retropharyngeal space. These spaces communicate with one another
and with other important structures in the head, neck, and thorax, providing
pathogens with easy access to areas including the mediastinum, carotid sheath,
skull base, and meninges. Once infection reaches these sensitive areas, mortality
rates can be as high as 20–50%.