Abscess, Stridor, Diabetes Mellitus Are Associated with Need for Airway Intervention in Adult Epiglottitis

by Amy E. Hamaker •

What are the predictors of airway collapse and the need for airway intervention in adult epiglottitis (≥15 years of age)?

Bottom line: In the postvaccine era, clinicians should expect to have to secure airways in 10.9% of cases. The presence of an epiglottic abscess, stridor, or a history of diabetes mellitus are the most reliable clinical features associated with need for airway intervention.

BACKGROUND: Epiglottitis in adults is rare but remains a serious, potentially life-threatening condition. With the advent of the Haemophilus influenzae vaccine, the effects of this on the changing microbiology, incidence, and clinical features of adult epiglottitis remain poorly documented. 

STUDY DESIGN: Comprehensive literature search of 30 studies (10 pre-vaccine, 16 post-vaccine, four both periods) and a total of 10,148 patients.

SETTING: MEDLINE and Embase databases.

SYNOPSIS: The overall airway intervention prevalence was 15%, from a total of 10,020 patients in 28 studies (pre-vaccine 18.83%, post-vaccine 10.88%). Overall intubation prevalence was 10.37% (pre-vaccine 11.29% post-vaccine 9.35%), and overall tracheostomy prevalence was 5.46% (pre-vaccine 4.80%, post-vaccine 4.53%). The most common symptoms were sore throat, odynophagia, dysphagia, voice change, hoarseness, muffled voice, and cough. Symptoms of pending airway obstruction, which occurred in a minority of patients, included stridor, drooling, and dyspnea. On flexible nasendoscopy, the most common findings were edema and erythema of the epiglottis. Arytenoid, aryepiglottic fold, and vocal cord inflammation; pharyngitis; and neck lymphadenopathy were observed. Meta-analysis of relative risk indicated that stridor, voice change, and dyspnea were predictive of the need for airway intervention, while sore throat was predictive of no airway intervention. Epiglottic edema on laryngoscopy, diabetes mellitus, abscess, and bacteremia were also associated with a higher risk of airway intervention. The most commonly identified pathogen was Streptococcus; Haemophilus and Staphylococcus were also identified. The most commonly used empiric antibiotic agents (used in 98.4% of cases) were penicillins (ampicillin, piperacillin, amoxicillin-clavulanate) and cephalosporins (cefuroxime, ceftriaxone, cefotaxime). Intravenous steroid therapy was used in 56.7% of cases.

CITATION: Sideris A, Holmes TR, Cumming B, et al. A systematic review and meta-analysis of predictors of airway intervention in adult epiglottitis. Laryngoscope. 2020;130:465-473