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Video transcript

diagnosis of epiglottitis starts with the clinical impression a patient will come in with difficulty breathing perhaps difficulty swallowing patients will commonly be drooling because they can't swallow and they'll have a very muffled voice like very hoarse and deep because they don't want to vibrate their epiglottis because their epiglottis is swollen that's epiglottitis and they have difficulty breathing because all of the swelling of their epiglottis causes narrowing of the airway and difficulty getting air into the lungs and this narrowing also causes what's known as Strider as a patient breathes in oxygen it has to pass through this very narrow airway now and when it's narrowed it can make this very musical sound and that musical sound is called Strider a lot of times it's referred to as inspiratory stridor on inspiration they have this musical sound aid it it kind of sounds like tryna O tryin to breathe and get air into the lungs with a narrow airway huh makes that sound so right along with fever right they've got fever other signs of infection they might have chills it might be severe enough for that they look very toxic they have this difficulty breathing and this drooling going on and one thing of note there are actually no cough receptors in the epiglottis so patients won't have a cough and that's a point I will come back to in a little bit and so again this musical sound I'll go ahead and write it over here is known as Strider and another sign that these patients may have is is commonly known as the tripod sign so first of all patients will try to keep their mouth open and they'll actually extend their neck and chin forward because that actually relieves some of this this narrowing of the airway helps them breathe a little bit it also decreases the pain because if the epiglottis touches something can be painful so they're trying to pull that epiglottis back by opening their airway up now to illustrate the tripod position I'm going to use a little stick figure so a patient may actually be sitting up and leaning forward and when they leaned forward they put their hands forward to possibly on their knees or on the bed in front of them this gives them a characteristic tripod position where they're leaning forward and they're using their hands to prop themselves forward this also relieves the airway obstruction or the pressure on their throat by going forward and you'll notice they'll prefer this sitting up position a patient cannot actually lean back lying flat on the back if patients do that then their airway will close up the swelling will press further on their airway and make it difficult for air to pass through so those are some clinical signs that health practitioner can use to help them diagnose epiglottitis now diagnosis itself comes by direct visualization of the swollen epiglottis now epiglottitis also includes swollen aryepiglottic folds as well as the a written oi cartilage just looking at this little diagram right here you can see the epiglottis is this flap that goes up the re epiglottis folds kind of go down from the epiglottis and the original cartilage is right here so really anything around here swollen would be diagnosed as epiglottitis so direct visualization of swelling is how you can diagnose epiglottitis but there are a couple other tricks in the bag and for that I'll go ahead and scroll down here to show some x-rays now normally what you would see without epiglottitis the normal epiglottis is going to be right here so this will be the normal epiglottis and there's some other pathology I'll show here in a second but you can see the normal epiglottis really is really tiny it's right here it's actually very thin I'll kind of color it in it's it's very thin flap that kind of sits over the voice box is able to close down when you swallow to protect the airway so the larynx would actually be right here this is where the vocal cords are so let's get rid of some of that again the epiglottis is right here this very thin flap now over here these two are cases of epiglottitis right here you can see the epiglottis in this lateral view looks about like that so you can see that I'll color it in again it's a little more swollen so really anything over 8 millimeters thick with a lateral view a lateral radiological view of the neck would be considered epiglottitis and over here in this picture you can actually see very severe epiglottitis this whole thing right here is the epiglottis it's completely swollen over really big we actually call that the thumb sign because it appears like a big thumb just kind of smudged on there whereas before here's the normal epiglottis again it's this very thin flap as I keep saying but here it's really swollen it can get really bad and you can see how that can close up the airway so radiology may be used to assist in the diagnosis of epiglottitis other things that can be used are throat cultures that's when a physician takes a piece of cotton or a q-tip and just swabs the back of the throat right back here past the uvula which is the little dangling thing in the backyard throat that can help identify the bacterial organism that's causing epiglottitis now back in the day the most common organism that would cause epiglottitis is Haemophilus influenzae also known as h flu influenza it's not actually the flu virus it's a bacterial muffle as' influence as a bacteria so it's somewhat of a misleading name now this used to be the major cause of epiglottitis in the United States and really in the world in fact very specifically it was some awfulest influenza type B so is this specific type of H flu that caused epiglottitis but thanks to modern medicine we have a vaccine called h ib home office influenza B vaccine so that has helped decrease the incidence of epiglottitis and some other bugs that have known to cause epiglottitis but not as severely as h flu are the staph and strep bugs so strep pneumoniae streptococcus and staph aureus so all of this you can use to help you diagnose and lead to the treatment of epiglottitis now before we talk about treatment I want to go down here and talk about the clinical picture the clinical symptoms again so there's actually another illness that is very similar to epiglottitis called khru croup is also known as trachea laryngitis it's inflammation of the trachea the throat so so let me just do a rough sketch of the airway again and we'll put the larynx in this circle right here it's a very rough sketch so croup is tricky Oh laryngitis so it includes the larynx which is where the voice box is and the trachea which is the windpipe just below the larynx whereas epiglottitis is really only swelling of the epiglottis and the re epiglottis enter it annoyed so everything kind of above the larynx now with croup it's swelling of the larynx in the trachea so you'll still get Strider because you have narrowing of this airway right here so you'll still get that musical noise of air trying to force its way into the lungs and you'll also see that of course with epiglottitis with croup a major difference is you won't see any drooling patients can swallow a little bit better so they don't have as much drooling whereas of course epiglottitis you do see drooling another major difference is in epiglottitis patients have the tripod sign so they're sitting up straight they can't lie down whereas croup they can actually lie down without any issues and finally a major difference is an epiglottitis there's no cough because there are no coughed receptors being stimulated epiglottis doesn't have any cough receptors whereas when you touch the larynx or the trachea it can very strongly stimulate cough in fact you actually get what's known as a barking cough now I keep moving us around but I want to move back up here for a couple last points this right here is actually a radiographic image of croup tracheal laryngitis you can see all this swollen tissue is closing up the airway but that's below the epiglottis here we don't have an issue in fact over here you can't really see it at all you have a very clear airway so that's a major difference in the radiographic image that you can see between croup and epiglottitis so now let's go ahead and finish off with the treatment of epiglottitis now first of all and this is a very major point you want to protect the airway this is the number one treatment of epiglottitis because it can close up so rapidly in fact one to two hours after getting a fever patients can actually start to swell up and have trouble breathing so airway protection is number one now a little side note if you would all suspect epiglottitis do not use a tongue blade this is actually very critical because that can cause more swelling you only want to examine the airway to diagnose epiglottitis when all the tools to establish airway protection to be able to put a tube into the throat are at hand to allow oxygen delivery to the lungs so airway protection is is critical and number two antibiotics should be given to the patient right away and the course is generally agreed to be about seven to ten days of treatment however around two to three days some resolution of the symptoms can start to be seen so a patient should be observed in the hospital until their symptoms start to resolve and antibiotics should be given for the full treatment if a patient doesn't take antibiotics for the full seven to ten days then epiglottitis may actually recur so patients must be reminded to take the full treatment the full course of antibiotics and last of all prevention is through the Hib vaccine the hip vaccine and of course you'd also want to follow some precautions like don't share any personal items make sure to wash hands thoroughly after encountering a patient with epiglottitis and so on and so forth