The rising incidence of adult acute epiglottitis and epiglottic abscess

doi:10.1016/S0196-0709(03)00083-8

American Journal of Otolaryngology

Volume 24, Issue 6, November–December 2003, Pages 374-383

https://doi.org/10.1016/S0196-0709(03)00083-8 Get rights and content

Abstract

Objective

To examine preliminary observations that the incidence of adult acute epiglottitis has risen between 1986 and 2000.

Materials and methods

Demographics, annual and seasonal occurrences, clinical presentation, diagnostic procedures, treatment, airway management, and complications of 116 consecutive adult patients with laryngoscopically confirmed acute epiglottitis are presented.

Results

The mean annual incidence of acute epiglottitis per 100,000 adults significantly increased from 0.88 (from 1986–1990) to 2.1 (from 1991–1995) and to 3.1 (from 1996–2000) (P < .001). This rise seems to be unrelated to Haemophilus influenzae type b infection but related to miscellaneous pathogenic bacteria. During these periods, the number of epiglottic abscesses increased concomitantly with the rise in the incidence of acute epiglottitis (from 4/14 episodes [29%], to 8/38 [21%], and to 16/66 [24%], respectively), showing a relatively constant ratio between both phenomena (P = .843). Twenty-five patients (21%) underwent airway intervention, 16 because of objective respiratory distress and 9 because of imminent respiratory obstruction. Stepwise logistic regression showed that drooling, diabetes mellitus, rapid onset of symptoms, and abscess formation were associated with airway obstruction. Diverse origins for the epiglottic abscess, either from coalescent epiglottic infection or from mucopyocele of the tongue base, are suggested.

Conclusions

A rise in the incidence of acute epiglottitis and a concomitant rise in the number of epiglottic abscesses were established. Although the course of acute epiglottitis is often benign and can be safely treated with a conservative management approach, delayed airway obstruction may develop from a few hours to days after admission.

Section snippets

Material and methods

The study population consisted of 116 consecutive patients, 16 years old and above, who had a diagnosis of AE or supraglottitis. Two female patients had recurrent AE, with a 2- and 3-year interval between each episode; accordingly, the total number of episodes was 118. Patients were admitted between 1986 and 2000 to the Department of Otolaryngology-Head and Neck Surgery, Meir Hospital, Sapir Medical Center, Kfar Saba, Isreal. Meir Hospital is a regional referral center, serving in the year 2000

Patients

Of the 116 patients enrolled in the study, 63 were men (54%) and 53 women (46%). The ratio of men to women was 1.2:1. Patients varied in age from 16 to 88 years (mean ± SD, 50.3 ± 14.9 years). Altogether, 16 patients (14%) had background diseases; 10 were diabetics, 3 had malignancies, 1 had a combined hepatitis types B and C, 1 had rheumatoid arthritis, and 1 was a drug addict. The mean hospital stay was 5.1 ± 4.2 days. Patients were discharged without documented sequelae; no deaths occurred

Discussion

The data show a significant increase in the incidence of the disease among adults in the Sharon area between 1986 and 2000 and agree with other studies on adult AE carried out elsewhere (Table 4). Notably, evidence of such a trend in adults was already apparent before the introduction of large-scale pediatric vaccination against Hib and continued after vaccination, despite the marked diminution of AE in children. This would imply that the vaccine has little effect on nonvaccinated adults.

Conclusions

Our 15-year experience from 1986 through 2000 suggests that (1) the incidence of adult AE increased significantly, a secular trend probably unrelated to Haemophilus influenzae type b infection, but to other pathogenic bacteria; (2) a selective management approach, which advocates airway intervention only in patients with severe airway symptoms or with imminent airway obstruction, yielded a relatively low rate of interventions (21%) and no fatalities; (3) although most patients requiring airway

Acknowledgements

We thank Estela Derazne, MSc, from the Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare, the Schneider Children’s Medical Center of Israel, Petah Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, for assistance with statistical analysis; and Rachel Berger, BA, for writing and editing assistance.

References (38)

M.F. Mayo-Smith et al.
Acute epiglottitis. An 18-year experience in Rhode Island
Chest
(1995)
C.M. Kucera et al.
Epiglottitis in adults and children in Olmsted County, Minnesota, 1976 through 1990
Mayo Clin Proc
(1996)
T.D. Frantz et al.
Acute epiglottitischanging epidemiologic patterns
Otolaryngol Head Neck Surg
(1993)
M. Ryan et al.
A changing pattern of epiglottitis
Clin Pediatr
(1992)
A.K. Takala et al.
Disappearance of epiglottitis during large-scale vaccination with Haemophilus influenzae type b conjugate vaccine among children in Finland
Laryngoscope
(1994)
O.P. Alho et al.
Acute epiglottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland
Arch Otolaryngol Head Neck Surg
(1995)
Ö. Garpenholt et al.
Epiglottitis in Sweden before and after introduction of vaccination against Haemophilus influenzae type b
Pediatr Infect Dis J
(1999)
C. Carenfelt et al.
Acute infectious epiglottitis in children and adultsannual incidence and mortality
Clin Otolaryngol
(1989)
P. Wurtele
Acute epiglottitis in children and adultsA large-scale incidence study
Otolaryngol Head Neck Surg
(1990)
S. Hugosson et al.
Acute epiglottitis—Aetiology, epidemiology and outcome in a population before large-scale Haemophilus influenzae type b vaccination
Clin Otolaryngol
(1994)

P.C. Hebert et al.

Adult epiglottitis in a Canadian setting

Laryngoscope

(1998)

M.F. MayoSmith et al.

Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island

N Engl J Med

(1986)

M.H. Yardley

Supraglottitis in adults

Practitioner

(1986)

L. Shih et al.

Acute epiglottitis in adults. A review of 48 cases

Ann Otol Rhinol Laryngol

(1988)

K.J. Murrage et al.

EpiglottitisAdult and pediatric comparisons

J Otolaryngol

(1988)

M.L. Navarrete et al.

Acute epiglottitis in the adult

J Laryngol Otol

(1991)

J.C. Dort et al.

Acute epiglottitis in adultsdiagnosis and treatment in 43 patients

J Otolaryngol

(1994)

T. Torkkeli et al.

A Changed clinical course and current treatment of acute epiglottitis in adults a 12-year experience

Laryngoscope

(1994)

S. Berg et al.

Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden

Scand J Infect Dis

(1996)

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Original contributionThe rising incidence of adult acute epiglottitis and epiglottic abscess

Abstract

Objective

Materials and methods

Results

Conclusions

Section snippets

Material and methods

Patients

Discussion

Conclusions

Acknowledgements

Chest

Mayo Clin Proc

Acute epiglottitischanging epidemiologic patterns

Otolaryngol Head Neck Surg

A changing pattern of epiglottitis

Clin Pediatr

Disappearance of epiglottitis during large-scale vaccination with Haemophilus influenzae type b conjugate vaccine among children in Finland

Laryngoscope

Acute epiglottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland

Arch Otolaryngol Head Neck Surg

Epiglottitis in Sweden before and after introduction of vaccination against Haemophilus influenzae type b

Pediatr Infect Dis J

Acute infectious epiglottitis in children and adultsannual incidence and mortality

Clin Otolaryngol

Acute epiglottitis in children and adultsA large-scale incidence study

Otolaryngol Head Neck Surg

Acute epiglottitis—Aetiology, epidemiology and outcome in a population before large-scale Haemophilus influenzae type b vaccination

Clin Otolaryngol

Adult epiglottitis in a Canadian setting

Laryngoscope

Acute epiglottitis in adults. An eight-year experience in the state of Rhode Island

N Engl J Med

Supraglottitis in adults

Practitioner

Acute epiglottitis in adults. A review of 48 cases

Ann Otol Rhinol Laryngol

EpiglottitisAdult and pediatric comparisons

J Otolaryngol

Acute epiglottitis in the adult

J Laryngol Otol

Acute epiglottitis in adultsdiagnosis and treatment in 43 patients

J Otolaryngol

A Changed clinical course and current treatment of acute epiglottitis in adults a 12-year experience

Laryngoscope

Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden

Scand J Infect Dis

Original contribution
The rising incidence of adult acute epiglottitis and epiglottic abscess