Med Student Corner: A Changing Epidemiology – A Patient with Stridor and Sore Throat

By Kelsey Sicker, MD Candidate, Class of 2019 // Edited by Michael Barrie, MD OSU EM Attending

Medicine is a constantly evolving field, with new therapies, preventive strategies, and understandings of disease pathology rapidly growing. As part of this evolution, vaccinations have become key to modern preventive medicine for children and have had a great impact on childhood morbidity and mortality.

With the implementation of universal vaccination recommendations, what long term effects have we seen on the epidemiology of epiglottitis?

A 42-year-old male presented to the emergency department with rapid onset of sore throat and voice changes. He woke up that day with a dry soreness in his throat that progressed to difficulty speaking and swallowing throughout the morning. He noted some mild dyspnea as well but denied prior upper respiratory symptoms including cough, rhinorrhea, sneezing, and denied any exposure to sick individuals. He had no pertinent past medical or surgical history. On exam, he had a low-grade fever of 100.6 F and other vitals within normal limits. He appeared uncomfortable on the bed, with head held leaning forward (sniffing position). He had difficulty speaking due to pain and his voice was hoarse. Pharynx and tonsils were difficult to visualize, but he did have apparent external swelling and tenderness to palpation of the submandibular area and anterior neck. He had tender anterior cervical lymphadenopathy. Heart had regular rate and rhythm, lungs were clear to auscultation bilaterally without wheezes, rhonchi, or rales. Otherwise his exam was within normal limits.

Given the patients voice changes and throat symptoms, a CT neck was performed. The results showed swollen epiglottis with lymphadenopathy consistent with epiglottitis.

Epiglottitis in adults? I thought this was a pediatric disease?

Epiglottitis is classically associated with Hemophilus influenza type B in children. The overall incidence has declined since the use of the Hib vaccine, but now the most commonly effected population is middle aged, Caucasian, urban males with comorbid medical conditions. Older patients age > 85 years are of particular concern and suffer greatest morbidity and mortality from the condition. It is important to note that adult rates of epiglottitis have not been shown to have changed since the vaccination era, but rather the childhood rates have greatly declined, making adult infection more common than pediatric. In addition, Hib is rarely isolated as the causative organism in adults. The most common isolated culprit is Streptococcus pneumoniae, but most cases are mixed infections or have incomplete microbial workup.

In our patient, the team was concerned about the patient’s airway but determined that he did not require immediate airway intervention. Blood cultures were drawn and he was started on empiric ceftriaxone and vancomycin. He was admitted for close observation and follow up care.

Bottom Line:
Epiglottitis is not an illness of children anymore. Although it is not incredibly common in adults, it should be on the differential for middle-aged or older patients with voice changes, stridor, or sore throat.

References:
Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010 Jun. 120(6):1256-62. https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.20921
Wood N, Menzies R, McIntyre P. Epiglottitis in Sydney before and after the introduction of vaccination against Haemophilus influenzae type b disease. Intern Med J. 2005 Sep. 35(9):530-5. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-5994.2005.00909.x
Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. 2006 Jun. 22(6):443-4. https://www.medscape.com/medline/abstract/16801849

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