“Dancing with the Stars” contestant Jeannie Mai has withdrawn from the show after she was admitted to the hospital with epiglottitis. Mai, a co-host on the afternoon talk show “The Real,” was shocked when what she thought was a simple sore throat was deemed to be a potentially life-threatening condition, and that she needed emergency surgery. According to Mai on Instagram, “What simply started as a sore throat had unbeknownst to me become a dangerous infection that already closed at least 60% of my airway and resulted in a throat abscess that spread in a matter of 3 days.”
Her physician, otolaryngologist Shawn Nasseri, MD, told her that the surgery had gone well, but: “If you had waited one more day, your throat would have closed up.”
In a video filmed from her hospital bed, Mai thanked her fans and “DWTS” family for her time there: “I’m just so thankful I had the experience on “Dancing with the Stars.” It was hands down one of the best journeys of my life, so thank you so much.”
Epiglottitis in adults
During my pediatrics residency, one of my most dreaded experiences was encountering a child in which you suspected epiglottitis. The thought of keeping a frightened child calm until he could be safely intubated by an anesthesiologist was enough to raise the hairs on the back of your neck. Fortunately, since the administration of Haemophilus influenzae type b (Hib) vaccine, epiglottitis in children has become increasingly rare. However, epiglottitis in adults is still present.
The epiglottis is a thin elastic cartilaginous structure located at the root of the tongue that folds over the opening of the larynx to prevent food and liquid from entering the trachea during the act of swallowing.
Epiglottitis, also called supraglottitis, is the inflammation of the epiglottis and adjacent anatomic structures. The tissues between the epiglottis and the posterior pharynx have a large network of lymphatics and blood vessels. Any infection and its inflammatory response can easily spread throughout the area. Edema of the epiglottis and supraglottic structures can gradually progress until a critical mass is reached, at which time the clinical scenario can deteriorate rapidly. This can lead to airway obstruction, respiratory distress, and even death.
Epiglottitis can be caused by a broad range of bacterial, viral, and fungal pathogens. Less commonly, it can have a non-infectious cause, such as thermal injury, foreign body ingestion, and caustic ingestion. The most common pathogens include Streptococcus pyogenes, S. pneumoniae, and S. aureus. In immunocompromised patients, Pseudomonas aeruginosa and Candida have also been found. Viral infections such as herpes simplex virus and Epstein-Barr virus have been associated with epiglottitis, although it is not clear whether they are the primary cause or if they optimize conditions for a bacterial superinfection.
Although the risk of epiglottitis in children has declined, the risk of epiglottitis in adults remains and may, in fact, be increasing. According to Guerra and Waseem, the incidence of acute epiglottitis in adults ranges from 0.97 to 3.1 per 100,000, with a mortality of approximately 7.1%. The mean annual incidence of acute epiglottitis per 100,000 adults significantly increased from 0.88 (from 1986 to 1990) to 3.1 (from 1996 to 2000). In addition, the number of epiglottic abscesses increased concomitantly with a rise in the incidence of acute epiglottitis and may be as high as 30%. An epiglottic abscess can be caused by an extension of epiglottitis into supraglottic structures and even up into the parapharyngeal space. It can also be caused by infection of a mucocele (a benign mucus containing cyst) in the epiglottis or at the base of the tongue. The lingual surface of the epiglottis is the most commonly involved site of epiglottal abscesses.
Important differences exist in the anatomy of the pediatric versus adult airway. The epiglottis in a child is located more superiorly and anteriorly and is at a more oblique angle than in adults. In addition, the cartilage of the epiglottis is more pliable in pediatric versus adult patients. These differences account for the increased likelihood that a pediatric patient will present earlier, and with symptoms of respiratory distress than would an adult.
The signs and symptoms in adult epiglottis may develop more slowly, occurring over days, rather than hours. They include severe sore throat, fever, a preference for sitting up rather than laying down, a muffled or hoarse voice, stridor when breathing in, difficulty or pain with swallowing (dysphagia, odynophagia), drooling, and difficulty breathing.
In children, manipulation of the oral cavity can lead to disaster, i.e., laryngospasm leading to respiratory arrest. They should be kept as calm as possible until they can be intubated by an anesthesiologist in an operating room setting. Oropharyngeal examination may be attempted in adults if they are stable, comfortable, and cooperative. A lateral x-ray of the neck may show swelling of the epiglottis, referred to as the “thumb sign.”
The primary initial focus in the management of epiglottitis is airway maintenance. In patients with signs of airway obstruction, securing the airway via intubation by an airway specialist in a controlled setting is the top priority. On rare occasions where the airway cannot be secured by intubation, a needle or surgical cricothyroidotomy may be required.
Some older children and most adults who are well oxygenated and can maintain their airways may be closely observed without the placement of an artificial airway, as long as experienced airway specialists are available should the patient’s condition deteriorate.
After an airway is secured, broad-spectrum antibiotics that cover common respiratory and oral cavity flora, such as a third-generation cephalosporin plus an antistaphylococcal agent such as vancomycin, are given.
Patients with epiglottic abscess have more severe symptoms and are at increased risk of airway compromise compared with those without this complication. In these patients, surgical aspiration or drainage may be required.
In summary, although epiglottitis can be a life-threatening emergency, the outcome is usually good with proper treatment.
Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.