今日の臨床サポート

喉頭蓋炎

著者: 上山伸也 津山中央病院 感染症内科

監修: 山本舜悟 大阪大学大学院医学系研究科 変革的感染制御システム開発学

著者校正/監修レビュー済:2022/10/12
患者向け説明資料

概要・推奨   

  1. 血液培養の陽性率は決して高くはないが、微生物診断の決め手となることが多いため、全例で血液培養を施行することが推奨される(推奨度2)
  1. 頚部軟部X線写真で特徴的な“thumb sign”を認めれば、診断は可能だが、感度38%、特異度78%と診断ツールとしては不十分である(推奨度2)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
上山伸也 : 特に申告事項無し[2022年]
監修:山本舜悟 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 喉頭蓋炎の起因菌は基本的にはHaemophilus influenzae type bが最多である。ついで肺炎球菌、黄色ブドウ球菌、A群溶連菌などが続く。免疫不全患者では緑膿菌やcandidaなども起因菌として検討が必要である。
  1. 小児におけるヒブワクチン導入後、世界各国で劇的に発症率が減少している。ヒブワクチン導入前は小児10万人あたり年間5例くらいの発症率であったが、導入後は10万人当たり0.6~0.8人まで激減している[1]
  1. 喉頭蓋炎とは端的にいえば、“喉頭蓋とその周辺組織(被裂軟骨、被裂喉頭蓋ヒダ)の蜂窩織炎”である。菌血症の結果として、あるいは近隣臓器からの起炎菌の直接浸潤によって生じる疾患であり、進行すると気道閉塞を引き起こす。
問診・診察のポイント  
  1. 喉頭蓋炎をいかにして鑑別疾患に入れるか、がすべてである。

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文献 

K Tanner, G Fitzsimmons, E D Carrol, T J Flood, J E Clark
Haemophilus influenzae type b epiglottitis as a cause of acute upper airways obstruction in children.
BMJ. 2002 Nov 9;325(7372):1099-100. doi: 10.1136/bmj.325.7372.1099.
Abstract/Text
PMID 12424174
J A Stankiewicz, A K Bowes
Croup and epiglottitis: a radiologic study.
Laryngoscope. 1985 Oct;95(10):1159-60.
Abstract/Text Because of the controversy regarding the benefits of the lateral neck and chest radiographs in the evaluation of croup and epiglottitis, a two-part retrospective study was initiated. Part I consisted of a retrospective chart review of 44 patients with a final diagnosis of croup and epiglottitis. Part II consisted of the 42 lateral neck and chest x-rays from patients in part I presented to six radiologists who knew only the patients age and the history of respiratory distress. Two hundred forty-six responses were obtained. The results of the part I study showed that 64% of patients with documented epiglottitis had a positive radiologic diagnosis. Only 33% of patients with croup had a positive radiologic diagnosis and importantly 27% had a diagnosis of possible epiglottitis. The results of part II showed 38% of the documented epiglottitis patients had a positive lateral neck radiograph. The croup patients had a lateral neck and/or chest x-ray positive in 38%. Of interest, 24% had readings consistent with possible epiglottitis. Based on this two-part study, it is our conclusion that the lateral neck and chest x-ray may be unreliable and inaccurate in the diagnosis of croup and epiglottitis. Caution and good clinical judgement should be utilized when interpreting these x-rays.

PMID 4046698
Gilead Berger, Tali Landau, Sivan Berger, Yehuda Finkelstein, Joelle Bernheim, Dov Ophir
The rising incidence of adult acute epiglottitis and epiglottic abscess.
Am J Otolaryngol. 2003 Nov-Dec;24(6):374-83.
Abstract/Text 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.

PMID 14608569
M F Mayo-Smith, J W Spinale, C J Donskey, M Yukawa, R H Li, F J Schiffman
Acute epiglottitis. An 18-year experience in Rhode Island.
Chest. 1995 Dec;108(6):1640-7.
Abstract/Text OBJECTIVE: To assess the incidence, clinical characteristics, management, and outcome of epiglottitis in a defined population over an 18-year period.
DESIGN: Case series.
SETTING: The state of Rhode Island, 1975 through 1992.
PATIENTS OR OTHER PARTICIPANTS: Cases who met predetermined criteria for acute epiglottitis identified from hospital discharges and the State Medical Examiner's log of prehospitalization deaths.
MAIN OUTCOME MEASURES: Incidence by year and age, clinical presentation, results of diagnostic evaluations, management, and outcome.
RESULTS: Four hundred seven cases were identified, 134 in children and 273 in adults. Incidence in children dropped from 38 cases in the first 3 years of the study to 1 case in the last 3 years (p < 0.001). Adult cases increased from 17 in the first 3 years to 69 in the last 3 years (p < 0.001). Seventy-nine percent of adults and 32% of children were treated without an artificial airway. Factors associated with airway obstruction included symptomatic respiratory difficulty, stridor, drooling, shorter duration of symptoms, enlarged epiglottis on radiograph, and Haemophilus influenzae bacteremia (p < 0.001 for each). Twelve patients died (3 children and 9 adults), with all cases of fatal respiratory obstruction occurring within 12 h of presentation.
CONCLUSIONS: There have been significant changes in the clinical epidemiology of epiglottitis, which now occurs almost exclusively in adults, often with less severe symptoms and a lower incidence of H influenzae infection. While careful observation is indicated for all patients, the data suggest that those with certain clinical characteristics can be treated safely without an immediate artificial airway.

PMID 7497775
N Wood, R Menzies, P McIntyre
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. doi: 10.1111/j.1445-5994.2005.00909.x.
Abstract/Text BACKGROUND: Acute epiglottitis due to infection with Haemophilus influenzae type b (Hib) is much less common in children following the introduction of Hib vaccination; however, adult epiglottitis cases have not decreased. In addition, epiglottitis hospitalizations are consistently more numerous than notifications and the reason for this is not clear.
AIMS: To more accurately describe the clinical, aetiological and epidemiological features of epiglottitis and to ascertain the accuracy of hospitalization data in an era of widespread Hib vaccination.
METHODS: Medical records in 11 public hospitals in three area health services in New South Wales with a principal or stay diagnosis (International Classification of Diseases (ICD)-9-CM or ICD-10-AM code) of acute epiglottitis between July 1990 and June 1992 (prior to Hib vaccination = pre-vaccine era) and July 1998 and June 2000 (widespread Hib vaccination = vaccine era) were reviewed. Case definitions of epiglottitis were applied.
RESULTS: One hundred and forty-two records were identified (114 pre-vaccine era and 28 vaccine era). Incorrect coding was more common in vaccine era records (32 vs 7%). Of correctly coded records, adults over 20 years old comprised the majority in the vaccine era (84 vs 17%). Hib bacteraemia was identified in 62% of cases in the pre-vaccine era compared to no cases in the vaccine era, despite equivalent blood cultures being taken between the two eras (84 vs 74%). Streptococcus pneumoniae was the only other organism isolated. Three deaths were recorded (1 child, 2 adults), all in the pre-vaccine era.
CONCLUSIONS: Acute epiglottitis hospitalizations in the current Hib vaccine era are predominantly in adults, and rarely are Hib or other causative organisms identified, although microbiological data are often incomplete. The discrepancy between hospitalization and notification data appears to be due to misclassification of hospitalization records.

PMID 16105154
Ira M Price, Ian Preyra, Christopher M B Fernandes, Karen Woolfrey, Andrew Worster
Adult epiglottitis: a five-year retrospective chart review in a major urban centre.
CJEM. 2005 Nov;7(6):387-90.
Abstract/Text OBJECTIVE: There is an increasing awareness of unvaccinated adults presenting with epiglottitis to the emergency department. This study examines the clinical presentations and outcomes of diagnosed cases of adult epiglottitis presenting to all emergency departments in Hamilton, Ont., between 1999 and 2003.
METHODS: We employed explicit protocols with defined variables, trained abstractors and standardized abstraction forms, and reviewed all diagnosed cases of adult epiglottitis during a 5-year period. Inter-rater agreement was measured using a kappa statistic.
RESULTS: Inter-rater reliability for data abstraction was kappa = 1. From a total of 1 million emergency department admissions, 54 cases of epiglottitis were identified. The mean age was 49, and 69% of the patients were male. The 3 most frequently documented symptoms were sore throat (100%) odynophagia (94%) and inability to swallow secretions (63%). The 2 most frequently documented signs were swelling of the epiglottis/supraglottis (100%), and tachycardia (53%). Organisms were isolated from blood in 11% of the cases. There was a white blood cell count >20 x 10(9)/L in 4 of the cases (7.4%). From the 54 cases, 9 of the patients were intubated and all patients were safely discharged from hospital.
CONCLUSION: Adults presenting with epiglottitis to the emergency department in Hamilton have good outcomes, with less airway management required than previously reported in children. Further study is needed to see if these conclusions are similar in other populations.

PMID 17355704
Steven E Sobol, Syboney Zapata
Epiglottitis and croup.
Otolaryngol Clin North Am. 2008 Jun;41(3):551-66, ix. doi: 10.1016/j.otc.2008.01.012.
Abstract/Text Infections of the upper airways are a frequent cause of morbidity in children. Viral laryngotracheobronchitis (croup) is the most common cause of stridor in children and usually has a self-limited course with occasional relapses in early childhood. Epiglottitis has become rare in developed countries with the advent of universal vaccinations against Haemophilus influenzae. It can be rapidly fatal, however, if not promptly recognized and appropriately managed. This article reviews the pathogenesis, epidemiology, clinical presentation, diagnosis, and management of these pediatric upper airway infections.

PMID 18435998

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