Acute Epiglottitis in Children—Treatment With Nasotracheal Intubation: Report of 14 Consecutive Cases

152

PEDIATRICS

Vol. 57 No.

histoplasmosis (including the brain) has been documented at necropsy despite the fact that premorbid cultures of several sources (including the cerebrospinal fluid) were negative for

H.

capsulatum.

The present case describes, for the first time, a child with acute histoplasmosis involving the central nervous system, presenting with promi-nent signs of cerebellar dysfunction and a speech disorder, who made a full recovery from her infection and neurological deficits without specif-ic therapy. Spontaneous recovery from dissemi-nated histoplasmosis (proven by culture and sero-logical evidence) has been reported. ‘ ‘#{149}12 These

findings emphasize the importance of the natural immune mechanisms in prevention of fatal fungal infections. While the normal immune response to

H.

report of the successful outcome of a case of resectable pulmonary histoplasmosis in a nonlym-phopenic, hypogammaglobulmnemic patient stresses the protective role of the cellular immune mechanisms in fungal infections.’3 Appropriate investigation for histoplasmosis seems warranted in cases of unexplained cerebellar ataxia.

WILLIAM T. SHEARER, M.D., PH.D.

GEORGE KOBAYASHI, PH.D.

ARTHUR L. PRENSKY, M.D.

Edward Mallinkrodt Department of Pediatrics and the Department

of Medicine,

Washington University School of Medicine, and

the Divisions of Immunology and Neurology,

St. Louis Children’s Hospital St. Louis, Missouri

Supported in part by Public Health Service Special Research Fellowship 1-F03-A153856 from the National

Insti-tute of Allergy and Infectious Diseases, by Public Health Service grant NS-05633, by a Research Scholar Award of the Cystic Fibrosis Foundation, and by a grant from the Allen P. and Josephine B. Green Foundation, Mexico, Missouri.

ADDRESS FOR REPRINTS: (W.T.S.) Division of Immu-nology, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, Missouri 63110.

REFERENCES

1. Schulz DM: Histoplasmosis of the central nervous system. JAMA 151:549, 1953.

2. Shapiro JL, Lux JJ, Sprofkin BE: Histoplasmosis of the central nervous system. Am J Pathol 31:319, 1955. 3. Snyder CH, White RS: Successful treatment of

Histo-plasma meningitis. J Pediatr 58:554, 1961. 4. Nelson JD, Bates R, Pitchford A: Histoplasnia

meningi-tis. Am J Dis Child 102:96, 1961.

5. Bellin EL, Silva M, Lawyer T: Central nervous system histoplasmosis in a Puerto Rican. Neurology 12:148,

1962.

6. Kaufman L, Terry RT, Schubert JH, et at: Effects of a single histoplasmin skin test on the serological diagnosis of histoplasmosis. J Bacteriol 94:798, 1967.

7. Riley HD Jr: Systemic mycoses in children. In, Gluck L (ed): Current Problems in Pediatrics. Chicago, Year Book Medical Publishers Inc, 1972, p 18.

8. Bradley C, Pine L, Reeves MW, et a!: Purification composition and serological characterization of histoplasmin h and m antigens. Infect Immun 9:870, 1974.

9. Karzon DT, Hayner NS, Winkelstein W Jr, Barron AL: An epidemic of aseptic meningitis syndrome due to

ECHO virus type 6. Pediatrics 29:418, 1962. 10. Jamieson WM, Kerr M, Sommerville RG: ECHO type-9

meningitis in East Scotland. Lancet 1:581, 1958. 11. Watanakunakorn C: Acute disseminated histoplasmosis

with spontaneous recovery. South Med J 66:1065, 1973.

12. Class RN, Cascio FS: Histoplasmosis presenting as acute polyarthritis. N Engl J Med 287: 1 133, 1972. 13. Biggar WD, Meuwissen HJ, Good HA: Successful

defense against Histoptas-ma capsutatton in hypo-gammaglobulinemia. Arch Intern Med 128:585, 1971.

Acute Epiglottitis

in Children-Treatment

With

Nasotracheal

Intubation:

Report

of

14 Consecutive

Cases

Acute epiglottitis is a life-threatening infection of supraglottic structures in children, due to Hemophilus influenzae type b. Sudden and un-expected complete upper airway obstruction is known to occur frequently, and often results either in death or brain damage.

Many authors advocate that immediate tra-cheostomy be performed as soon as the diagnosis is made,’4 insisting on possible catastrophic

consequences of a more conservative approach, even when signs of upper airways obstruction are initially mild or absent.

Nasotracheal intubation (Fig.1) can be consid-ered as a good compromise between the two above alternative forms of therapy. It protects the patients against both asphyxia and possible corn-plications of tracheostomy. It appears a logical approach since acute epiglottitis is a very short-lived disease when treated with appropriate anti-bacterial agents. Furthermore, in many centers, mtubation is routinely performed prior to tracheostomy.

Nasotracheal intubation has been used for

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FIG. 1. Nasotreacheal intubation.

EXPERIENCE

AND REASON

acute epiglottitis with good results in Europe5 and

in Australia6 but, to our knowledge, this thera-peutic approach has only been occasionally re-ported in North America.76 In order to confirm the value of this form of treatment, the successful

use of nasotracheal intubation in 14 consecutive cases of acute epiglottitis is described.

CLINICAL MATERIALS

During a period extending from January 1 to October 31, 1974 (ten months), 14 patients were

admitted to Sainte-Justine Hospital with acute epiglottitis. Most children developed their disease during the summer months (February, 1; June, 4; July, 5; August, 1; September, 2; and October, 1). Pertinent data on each patient are summarized in Table I.

Unfortunately, blood cultures were overlooked in several patients. This error was due to the particular stress involved in some of these cases. The adherence to the strict protocol described further on in this article should prevent such

omissions.

Nasotracheal intubation was performed in all patients for an average duration of 47.2 hours

(range, 12 to 64 hours). Two patients were intu-bated without any kind of anesthetic, one re-ceived intravenously administered diazepam only, two intravenously administered diazepam and succinylcholine, two halothane and nitrous oxyde by face mask, three halothane only, and four intravenously administered thiopental and succinylcholine. No difficulties were encountered during intubation.

The patients were observed in the intensive-care unit, and the customary care of the airway was provided; the nasotracheal tube was con-nected via a T-tube to an oxygen-enriched air source (30%) humidified with nebulized water. The tubes were surprisingly well tolerated: 3 patients received no sedation at all, and 11 received an occasional dose of intravenously administered diazepam (0.2 mg/kg/dose). All patients were given ampicillin intravenously (200 mg/kg/24 hr in four or six divided doses). No patients had any degree of upper airway obstruc-tion at the time of extubation which was preceded by a dose of intravenously administered methyl-prednisolone (5 mg/kg/dose) in the first 1 1 pa-tients (this procedure was abandoned for the remaining three cases).

RESULTS

Very few complications were encountered: two patients extubated themselves spontaneously, one after 64 hours, and the other twice after 4 and 12 hours, without resulting problem. One nasotra-cheal tube was changed without difficulty because it was too narrow, and one patient had a transient segmental atelectasis. All patients left the hospital without any sequelae, after an average of 4.6 days of hospitalization (range, three to eight days).

DISCUSSION

This report demonstrates that nasotracheal intubation can be a very safe approach to the management of acute epiglottitis. In these 14

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TABLE I

154 ACUTE EPIGLOTTITIS

ACUTE EPIGL0rrITI5: CLINICAL DATA

No. Sex Age

Tern- per-ature (C)

Respiratory Distress

WBG (per cu mm)

Neutro-phils

(%)

Diag-nostic

X-Ray

Positive Direct

Exam-ination

Pharyngeal Blood

Culture Culture

Duration of In-tubation

(hr)

Duration

of Hos- pitat-ization

(days)

1 M 5 yr 5 mo 40.0 None 43,500 92 + + Nasal flora

Hemophi-his

49 8

2 F 4 yr 10

mo

39.4 Moderate 23,300 86 + + Hemophilus Not done 46 4

3 M 1 yr 4 mo 38.4 Moderate 21,000 87 + + Nasal flora Negative 38 5

4 M 1 yr 10

mo

39.4 Moderate 16,000 78 + + Nasal flora Not done 35 3

5 F 5 yr 8 mo 39.4 Severe 10,000 85 + + Nasal flora Not done 57 5

6 M 2 yr 0 mo 39. 1 Moderate 22,350 80 Not done + Not done Not done 64 4

7 F 5 yr 8 mo 39.2 Moderate 19,000 90 Not done + Nasal flora Negative 47 4

8 M 6 yr 8 mo 38.8 Moderate 24,500 89 + + Nasal flora

Hemophi-his

48 5

9 F 2 yr 1 mo 38.6 Moderate 14,300 84 + + Nasal flora Not done 51 3

10 M 2 yr 1 mo 38.4 Moderate 12,600 80 + + Not done Negative 48 5

11 M 1 yr 8 mo 38.4 Severe 18,700 77 + + Not done Not done 64 6

12 M 2 yr 5 mo 39.4 Moderate 26,500 91 Not done + Nasal flora

Heinophi-los

46 6

13 M 6 yr 0 mo 38.6 Moderate 13,900 86 + + Hemophitus Negative 56 4

14 F 3 yr 6 mo 40.0 Moderate 25,500 95 + + Nasal flora

Hemophi-los

12 3

Mean 3 yr 8 mo 39.0 20,860 85. 7 47.2 4.6

cases, the duration of hospitalization was one of the shortest reported and no mortality or morbidity occurred. Scarring and other possible complications of tracheostomy were avoided and the dilemma between immediate operative action and close observation was solved satisfactorily.

The protocol that has been established because of the encouraging results of this series is the following:

(1) If a patient clinically suspected of having acute epiglottitis is admitted to the emergency room, immediate examination of the pharynx is prohibited.

(2) Consultants in anesthesiology and otolaryn-gology are called at once.

(3) If clinical condition permits, radiologic studies of the soft tissue of the neck are quickly

obtained in the emergency room. The patient re-mains in a sitting position during this procedure which requires only a few minutes, and an expe-rienced physician remains in constant attend-ance.

(4) If the X-ray study is diagnostic, the patient is immediately transfered to the operating room for a direct examination of the epiglottis, usually under general anesthesia. At this time throat and blood cultures are obtained. If the X-ray study shows signs of laryngitis instead of epiglottitis, therapy for laryngitis is started.

(

(6) The patient is then transferred to the intensive-care unit for continuous observation.

(7) The following medications are given:

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PEDIATRICS

Vol. 57 No. 1 January

1976

cillin (200 mg/kg/24 hr intravenously in four divided doses); acetylsalicylic acid (rectally, as

necessary); fluids, electrolytes, and glucose (intra-venously); and diazeparn (0.2 mg/kg/dose, intra-venously, as necessary).

(8) An extubation is attempted after 36 or 48

hours, early in the morning, in the operating room under the supervision of both an anesthesiologist and an otolaryngologist.

(9) The patient is observed in a mist tent for an additional 24 hours and then discharged with orally administered ampicillin for a total of ten days.

SUMMARY

Fourteen consecutive cases of acute epiglottitis

were treated by nasotracheal intubation during a

ten-month period. The duration of intubation

averaged 47.2 hours. No mortality or morbidity

occurred. Mean hospitalization was 4.6 days. This study demonstrates the ease of maintaining an

assured airway by nasotracheal intubation in

cases of acute epiglottitis.

MICHEL L. WEBER, M.D., F.R.C.P.(C)

ROGER DESJARDINS, M.D.

GILLE5 PERREAULT, M.D., F.R.C.P.(C)

Cu RIVARD, M.D.

YVON TURMEL, M.D., F.I.C.S., F.R.C.P.(C) Departments of Pediatrics, Anesthesiology,

Otolaryngology, and Radiology,

H#{244}pital Sainte-Justine and University of Montreal

Montreal, Quebec, Canada

ADDRESS FOR REPRINTS: (M.L.W.) Department of Pediatrics, H#{244}pitalSainte-Justine, 3175 Ste Catherine Road,

Montreal, P.Q. H3T 1C5, Canada.

REFERENCES

1. Rapkin RH: Acute epiglottitis: Pitfalls in diagnosis and management. Clin Pediatr 10:312, 1971.

2. Margolis CZ, Ingram DL, Meyer JH: Routine

tracheo-tomy in Hemophitus influenzae type b epiglottitis. J

Pediatr 81:1150, 1972.

3. Rapkin RH: Tracheostomy in epiglottitis. Pediatrics

52:426, 1973.

4. Johnson GK, Sullivan JL, Bishop LA: Acute epiglottitis: Review of 55 cases and suggested protocol. Arch Otolaryngol 100:333, 1974.

5. Tos M: Nasotracheal intubation in acute epiglottitis. Arch Otolaryngol 97:373, 1973.

6. Sweeney DB, Allen TH, Steven IM: Acute epiglottiditis: Management by intubation. Anesth lntens Care 1:526, 1973.

7. Geraci RP: Acute epiglottitis: Management with pro-longed nasotracheal intubation. Pediatrics 41:143, 1968.

8. Milko DA, Marshak G, Striker TW: Nasotracheal

into-bation in the treatment of acute epiglottitis.

Pediat-ric.s53:674, 1974.

ACKNOWLEDGMENT

Drs. R. Gervais, A. Guerguerian, A. Lamarre, C. Leduc, and many residents and nurses of the intensive-care unit contril)uted to the excellent care of these patients. The authors are grateful to Dr. H. Bard who reviewed the manu+script.

Cerebellar

Hypoplasia

in an Infant

With

Congenital

Cytomegalovirus

Infection

Cerebellar hypoplasia is a prominent feature of fetal brain pathology as produced in experimental animal models with various congenital viral

infec-tions.’-’

We have recently studied an infant with clas-sical congenital cytomegalovirus (CMV) syn-drome. The pathologic changes noted in the brain of micropolygyria, periventricular calcifications, and chronic inflammation have long been regarded as the hallmarks of chronic CMV

infec-tion of the fetal brain.’5 However, the presence of

striking cerebellar hypoplasia, reminiscent of some viral infections of the central nervous

system described in the experimental animal models, has prompted this short communica-tion.

CASE REPORT

B.B.P. was born to a 22-year-old mother, gravida 2 para 1, after an uncomplicated pregnancy. The birthweight was 2,599 gm. The infant was icteric from birth. During the first ten hours of life, he had respiratory distress and was cyanotic. Scattered petechiae were reported over his entire body.

He was transferred to the University of Alabama Medical Center in Birmingham at the age of 4 days with hyperbiliru-binemia (serum 1)ilifllhifl was 32.7 mg per 100 ml). On ad-mission the infant was alert. Microcephaly (head circumfer-ence, 29.5 cm) and hepatosplenomegaly (liver 5 cm below the right costal margin and the spleen 9 cm under the left costal margin) were obvious on physical examination.

Extensive investigation for perinatal infection was

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1976;57;152

Pediatrics

Michel L. Weber, Roger Desjardins, Gilles Perreault, Guy Rivard and Yvon Turmel

14 Consecutive Cases

Treatment With Nasotracheal Intubation: Report of

−−

Acute Epiglottitis in Children

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1976;57;152

Pediatrics

Michel L. Weber, Roger Desjardins, Gilles Perreault, Guy Rivard and Yvon Turmel

14 Consecutive Cases

Treatment With Nasotracheal Intubation: Report of

−−

Acute Epiglottitis in Children

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