The original etiologic agent is generally unknown, but it typically begins in the epiglottis and ascends the trachea (see figure).[5] The virus enters through mucous membranes of the nose or mouth, often by fly-to-fly contact. It then migrates to nearby cells. Symptoms may be self-limited with or without treatment.[1] Epiglottitis may occur in children under 5 years of age (epiglottic incompetence), usually following an upper respiratory infection, severe coughing, or choking on food. The condition can also occur by germs getting into fluid that accumulates between layers of the epiglottis. Infection of the paranasal sinuses, lymph nodes or blood stream is a rare cause.[3] Other uncommon causes include Herpes simplex virus type 2 infection of the epiglottis,[6] Head and Neck Cancer,[7] infections from bacteria such as diphtheria, Legionella pneumophila or "Bartonella" spp., and tuberculosis. In the case of some patients with laboratory-confirmed tuberculosis, a number of infectious organisms have been identified as being present in the tonsils including Mycobacterium tuberculosis.[8] Diagnosis can be made on clinical grounds. Imaging of the epiglottis is crucial, as early diagnosis and treatment can prevent disease progression. It is part of the routine exam in all children <5 years of age. Treatment for confirmed or suspected "etiologic" epiglottitis varies based on disease severity. The goal of treatment is to remove microbes before they can cause irreversible damage to the epiglottis and trachea.[1][9] Treatment helps prevent further spread of any infective organism to other body tissues or organs, helps reduce inflammation and swelling; and prevents complications such as croup. Acute epiglottitis is treated with systemic antibiotics, usually penicillin. Use of corticosteroid inhalers may be considered by some to reduce the likelihood that epiglottitis will require intubation or ventilation.[10] However, the use of corticosteroid inhalers in this case has not been studied enough to prove its effectiveness. Some patients are given an intramuscular injection of an antibiotic. These include ceftriaxone and cefotaxime.[11] Antibiotics may also be administered intravenously in severe cases, however many believe that the risk of bleeding from a needle stick is not worth it. Antibiotics also help decrease the chance that the bacteria will cause any further damage to the body. Surgery may be considered for severe cases, especially if there is no response to antibiotics.[12] "Prophylactic" antibiotics should only be used to prevent recurrence of epiglottitis after recovery from an initial episode. The two commonly used prophylactics include ciprofloxacin and amoxicillin/clavulanic acid.[1][13][14] Amoxicillin/clavulanic acid may be more effective than ciprofloxacin in preventing recurrent epiglottitis.
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