Sarah Silverman's Epiglottitis Scare Was a Wake-Up Call

Health Professional, Medical Reviewer
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In July 2016 the comedian Sarah Silverman suffered a medical scare that took her to the emergency room, where she was intubated and placed on a ventilator. The condition she was diagnosed with is called epiglottitis, a medical emergency in which the epiglottis becomes swollen to the point that air cannot enter the windpipe.

The epiglottis is a valve-like structure located inside the larynx (voice box) in the throat. Its function is to separate the opening of the windpipe (trachea) from the esophagus, which is the duct directed to the stomach. When we eat, during the process of swallowing, this valve -- which is usually open to allow for air flow -- switches direction to blocks the windpipe and allow food to enter the esophagus and not the lungs.

The area that air passes through is narrow; under normal circumstances this location is the area with the highest airway resistance so inflammation of the epiglottis can result in complete blockage of air to the lungs.

The initial symptoms of epiglottitis, in addition to marked shortness of breath are a severe sore throat, fever, and difficulty swallowing or managing oral secretions.  Patients will almost always develop a characteristic high-pitched voice known as stridor. As the blockage of air gets more severe, the patient will typically lose his or her voice.

Epiglottitis is often caused by an infection, usually bacterial in nature.  The most common organisms are either Streptococcus or Haemophilus Influenza. With the routine vaccination given to infants, the condition is a rare occurrence in that age group.  The second most common cause of epiglottitis is a thermal injury, from exposure to and inhalation of fire smoke or fumes from noxious gases.

Since the infection is caused by bacteria, it can be treated with antibiotics, but it is not the infection that poses the actual danger. Instead, the airway obstruction that must be treated with urgency.

One of the most critical moments during the progression of this condition can occur in an emergency room, where an individual displays severe shortness of breath.  The differential diagnosis can be another respiratory ailment, and epiglottitis can be confused with an asthma attack.

Asthma is a narrowing of the lower bronchial airways, and is treated with medications including steroids or bronchodilators administered by a nebulizer.  But none of these medications are appropriate or helpful in treating epiglottitis, and precious time can be lost if epiglottitis is not immediately recognized and treated effectively.  Only a few minutes without oxygen can cause irreparable brain damage.  The key observation for a doctor to note is whether or not the patient has a voice. The most ominous sign of this condition is when the voice is completely lost. That means that the epiglottis has swelled dramatically and air is not getting through.

It is critical to make a quick diagnosis, since the lost voice signals a medical emergency and the only treatment, which has to be administered quickly, is to keep the upper airway open -- usually by inserting a tube through the throat so the patient can be ventilated by a machine (ventilator).  In some extreme cases intubation is no longer possible because of severe swelling of the epiglottis can be so severe that it prevents the introduction of a breathing tube.  In this cases, an emergency procedure called a tracheotomy is done, with an incision made through the skin directly into the trachea, to allow air to enter the lungs, bypassing the epiglottis.

(Note: Under unusual circumstances asthma and epiglottitis can present together in the same patient.)

Sarah Silverman’s life being saved at Cedar Sinai Hospital in Los Angeles is noteworthy, but she is not the only famous person to have contracted this condition.

The most famous person to die from swelling of the epiglottis is George Washington. According to Knox and Mason in The Medical History of George Washington, in December 1799 the former President was riding his horseat Mount Vernon all day long in snow, hail, and cold wind. When he returned from his ride, his neck was wet and red, and he remained in his wet clothes during dinner.  Two days later he experienced chills, breathing with difficulty, and was hardly able to utter a word clearly.  He was given a mixture of molasses, vinegar, and sage tea, but in attempting to swallow the thick liquid he experienced further respiratory distress.  Washington convulsed and almost suffocated.  Shortly thereafter, he succumbed to what most medical historians believe to be epiglottitis.

For better or worse, it often takes famous people speaking out to raise awareness about serious but little-known health conditions. With luck, Sarah Silverman’s story has raised awareness about epiglottitis, its symptoms and the need to act quickly to save patients' lives.

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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, Qualified Medical Examiner for the State of California Department of Industrial Relations, and Director of Intensive Care Services at Glendale Memorial Hospital.His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.

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