Original ResearchGeneral Otolaryngology

Efficacy of Spinal Needle Aspiration in

Patients with Epiglottic Abscess:
A Prospective, Randomized, Controlled
Study

Otolaryngology
Head and Neck Surgery
2015, Vol. 153(1) 4853
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2015
Reprints and permission:
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DOI: 10.1177/0194599815583475
http://otojournal.org

Young Chan Lee, MD, PhD1, Jung-Woo Lee, DMD, MSD, PhD2,
Gi Cheol Park, MD3, and Young Gyu Eun, MD, PhD1

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objective/Hypothesis. To evaluate the efficacy of spinal needle
aspiration for symptom improvement in awake patients with
epiglottic abscess (EA).
Study Design. Prospective randomized controlled study.
Setting. Tertiary center.
Subjects and Methods. Twenty-two patients who were diagnosed with EA were randomly allocated to group A (needle
aspiration and antibiotics) or group B (antibiotics only).
Patients characteristics, laryngoscopic findings of epiglottic
swelling and arytenoid swelling by scope classification, and initial laboratory findings were analyzed. Needle aspiration was
done under local anesthesia in awake patients using an 18gauge spinal needle and indirect laryngoscope. Changes in the
following symptoms during hospital stay were assessed: sore
throat, hoarseness, dyspnea, odynophagia, and dysphagia.
Results. Eleven patients were treated with needle aspiration and
antibiotics, and 11 patients were treated with antibiotics only.
There was no statistically significant difference between the 2
groups regarding age, sex, white blood cell count, C-reactive protein, presenting clinical symptoms, abscess size, and scope classification at time of diagnosis. Patients in both groups had significant
improvement in all clinical symptoms. While there were no
between-group differences in improvement for any of the symptoms, the length of hospitalization was significantly lower in group
A (4.0 6 1.9 days) than in group B (5.7 6 1.2 days) (P = .037).
Conclusion. We did not find any significant additional benefit
of needle aspiration for the treatment of EA, with the
exception that needle aspiration reduced the length of hospitalization. Further proof with a large-scale study is needed.
Keywords
epiglottitis, abscess, aspiration, symptom
Received July 9, 2014; revised November 13, 2014; accepted
November 25, 2014.

piglottic abscess (EA) results from coalescent epiglottic infection or secondary infection of an epiglottic
mucocele.1 Epiglottic abscess can be a serious and lifethreatening disease because it can cause sudden airway
obstruction. Although EA has generally been thought to be an
uncommon complication of acute epiglottitis, occurring in up
to 4% of cases, several recent studies have reported a higher
rate.2-4 Berger et al5 suggested that the rise in the incidence of
EA could be due to misuse of antibiotics, leading to the emergence and spread of antimicrobial resistance. However, some
authors have suggested that EA could be more frequently identified if patients are diagnosed using radiological technology,
such as computed tomography (CT) scan.6 In a previous study,
we prospectively investigated the presence of hidden abscess
formation in patients with acute supraglottitis using routine
CT. The incidence of EA in patients with acute supraglottitis
was 22%.4 However, most of these found EAs would be
untreated if CT was not performed. Several previous reports
have suggested that EA is a predictor of airway obstruction.7-9
Therefore, EA management should involve aggressive airway
intervention, surgical drainage, and antibiotics treatment.
When patients with EA have acute airway obstruction, they
should be transferred to the operating room for airway management and drainage, usually after undergoing endotracheal
intubation.3 It is important to find a more effective and lesser
invasive process for the management of patients with mild
EA.
Currently, there is no consensus on optimal management
in patients with small or hidden EA. Kim et al10 performed
the spinal needle aspiration in patients with EA, which they
1
Department of OtolaryngologyHead and Neck Surgery, Kyung Hee
University School of Medicine, Seoul, Korea
2
Department of Oral & Maxillofacial Surgery, School of Dentistry, Kyung
Hee University, Seoul, Korea
3
Department of Otolaryngology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea

Corresponding Author:
Young Gyu Eun, Department of OtolaryngologyHead and Neck Surgery,
Kyung Hee University School of Medicine, No. 1 Hoegi-dong,
Dongdaemun-gu, Seoul 130-702, Korea.
Email: ygeun@hanmail.net

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49
protocol. All participants provided written informed consent
for their participation.

Treatment Protocol

Figure 1. Axial contrast-enhanced computed tomography scan

demonstrating an epiglottic abscess on the lingual surface of
epiglottis.

concluded was a safe and effective treatment method.

However, there is no evidence that aspiration of pus prevents disease progression either in the form of airway compromise or, in mild EA cases, resolution of symptoms.
In this study, we evaluated the efficacy of spinal needle
aspiration for symptom improvement in patients with EA in
a randomized controlled study.

Subjects and Methods

An ear, nose, and throat (ENT) doctor assessed patients laryngeal aperture with a flexible fiberoptic laryngoscope to
determine whether the airway was patent or compromised.
If patients had conspicuous respiratory difficulties, such as
cyanosis, stridor, oxygen desaturation, or need to sit erect,
airway intervention (intubation or tracheostomy, depending
on symptoms and airway appearance) was immediately
attempted. If patients had a very imminent respiratory distress, making it impossible to undertake a laryngoscopic
examination, we planned to perform tracheostomy or cricothyroidotomy immediately in a treatment protocol. After
the airway was secured, assessment and treatment of
patients were carried out simultaneously. Patients clinical
characteristics, presenting symptoms, laboratory findings,
and laryngoscopic findings were obtained. Laryngoscopic
findings were classified according to epiglottic swelling
with the following scope classification (SC classification):
I (slight swelling): The patients epiglottis is slightly
swollen, but the entire length of the vocal folds is
still visible by scope.
II (moderate swelling): The patients epiglottis is
moderately swollen, with more than half of the
posterior vocal folds visible by scope.
III (severe swelling): The patients epiglottis is
severely swollen, with less than half of the posterior vocal folds visible by scope.
In addition, we also observed the swelling of arytenoids and
classified them into 2 groups as follows:

Study Design
Eligible participants included consecutive patients diagnosed with EA who were 18 years and older. The time
period of this study was from March 2012 to May 2014. All
patients who were suspected to have acute epiglottitis based
on fiberoptic laryngoscopic observation of an inflamed and
swollen epiglottis routinely underwent contrast-enhanced
CT with a GE 9800 scanner (GE Medical Systems,
Waukesha, Wisconsin) on the day of admission. Epiglottic
abscess was diagnosed as complete abscess formation on
the free edge or lingual surface of the epiglottis based on
the official report by the radiologist (Figure 1). Only
patients with true abscess formation in the epiglottis were
included. Patients younger than 18 years due to the difficulty of cooperation and patients with deep neck abscesses,
a severe coagulopathy, and a known history of head and
neck cancer were excluded. Enrolled participants were
divided into either group A or B by randomization using a
block of 4 and a random-number allocation list. Participants
in group A underwent spinal needle aspiration with antibiotic therapy, and participants in group B received antibiotic
therapy only for at least 6 days. The Institutional Review
Boards of Kyung Hee University Hospital approved the

A: There is no extension of the swelling to the arytenoids

and the aryepiglottic folds.
B: There is extension of the swelling to the arytenoids
and the aryepiglottic folds.
This SC classification using a flexible nasopharyngolaryngoscope was developed by Katori and Tsukuda,11 who
reported that SC classification is useful to assess the severity and predict the clinical course in patients with acute
epiglottitis.
Treatment with intravenous third-generation cephalosporin (ceftriaxone), metronidazole, and dexamethasone was
initiated after admission. Spinal needle aspiration was performed as described in detail in a previous study.10 Patients
were placed in the 110 sitting position, and the epiglottis
was assessed by using a 70 indirect laryngoscope. An 18gauge spinal needle, in which the distal 3 cm was bent
approximately 120, was connected to a 20-mL syringe.
Spinal needle aspiration could be performed in several areas
depending on the size and location of abscess. The abscess
was aspirated by applying negative pressure on the syringe
or curved suction (Figure 2). If some of the abscess

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OtolaryngologyHead and Neck Surgery 153(1)

Figure 2. Abscess aspiration using an 18-gauge spinal needle, syringe, curved suction, and 70 rigid endoscope.

remained, additional aspiration was performed. After the

aspiration, patients were transferred to the intensive care
unit, and humidification was provided under monitoring
oxygen saturation. If airway compromise did not progress
and oxygen saturation level remained stable over 24 hours,
patients were moved to a general ward.

Patient Follow-up and Outcome Measures

During hospitalization, all patients were assessed for symptoms (sore throat, hoarseness, dyspnea, odynophagia, and
dysphagia) at baseline and again at days 2, 4, and 6, postprocedure, according to the 10-cm visual analog scale. The
duration of time until symptom resolution was recorded.
Criteria for discharge included the stable airway (SC classification group I: entire length of the vocal folds is visible
by scope; status A: no extension of the swelling to the arytenoids and the aryepiglottic folds), all symptoms controlled
by oral medications, and toleration of a soft diet. Length of
hospitalization was defied as the time span from hospital
admission to hospital discharge. The discharge date was
defined as the date of discharge to home.

Statistical Analysis
Statistical analyses were performed using SPSS version 18.0
for Windows (SPSS, Inc, an IBM Company, Chicago,
Illinois). Categorical data were analyzed using the x2 test,
and continuous data were analyzed with the independent t
test. A 2-way repeated-measures analysis of variance was
used to assess symptom changes over time and differences
between the treatment groups. P values \.05 were considered to have statistical significance.

Results
Twenty-six patients were assessed for eligibility for this
study. Three patients were excluded because they did not
meet the inclusion criteria (no abscess formation on CT); 23
patients were subsequently randomized to 1 of the 2 study
groups. One participant in group A withdrew after discontinuing the intervention 2 days after admission. Finally, there

were 22 participants among both groups who were followed

up and analyzed until 6 days after admission (Figure 3).
The G power statistical program was used in post hoc mode
to calculate the statistical power of the present study.
Choosing a = .05 as per convention and a large effect size
of 0.8, with 11 patients in each study group, gives a power
of 0.43.
Clinical characteristics at diagnosis (ie, baseline) were
similar between the aspiration and antibiotics group (group
A) and the antibiotics-only group (group B). Symptom
severity and laryngoscopic findings for evaluating the swelling of the epiglottis and arytenoids at inclusion were studied. Symptoms, such as sore throat, hoarseness, dyspnea,
odynophagia, and dysphagia, and layngoscopic findings
based on scope classifications were analyzed. We identified
no significant differences between the 2 groups regarding
severity in any of the above symptoms. There were also no
significant differences in epiglottic and arytenoid swelling
between the 2 groups. No statistically significant difference
was observed in the mean diameter of the abscess on CT
between the 2 groups. Furthermore, there was no significant
difference in the mean white blood cell count and C-reactive
protein level at the time of presentation (Table 1).
Frank pus was extracted from the abscesses in all 11
patients in group A. For all participants in group A, only 1
aspiration was required, as confirmed by observing pusdraining activity at the aspiration site after needle aspiration.
Patients in group A and group B showed a significant
improvement in all recorded symptoms, including sore
throat, hoarseness, dyspnea, and odynophagia and dysphagia, from baseline to day 6, but the between-group differences in these improvements were not significantly different
(P = .744, P = .358, P = .767, P = .727, and P = .794,
respectively) (Table 2).
Patient outcome parameters, including time to symptom
resolution and length of hospitalization, are summarized in
Table 3. Time to resolution of symptoms was not statistically significant between the 2 groups. The mean length of
hospitalization was 4.0 6 1.9 days for the aspiration and
antibiotics group and 5.7 6 1.2 days for the antibiotics-only
group. The mean difference in length of hospital stay was
statistically significant (P = .037).

Discussion
This study is a prospective randomized trial evaluating the
efficacy of the needle aspiration for treatment outcome in
patients with EA. Epiglottic abscess is commonly regarded
as a life-threatening disease with an increased risk of developing a rapid and a fulminant course. Stack and Ridley1
assumed that EA originates from either coalescent epiglottic
infection or epiglottic mucocele infection. Coalescent epiglottic infection is a type of severe infection that causes
patchy necrosis and accumulation of numerous leukocytes
and tends to progress rapidly. Epiglottic mucocele infections
arise from an infected mucus retention cyst at the base of
the tongue or the vallecula; these infections are characterized by a relatively reduced probability of developing

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Figure 3. CONSORT diagram. CT, computed tomography; Tx, treatment.

Table 1. Comparison of Baseline Characteristics, Symptoms, Scope Classification, and Laboratory Findings on Diagnosis.

No. of patients
Age, mean 6 SD, y
Sex, male/female, No.
Subjective symptoms, mean 6 SD, No.
Sore throat
Hoarseness
Dyspnea
Odynophagia
Dysphagia
Scope classification, No. (%)
Epiglottic swelling
I
II
III
Arytenoid swelling
A
B
Diameter of abscess on CT, mean 6 SD, mm
WBC count, mean 6 SD
CRP, mean 6 SD

Aspiration 1 Antibiotics Group

Antibiotics-Only Group

P Value

11
43.4 6 12.3
8/3

11
42.0 6 22.2
5/6

.853
.387

6 3.0
6 3.4
6 2.1
6 2.7
6 2.3

6.6 6 2.6
4.7 6 3.1
4.0 6 3.7
7.0 6 2.6
6.9 6 2.5

.513
.484
.850
1.000
.730

3 (27.3)
3 (27.3)
4 (45.5)

2 (18.2)
3 (27.3)
6 (54.5)

1.000

5.8
5.7
4.0
7.0
7.2

7
4
15.6
9937.5
10.0

(63.6)
(36.4)
6 5.1
6 3800.3
6 9.2

4 (36.4)
7 (63.6)
12.7 6 4.2
11885.7 6 6844.0
6.8 6 7.5

.201
.171
.500
.501

Abbreviations: CRP, C-reactive protein; CT, computed tomography; SD, standard deviation; WBC, white blood cell.

airway obstruction.9 Epiglottic abscess can generally be

diagnosed with a flexible laryngoscope because abscesses
are frequently found on the lingual side or free edge of the
epiglottis.12 Recently, advanced imaging tools, including

magnetic resonance imaging and CT, can help in the diagnosis of hidden EA in patients with epiglottitis. Our previous study showed that hidden abscess formation was found
during routine CT in 24% of patients with acute

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OtolaryngologyHead and Neck Surgery 153(1)

Table 2. Comparison of Improvement in Subjective Symptoms between Aspiration 1 Antibiotics and Antibiotics-Only Groups.a
Aspiration 1 Antibiotics Group
Baseline
Sore throat
Hoarseness
Dyspnea
Odynophagia
Dysphagia

8.0
7.3
4.0
7.6
4.0

6 2.6
6 2.5
6 5.1
6 3.2
6 5.1

Antibiotics-Only Group

Post
2d

Post
4d

Post
6d

P
Value

Baseline

Post
2d

Post
4d

3.0 6 3.4
2.6 6 1.5
2.3 6 2.3
4.0 6 4.3
2.3 6 2.3

2.6 6 3.7
1.6 6 0.5
0.6 6 0.5
3.0 6 3.0
0.6 6 0.5

2.3 6 3.2
1.3 6 1.1
0.6 6 0.5
2.6 6 2.5
0.6 6 0.5

\.001
\.001
\.001
\.001
\.001

8.0 6 2.1
3.5 6 3.8
4.0 6 2.0
7.2 6 2.5
4.0 6 2.0

3.5 6 3.3
1.7 6 1.5
2.2 6 2.6
2.0 6 1.4
2.2 6 2.6

2.5 6 2.6
0.7 6 1.5
1.7 6 2.0
1.7 6 2.0
1.7 6 2.0

Post
6d
1.5 6
0.0 6
0.2 6
0.7 6
0.2 6

2.3
0.0
0.5
1.5
0.5

P
P Value
Value between Groups
\.001
\.001
\.001
\.001
\.001

.744
.358
.767
.727
.794

All data are expressed as mean 6 standard deviation.

Table 3. Comparison of Time to Symptom Resolution and Length of Hospitalization.a

Sore throat
Hoarseness
Dyspnea
Odynophagia
Dysphagia
Length of hospitalization (median value, d)

Aspiration 1 Antibiotics Group

Antibiotics-Only Group

P Value

3.4 6 2.0
3.4 6 2.8
1.2 6 2.0
4.00 6 2.3
4.0 6 2.3
4.0 6 1.9 (3)

3.9 6 2.1
3.0 6 2.0
2.1 6 2.2
4.0 6 2.1
4.0 6 2.0
5.7 6 1.2 (6)

.612
.735
.909
1.000
1.000
.037

Values are presented as days (mean 6 standard deviation).

supraglottitis.4 Previously, these patients would have been

diagnosed as having supraglottitis, especially because their
symptoms usually improved after antibiotic treatment.
Many previous studies recommended the following treatments for patients with EA: immediate airway management,
indirect laryngoscopy with incision and drainage of the
abscess, and intravenous administration of broad-spectrum
antibiotics.3,5,13 Yoon et al14 reported that among patients
with acute epiglottitis, 25% had coexisting infected epiglottic cyst. They underwent pharyngoscopic marsupialization
or cyst excision under general anesthesia. Berger et al15
found a high incidence of EQ formation in adults with
infected vallecular cysts (19/22, 79.2%). Among 19 patients,
15 underwent incision and drainage under general anesthesia,
and 4 experienced spontaneous drainage. However, incision
and drainage of abscess under general anesthesia could be
invasive for patients with a stable airway and mild symptoms.
Initial airway management for patients with EA with mild
symptoms without evidence of airway compromise is still
unknown; there is no consensus regarding which patients
should have prophylactic airway intervention.16 Therefore,
there is a need for appropriate selection and caution in deciding on the treatment approach for patients with EA.
Treatment of abscesses with needle aspiration has been previously advocated for many types of infections and is considered efficacious and less invasive compared with medical
treatment or incision and drainage. Therefore, we aimed to
evaluate the efficacy of spinal needle aspiration for symptom

improvement in patients with EA using a randomized controlled study design.

We found no significant differences between group A (aspiration and antibiotics group) and group B (antibiotics-only group)
regarding symptom improvement and time to symptom resolution. However, patients who were treated with aspiration and antibiotics had a shorter hospital stay than those treated with
antibiotics only. All the patients in the aspiration group required
only a single aspiration session. Usually, resolution of acute epiglottitis occurs over 36 to 48 hours, which can be confirmed by
flexible laryngoscopy.17 Because the criteria for discharge in the
present study included the resolution of laryngoscopic finding and
overall symptoms, a faster improvement of epiglottic swelling by
aspiration could result in a shorter hospital stay. In this study, the
mean time to symptom resolution was 3 to 4 days. It is important
to note that no patients with EA in this study required airway
interventions, such as intubation or tracheostomy. This result is
contrary to previous findings in which abscess formation in the
epiglottis was a predictor of airway obstruction.7-9 This discordant
result could be due to differences in disease severity of the
enrolled patients in the 2 studies. Most patients with EA in our
study were diagnosed via routine CT, and thus their abscess formations were small and mild.
Because the manipulation of airway edema while the
patient is in an awakened state could increase the risk of
airway deterioration, we prepared the necessary equipment to
perform an emergency tracheostomy or endotracheal intubation
during aspiration. Patients with EA who underwent aspiration

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53

were moved to the intensive care unit and were observed for
24 hours while their O2 saturation was closely monitored.
Before being moved to the general ward, patients were evaluated for the presence of dyspnea and epiglottic swelling or
remaining abscess using flexible nasopharyngoscopy. No
airway compromise after aspiration occurred during our study.
In addition, the complications from needle aspiration in
patients with EA include bleeding, infection, aspiration pneumonia, cardiac arrest, and airway obstruction.10 Fortunately,
there was no complication after needle aspiration in our study.
Although complications are relatively uncommon, they may be
serious and even life-threatening. Therefore, preparing for any
emergency tracheostomy or endotracheal intubation and close
monitoring after aspiration should be mandatory.
This study has several limitations. The most important
limitation of the study is its small sample size. However, we
think that the small sample size of this study might reflect
the relatively low incidence rate of EA. A much larger
study is required to generate more robust findings regarding
the benefit of aspiration for patients with EA. Furthermore,
the mean diameter of the EA on CT scan in the present
study was 14.2 mm. This study needed to have a variety of
types of EA, particularly more severe cases of EA, to evaluate the efficacy of needle aspiration for large abscesses. A
second possible limitation of the study is in the measurement of symptom improvement using nonvalidated 10-cm
visual analog scales. Because this outcome is susceptible to
bias, validated subjective outcome tools or objective measurement for improvement in EA are required in a future
study. The results of the present study suggest that needle
aspiration is safe and can shorten the length of hospitalization. The shorter hospitalization is desirable from both a
cost and convenience standpoint. These results justify future
efforts to undertake a large-scale study.

Conclusion
In conclusion, we did not find any significant additional
benefit of needle aspiration for the treatment of EA, with
the exception that needle aspiration reduced the length of
hospitalization. Further proof with a large-scale study is
needed.
Author Contributions
Young Chan Lee, study design, data collection and analysis, writing, revising article, final approval of the version; Jung-Woo Lee,
data collection and analysis, revising article, final approval of the
version; Gi Cheol Park, data collection and analysis, revising article, final approval of the version; Young Gyu Eun, study design,
data collection and analysis, revising article, final approval of the
version, supervising this study.

Disclosures

Sponsorships: None.
Funding source: None.

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Competing interests: None.

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