• Clinical science

Epiglottitis (Supraglottitis)

Abstract

Epiglottitis is the rapid progressive inflammation of the epiglottis and surrounding supraglottis that historically was primarily caused by Haemophilus influenzae type b (Hib). Acute epiglottitis has become rare following the implementation of the Hib vaccine and most cases now involve other bacteria. Although acute epiglottitis can occur at any age, especially when unimmunized, young children are most commonly affected. Children suffering from epiglottitis typically appear toxic and position themselves in a tripod stance (sitting and leaning forward) in an attempt to improve their airway diameter. The disease is characterized by the acute onset of fever, drooling, sore throat, dysphagia, and in severe cases, respiratory distress accompanied by inspiratory retractions and cyanosis. Impending airway obstruction is also accompanied by a muffled voice and restlessness. Epiglottitis is diagnosed based on the clinical presentation. A lateral cervical x-ray may be considered if the diagnosis is unclear and the child is stable, in which a thumbprint sign may be present. However, appropriate management should not be delayed. Epiglottitis is a medical emergency since severe hypoxia and airway obstruction can lead to cardiopulmonary arrest. Therefore, patients should be closely monitored in a hospital and receive IV antibiotics, while severe cases require immediate intubation. Direct laryngeal examination may be performed in a controlled environment after airway control. Most patients make a full recovery after prompt and adequate treatment.

Epidemiology

  • Peak incidence: 6–12 years; (but can occur in any age, including adults, especially when unimmunized)

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Pathophysiology

Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and vallecula) → supraglottic inflammation and edema → narrowing of the airwayairway obstruction (partial or complete)
References:[1][2]

Clinical features

  • Acute onset of high fever (39–40 °C or 102–104 °F)
  • Toxic appearance
  • Tripod” position
  • Sore throat
  • Dysphagia
  • Drooling
  • Muffled voice (i.e., resembling a “hot-potato” voice) with painful speech
  • Respiratory distress (inspiratory retractions, cyanosis) and inspiratory stridor
  • Restlessness and/or anxiety

The hallmarks of epiglottitis are the three D's: dysphagia, drooling, and distress!
References:[3][1]

Diagnostics

Diagnostic approach

  • Epiglottitis is primarily a clinical diagnosis
  • Consider further investigations
    • In a stable patient with atypical presentation
    • In an unstable patient only after appropriate airway management and control.
    • Investigations should be performed in a controlled environment

If there are definitive signs of epiglottitis present → airway management before attempting to visualize the epiglottis and supraglottic structures!

Pharyngoscopy (with a tongue blade)

Soft-tissue lateral neck x-ray

  • Indication: To exclude other diagnoses (e.g., if barking cough of croup is present) or in unclear pharyngoscopy findings
  • Findings

Culture

  • Of blood and swab of the epiglottis; should only be performed after airway management!

References:[1][2][4]

Differential diagnoses

References:[2]

The differential diagnoses listed here are not exhaustive.

Treatment

  1. Keep child comfortable and as calm as possible
  2. If signs of respiratory distressemergency airway management
    • Move child to a controlled environment (i.e., operating room)
    • Use a nasotracheal tube with a small diameter to reduce the risk of post‑intubation sequelae
    • Emergency tracheostomy needs to be considered if intubation fails.
    • Extubation should be performed 2–3 days (at the earliest) after starting antibiotic treatment.
  3. IV Antibiotics
  4. IV fluid resuscitation if required

References:[2][5]

Prognosis

References:[5][6]

Prevention

References:[6][7]