- Clinical science
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.
- Peak incidence: 6–12 years; (but can occur in any age, including adults, especially when unimmunized)
Epidemiological data refers to the US, unless otherwise specified.
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 airway → airway obstruction (partial or complete)
- Acute onset of high fever (39–40 °C or 102–104 °F)
- Toxic appearance
- “Tripod” position
- Sore throat
- 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!
- 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
Pharyngoscopy (with a tongue blade)
- Fiberoptic nasolaryngoscopy
- Indirect laryngoscopy (with an endoscope)
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
- Keep child comfortable and as calm as possible
If signs of respiratory distress → emergency 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.
- IV Antibiotics
- IV fluid resuscitation if required
- Administer supplemental oxygen as needed.
- Immediate otolaryngology and anesthesiology consultation
- Airway management
- Obtain blood cultures and epiglottis cultures prior to starting antibiotic therapy.
- Start empiric antibiotics.
- Admit to the ICU.
- Continuous pulse oximetry, serial pulmonary examination
- IV fluids