Pulmonary · PANCE / PANRE

Epiglottitis

Life-threatening supraglottic bacterial infection with risk of complete airway obstruction.

Also known as: epiglottitis, supraglottitis, Hib epiglottitis

Overview

Bacterial cellulitis of the epiglottis and surrounding supraglottic structures, causing rapid swelling that can occlude the airway. A true otolaryngologic emergency requiring secure airway management.

Epidemiology

Historically a pediatric disease driven by Haemophilus influenzae type b (Hib); now far less common in children due to Hib vaccination. Increasing relative proportion in adults. Estimated annual incidence ~1-4 per 100,000 in adults.

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Risk factors

Unvaccinated children (Hib)
Adults (now exceed pediatric cases in absolute numbers in US)
Immunocompromise (HIV, diabetes, hematologic malignancy, transplant)
Recent upper respiratory infection
Tobacco use, crack cocaine inhalation, thermal injury (mimic)
Foreign body, caustic ingestion (mimic)

Pathophysiology

Bacterial infection (Hib historically; now also S. pneumoniae, S. aureus including MRSA, Streptococcus pyogenes, H. parainfluenzae) seeds the epiglottis → cellulitis and edema → narrowing of the supraglottic airway → risk of complete obstruction. Adults have larger airways and slower progression than children; children more prone to abrupt total obstruction.

Clinical presentation

Symptoms

Classic adult/pediatric: rapid onset (hours) of severe sore throat, odynophagia, drooling, muffled 'hot potato' voice
Fever, often high
Inspiratory stridor (late finding, signals impending obstruction)
Dyspnea, anxiety
Tripod or sniffing position (leaning forward, neck extended, jaw thrust)
NO barking cough (distinguishes from croup)

Signs / physical exam

Toxic appearance, anxiety, restlessness
Drooling, inability to swallow secretions
Tripod posture
Inspiratory stridor (late)
Tachycardia, tachypnea, hypoxia in severe cases
DO NOT examine the throat with a tongue depressor in suspected pediatric epiglottitis — can precipitate complete airway closure

Classic findings

Pediatric 'four D's': dysphagia, drooling, dyspnea, dysphonia, in a toxic-appearing child sitting in tripod position. Always consider in any adult with severe sore throat plus muffled voice or stridor.

Differential diagnosis

Croup (laryngotracheobronchitis) — Younger age, barking cough (epiglottitis lacks cough), gradual onset over days, non-toxic appearance
Bacterial tracheitis — Toxic-appearing child, copious thick secretions, fails to respond to croup treatment; bronchoscopy diagnostic
Peritonsillar abscess — Older child or adolescent, muffled voice, trismus, uvular deviation, unilateral tonsillar bulge
Retropharyngeal abscess — Drooling, neck stiffness, fever; widened prevertebral soft tissue on lateral neck XR
Ludwig angina — Submandibular swelling, woody floor of mouth, dental source
Foreign body aspiration — Sudden choking event; focal findings; bronchoscopy
Anaphylaxis with angioedema — Acute onset after exposure, urticaria, hypotension; rapid response to epinephrine
Thermal/caustic airway injury — History of exposure; oral burns, soot in airway

Diagnostic workup

Diagnostic criteria

Clinical suspicion based on presentation + visual confirmation by laryngoscopy in OR or controlled setting (cherry-red, edematous epiglottis).

Labs

Defer all blood draws and IV placement in unstable children until airway is secured (agitation can precipitate obstruction)
Once airway secured: CBC (leukocytosis), blood cultures, throat cultures (after intubation)
Hib antigen if pediatric

Imaging

Lateral neck soft-tissue radiograph (if patient stable): 'thumbprint sign' — enlarged, thickened epiglottis; specific but only obtain if it will not delay airway management
DO NOT delay airway intervention for imaging in unstable patient
Direct visualization with flexible fiberoptic laryngoscopy by ENT/anesthesia in controlled setting is the gold standard

Diagnostic algorithm

Feature	Croup	Epiglottitis
Age	6 months - 3 years	Historically 2-6 years (peds), now mostly adults
Onset	Days, gradual	Hours, rapid
Cough	Barking, prominent	Absent
Voice	Hoarse	Muffled 'hot potato'
Drooling	Absent	Present
Appearance	Non-toxic	Toxic, anxious
XR	Steeple sign (AP)	Thumbprint sign (lateral)
Pathogen	Parainfluenza	Hib (children), S. pneumoniae, S. aureus, GAS
Management	Dexamethasone ± nebulized epi	Secure airway in OR + IV antibiotics

Croup vs epiglottitis — key differentiating features in pediatric upper airway emergencies.

Treatment

First-line

Secure the airway is the priority — minimize handling, keep child calm with caregiver
Transport to OR or controlled environment with ENT and anesthesia for awake fiberoptic laryngoscopy and intubation; surgical airway (cricothyrotomy or tracheostomy) backup plan ready
Empiric IV antibiotics covering H. influenzae, S. pneumoniae, S. aureus (including MRSA): ceftriaxone 50-100 mg/kg/day (max 2 g) + vancomycin 15 mg/kg q6-8h
Alternatives: ampicillin-sulbactam, cefotaxime; add clindamycin or vancomycin for MRSA coverage
Duration: 7-10 days; transition to oral after clinical improvement
IV fluids, supplemental oxygen as tolerated (do not force mask on agitated child)
Avoid sedation until airway secured by experienced provider

Second-line / adjunct

Corticosteroids — controversial; some use dexamethasone IV but data limited
Extubation typically within 24-72 h once epiglottic swelling improves by repeat laryngoscopy and air leak around endotracheal tube
Close contact post-exposure prophylaxis for Hib: rifampin for household contacts when an unvaccinated child <4 years is present
Long-term: ensure Hib vaccination status; Hib conjugate vaccine on routine schedule prevents most pediatric cases

Complications

Complete airway obstruction, cardiopulmonary arrest
Sepsis, meningitis, septic arthritis, pneumonia (Hib bacteremia)
Epiglottic abscess
Post-extubation laryngeal complications
Death (mortality ~1% with modern care; higher in delayed presentation)

PANCE pearls

DO NOT examine the throat with a tongue depressor or attempt visualization without airway-management backup in suspected pediatric epiglottitis.
Hib conjugate vaccine has dramatically reduced pediatric epiglottitis — modern cases are increasingly adults with non-Hib pathogens.
Drooling + tripod + fever + dysphagia + muffled voice = epiglottitis until proven otherwise; secure airway first.
Lateral neck radiograph thumbprint sign confirms diagnosis but should not delay airway management in unstable patients.
Empiric antibiotics: ceftriaxone + vancomycin (or clindamycin) cover the relevant organisms (Hib, pneumococcus, MRSA).

References

AAO-HNS — Acute Epiglottitis: Trends, Diagnosis and Management (Guldfred et al., J Laryngol Otol 2008)
CDC ACIP — Haemophilus influenzae type b Vaccination Recommendations (Briere et al., MMWR Recomm Rep 2014)
BMJ Review — Epiglottitis (Glynn and Fenton, BMJ 2008)
Pediatrics — Acute Epiglottitis: Epidemiology, Clinical Presentation, and Management (Sobol and Zapata, Pediatrics 2008)

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