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 |
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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