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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Question 1PulmonaryMedium
A toxic-appearing 4-year-old has high fever, drooling, a muffled voice, and inspiratory stridor with rapid onset. Which of the following is the most appropriate initial management?
ASecure the airway in a controlled setting
BObtain a portable lateral neck radiograph
CGive nebulized albuterol and observe
DExamine the oropharynx with a tongue blade
Reveal answer & full explanation
Correct answer: A — Secure the airway in a controlled setting
ASecure the airway in a controlled setting✓
BObtain a portable lateral neck radiograph
CGive nebulized albuterol and observe
DExamine the oropharynx with a tongue blade
Why Secure the airway in a controlled setting is correct
This presentation is epiglottitis, a true airway emergency in which obstruction can occur abruptly.
Definitive management is controlled airway protection in the operating room with anesthesia and ENT before any other testing.
Keeping the child calm and avoiding agitation prevents triggering complete obstruction.
Why the others are wrong
Examine the oropharynx with a tongue blade — Instrumenting the pharynx can provoke laryngospasm and complete airway closure; it is the classic procedural-harm trap.
Obtain a portable lateral neck radiograph — A thumb sign can support the diagnosis, but imaging is reserved for stable, equivocal cases; here positioning risks agitating the child and delays definitive airway control.
Give nebulized albuterol and observe — Albuterol treats lower-airway bronchospasm and does nothing for supraglottic swelling while the airway deteriorates.
Question 2PulmonaryMedium
A 5-year-old unvaccinated child presents with 8 hours of high fever, drooling, and severe sore throat. He is anxious, sitting in a tripod position with his neck extended, and has muffled 'hot-potato' voice and inspiratory stridor without a barky cough. He appears toxic and is reluctant to lie down. Blood cultures later grow Haemophilus influenzae type b. Which of the following antibiotics is most appropriate, and by what mechanism does it act?
ACeftriaxone, which inhibits bacterial cell wall synthesis
BAzithromycin, which inhibits the 50S ribosomal subunit
CCiprofloxacin, which inhibits bacterial DNA gyrase
DVancomycin, which inhibits DNA-dependent RNA polymerase
Reveal answer & full explanation
Correct answer: A — Ceftriaxone, which inhibits bacterial cell wall synthesis
ACeftriaxone, which inhibits bacterial cell wall synthesis✓
BAzithromycin, which inhibits the 50S ribosomal subunit
CCiprofloxacin, which inhibits bacterial DNA gyrase
DVancomycin, which inhibits DNA-dependent RNA polymerase
Why Ceftriaxone, which inhibits bacterial cell wall synthesis is correct
This is epiglottitis, and the highest-yield risk factor is absent Hib immunization: routine Hib vaccination dramatically reduced pediatric epiglottitis, so unvaccinated children remain susceptible to invasive Haemophilus influenzae type b, which bacteremically seeds the supraglottic tissue and produces the toxic, drooling, tripod, muffled-voice presentation.
After securing the airway, first-line therapy is a third-generation cephalosporin such as ceftriaxone, which acts by binding penicillin-binding proteins to inhibit bacterial cell wall (peptidoglycan) synthesis; this both covers H. influenzae and is correctly paired with its mechanism, making it the answer.
Why the others are wrong
Azithromycin, which inhibits the 50S ribosomal subunit — the mechanism statement is accurate (macrolides bind the 50S subunit) but azithromycin is not the drug of choice for invasive Hib epiglottitis.
Ciprofloxacin, which inhibits bacterial DNA gyrase — the mechanism is correct for fluoroquinolones, but ciprofloxacin is not first-line here and is avoided in young children when alternatives exist.
Vancomycin, which inhibits DNA-dependent RNA polymerase — vancomycin actually inhibits cell wall synthesis (D-Ala-D-Ala binding), not RNA polymerase, so both the drug choice and the stated mechanism are wrong (RNA polymerase inhibition describes rifampin).
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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
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.
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
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