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 1EENTMedium
A 6-year-old child has fever, severe sore throat, drooling, muffled voice, and tripod positioning. Which of the following is the most appropriate initial management?
APerform a rapid strep test
BSecure a definitive airway
CInspect throat with blade
DGive nebulized epinephrine
EObtain a lateral neck x-ray
Reveal answer & full explanation
Correct answer: B — Secure a definitive airway
APerform a rapid strep test
BSecure a definitive airway✓
CInspect throat with blade
DGive nebulized epinephrine
EObtain a lateral neck x-ray
Why Secure a definitive airway is correct
Drooling, muffled voice, and tripod posture in a febrile child are classic acute epiglottitis with impending obstruction.
Controlled airway management with ENT and anesthesia available is the immediate priority.
Keeping the child calm and undisturbed prevents sudden complete obstruction.
Why the others are wrong
Inspect throat with blade — Instrumenting the pharynx can trigger laryngospasm and total obstruction; a dangerous-exam trap.
Obtain a lateral neck x-ray — A thumbprint sign can support epiglottitis, but imaging delays airway control and takes an unstable child away from airway-capable staff; radiographs are reserved for stable patients whose diagnosis is uncertain.
Perform a rapid strep test — Swabbing delays airway control and can agitate the child; a sore-throat anchoring trap.
Give nebulized epinephrine — it reduces subglottic edema in croup, but drooling, a muffled voice, and tripod posture point to supraglottic epiglottitis, where it has no established role and applying a mask can agitate the child and precipitate complete obstruction; a croup-treatment trap.
Question 2PulmonaryMedium
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?
AGive nebulized albuterol and observe
BStart an IV and draw blood cultures
CObtain a portable lateral neck radiograph
DSecure the airway in a controlled setting
EExamine the oropharynx with a tongue blade
Reveal answer & full explanation
Correct answer: D — Secure the airway in a controlled setting
AGive nebulized albuterol and observe
BStart an IV and draw blood cultures
CObtain a portable lateral neck radiograph
DSecure the airway in a controlled setting✓
EExamine 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.
Start an IV and draw blood cultures — blood cultures and IV antibiotics are part of epiglottitis care, but venipuncture before the airway is secured can agitate the child and precipitate complete obstruction, so IV access and cultures wait until the airway is controlled.
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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.
Serotype any H. influenzae isolate and report invasive H. influenzae disease to public health (Hib antigen testing of serum or urine is not recommended)
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
Children: take to the OR with anesthesia and ENT; inhalational induction with spontaneous breathing preserved, then laryngoscopy and intubation (IV placement waits until the child is anesthetized), with rigid bronchoscopy or tracheostomy ready as backup. Adults: flexible laryngoscopy in a monitored setting with airway equipment ready; awake fiberoptic intubation (surgical airway backup) for stridor, respiratory distress, or rapid progression, otherwise ICU observation
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 the household includes a child <4 years who is not fully vaccinated or an immunocompromised child <18 years (regardless of vaccination status)
Long-term: ensure Hib vaccination status; Hib conjugate vaccine on routine schedule prevents most pediatric cases
Lateral neck radiograph thumbprint sign supports the diagnosis (a normal film does not exclude it) but should not delay airway management in unstable patients.
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