Epiglottitis
Background
- Inflammation and edema of the epiglottis and supraglottic structures
- A life-threatening airway emergency — can progress to complete obstruction within hours
- Incidence in children has decreased dramatically since Hib vaccine; now more common in adults[1]
- Common pathogens:
- Children: Haemophilus influenzae type b (unvaccinated)
- Adults: Streptococcus, Staphylococcus, H. influenzae (non-typeable), polymicrobial
- Non-infectious causes: thermal injury, caustic ingestion, foreign body, crack cocaine
Clinical Features
Adults
- Severe sore throat (out of proportion to pharyngeal exam findings)
- Odynophagia (pain with swallowing), dysphagia, drooling
- Muffled or "hot potato" voice
- Stridor (late finding — suggests impending obstruction)
- Fever
- Anterior neck tenderness ("thyroid cartilage tenderness")
Children (Classic Presentation)
- Abrupt onset high fever, toxic appearance
- Tripod positioning (sitting forward, neck extended, chin protruding)
- Drooling, stridor, refusal to swallow
- Anxiety, air hunger
- Do NOT agitate the child (crying/agitation may precipitate complete obstruction)
Differential Diagnosis
- Croup (lower-grade fever, barking cough, younger age)
- Peritonsillar abscess
- Retropharyngeal abscess
- Ludwig angina
- Angioedema
- Foreign body aspiration
- Bacterial tracheitis
Evaluation
- Lateral soft tissue neck X-ray (if patient is stable):
- Thumbprint sign (swollen epiglottis) — ~90% sensitive in adults
- Thickened aryepiglottic folds
- Flexible nasopharyngolaryngoscopy (definitive diagnosis in adults; by ENT or ED)
- CT neck with contrast if concern for deep space infection, abscess
- Labs: CBC, blood cultures
- Do NOT examine the oropharynx in a child with suspected epiglottitis (risk of laryngospasm)
- Do NOT delay airway management for imaging if patient is in distress
Management
Airway
- Airway management is the top priority
- Keep patient in position of comfort
- Have surgical airway equipment immediately available (cricothyrotomy kit)
- If intubation needed: most experienced provider, preferably in OR with ENT standby
- Ideally double setup: direct/video laryngoscopy + surgical airway prepared
- Heliox (70:30 helium:oxygen) may temporize in partial obstruction
- Nebulized epinephrine (racemic 2.25% 0.5 mL or L-epinephrine 1:1000 5 mL) for stridor
Antibiotics
- Ceftriaxone 2 g IV (or Cefotaxime) PLUS
- Vancomycin if MRSA concern or critically ill[2]
- Alternative: Ampicillin-sulbactam 3 g IV
Adjuncts
- Dexamethasone 10 mg IV (or methylprednisolone) — may reduce edema (limited evidence)
- IV fluids (patients often dehydrated due to inability to swallow)
- Humidified oxygen
Disposition
- Admit all patients with epiglottitis
- ICU for airway monitoring, especially if stridor, drooling, or respiratory distress
- ENT consultation
- Observation for 24-48 hours minimum; typically improves within 48-72 hours