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Epiglottitis
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Epiglottitis

Summary
(Supraglottitis)

Last edited: Apr 13, 2023

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Clinical Sciences

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Summary

Epiglottitis is the rapid progressive inflammation of the epiglottis and surrounding

supraglottis that classically was primarily caused by Haemophilus influenzae type b
(Hib). Acute epiglottitis has become rare following the implementation of the Hib vaccine
and most cases now involve other bacteria. Although acute epiglottitis can occur at any
age, especially when unimmunized, young children are most commonly affected. Children
suffering from epiglottitis typically appear toxic and position themselves in a tripod
stance (sitting and leaning forward) in an attempt to improve their airway diameter. The
disease is characterized by the acute onset of fever, drooling, sore throat, dysphagia, and,
in severe cases, respiratory distress accompanied by inspiratory retractions and cyanosis.
Impending airway obstruction is also accompanied by a muffled voice and restlessness.
Epiglottitis is diagnosed based on the clinical presentation. If the diagnosis is unclear and
the patient is stable, a lateral cervical x-ray may be considered on which a thumbprint
sign may be seen. If the patient is unstable, their airway should first be secured, after
which direct laryngeal examination may be performed. Patients should be closely
monitored in a hospital and receive IV antibiotics. Most patients make a full recovery
after prompt and adequate treatment.

Epidemiology

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Peak incidence: 6–12 years (but can occur at any age, including adults, especially
[1]
when unimmunized)
Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors
Not immunized against Hib
Immunodeficiency

References:[2]

Pathophysiology

Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis

and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and
vallecula) → supraglottic inflammation and edema → narrowing of the airway → airway
obstruction (partial or complete) [2]

Clinical features

Respiratory distress (inspiratory retractions, cyanosis)

Inspiratory stridor
Tripod position: eases respiration as the airway diameter is increased by leaning
forward and extending the neck in a seated position
Sore throat
Dysphagia and odynophagia
Drooling
Muffled voice (i.e., resembling a “hot-potato” voice) with painful speech
Acute onset of high fever (39–40°C; 102–104°F)
Toxic appearance
Restlessness and/or anxiety
Absence of cough
Tenderness to palpation over larynx/throat [3]

The hallmarks of epiglottitis are the three Ds: Dysphagia, Drooling, and Distress.
References:[2][4]

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Airway management

In young children, airway management is a higher priority than diagnostic evaluation

. Advanced airway placement is rarely required in adults. [3]

Approach [3][5][6]

Keep the patient sitting upright to prevent further airway compromise.

Minimize external stressors and stimuli that could worsen respiratory distress and
airway edema.
Consult an airway specialist early.
Provide supplemental oxygen as needed.
Assess for:
Risk factors for acute deterioration (e.g., immunocompromise or diabetes,
epiglottic abscess, rapid onset of symptoms, or rapid progression of severe
symptoms) [3]
Patients with clinical features of airway obstruction or risk factors for acute
deterioration
Consider racemic epinephrine in otherwise healthy adults as a temporizing
[5][7]
measure until a definitive airway is established.
Secure the airway with emergency endotracheal intubation in a controlled
setting by an experienced practitioner.
Prepare to perform an emergency surgical airway if endotracheal intubation is
unsuccessful.
Patients without severe airway obstruction or risk factors for acute deterioration:
intubation may not be required.
Consider careful visualization of the epiglottis or imaging to confirm the
diagnosis.
Start treatment for epiglottitis.
[4]
Monitor in an ICU setting for at least 12 hours.

Acute epiglottitis is an airway emergency. Urgently consult a physician experienced

in difficult airway management (e.g., an emergency physician, anesthesiologist, or
otolaryngologist).

[4][6][8]
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Endotracheal intubation [4][6][8]

Indications
Respiratory distress
Altered mental status
Inability to swallow
Stridor
Drooling
Voice changes
Procedure: Should be performed by an anesthesiologist, emergency physician, or
otolaryngologist, ideally in an OR, ICU, or resuscitation area of an emergency
department.
Ensure difficult airway cart is at the bedside.
Prepare for difficult intubation with a backup plan, e.g., emergency surgical
airway.
Use video-assisted laryngoscopy, if available.
Consider flexible fiberoptic intubation or rigid bronchoscopy, if available
and trained.
Maintaining spontaneous ventilation under general anesthesia is preferable.

Consider rapid sequence induction if there is rapid clinical deterioration.

Intubation tubes
In adults: small-sized endotracheal tubes
In children: nasotracheal tubes with a small diameter
Confirm and check the adequacy of ventilation.
Extubation should be performed 2–3 days (at the earliest) after starting
antibiotic treatment.

Intubation should be performed under direct visualization; avoid blind nasotracheal

intubation as it risks airway obstruction. [3]

Emergency surgical airway [8][9]

Indicated if intubation is unsuccessful
Adults and older children: surgical cricothyroidotomy (See “Surgical airway
management” for details)
Children < 8 years old: needle cricothyrotomy

Diagnostics

[5][10][11][12][13]
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Approach [5][10][11][12][13]

Epiglottitis is primarily a clinical diagnosis.

See “Clinical features.”
If the diagnosis is uncertain and there are no signs of impending airway obstruction:
Visualize the epiglottis to confirm the diagnosis.
Consider imaging to confirm the diagnosis if:
Visualization of the epiglottis is unclear or unsuccessful.
Alternate diagnoses need to be ruled out, e.g., croup, abscess, foreign
body aspiration.

Secure the airway before initiating diagnostic studies or procedures in patients with
impending airway compromise, especially in children.

Visualization of the epiglottis [5][10][11][12][13]

Indication: There is suspicion for epiglottitis but no clinical features of airway

obstruction.
Procedure
Direct pharyngoscopy: oropharyngeal examination with a tongue blade
Direct laryngoscopy: can be performed during or after intubation
Indirect laryngoscopy (mirror examination) or flexible fiberoptic laryngoscopy
Perform in an OR, ICU, or emergency department.
Additional considerations
Avoid increasing anxiety (especially in children).
Keep the patient comfortable and in a calm setting.
Keep the patient in a sitting position at all times (do not force the patient
to lie supine).
If the patient is a child, let the parent/guardian hold the mask, and use
distractions and humor to help keep the child relaxed.
In children, this procedure should only be performed by a skilled
otolaryngologist.
Characteristic findings
Direct pharyngoscopy: often normal; epiglottis is often not seen.
Indirect laryngoscopy or flexible fiberoptic laryngoscopy
Cherry-red epiglottis
Pooled secretions
Inflammation and edema of the supraglottic structure

[5][10][11][12][13]
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Imaging [5][10][11][12][13]

Soft-tissue lateral neck x-ray [14]

Indication: mainly performed in children if the clinical presentation in early cases is

inconclusive
Procedure: should be carried out under the supervision of an experienced physician

Characteristic findings
Thumbprint sign: enlarged epiglottis and supraglottic narrowing
Narrowing or complete loss of the normal pre-epiglottic air shadow (vallecula
sign)
Thick aryepiglottic folds

[15]
CT of the neck with IV contrast

Indication: only performed in adults, mainly to exclude other diagnoses

Procedure: requires the supine position, which can compromise the airway
Characteristic findings
Thickening of any of the following may be present:
Epiglottis
Aryepiglottic folds
False vocal cords and true vocal cords
Platysma muscle and prevertebral fascia
Loss of vallecular air space
Obliteration of preepiglottic fat

Additional diagnostic studies [10]

Blood cultures (2 sets)

Swab of the epiglottis and epiglottic culture : to guide antibiotic therapy
Hib immunization status of the patient (and close contacts, if applicable)

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Treatment

Empiric IV antibiotics [6][10]

There are no guidelines on specific empiric antibiotic recommendations. All patients

should receive IV antibiotics that are active against Hib, S. aureus, S. pyogenes, and S.
pneumonia. Following cultures, antibiotics can be narrowed according to identified
organisms.
Most sources recommend monotherapy with a third-generation cephalosporin (e.g.,
cefotaxime DOSAGE , ceftriaxoneDOSAGE ) or a beta-lactam with a beta-
lactamase inhibitor (e.g., ampicillin/sulbactam DOSAGE ,
amoxicillin/clavulanate DOSAGE , piperacillin/tazobactam DOSAGE ). [5]
[16][17][18]

For patients with severe penicillin allergy, consider a fluoroquinolone (e.g.,

levofloxacin DOSAGE ). [6][18]
Consider the addition of an antibiotic with anti-MRSA activity (e.g., vancomycin
[5][17][18]
DOSAGE , clindamycin DOSAGE ).

Adjunctive therapy [10][13][19][20]

Consider empiric steroids. [20]

Dexamethasone DOSAGE [20]

OR methylprednisolone DOSAGE [20]

IV fluid resuscitation: 20–30 mL/kg of isotonic fluids in children.

Acute management checklist

Differential diagnoses

See “Differential diagnoses of pediatric inspiratory stridor” and “Differential

diagnosis of dyspnea.”
Foreign body aspiration
Anaphylactic reaction
Chemical injury or thermal injury (burns)
Laryngitis
Peritonsillar abscess or retropharyngeal abscess

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The differential diagnoses listed here are not exhaustive.

Prognosis

Mortality rate < 1% (in patients without endotracheal intubation ∼ 10%) [21]

Prevention

[10][22][23]
Postexposure prophylaxis with rifampin DOSAGE
Indications
All index patients that are < 2 years of age and did not receive
ceftriaxone or cefotaxime to treat Hib infections should receive
postexposure prophylaxis.
All household contacts: if any member of the household is < 4 years of
age and unimmunized and/or < 18 years of age and
immunocompromised
All daycare attendees: if ≥ 2 cases of invasive Hib disease occurred
within 60 days in this setting and unimmunized children attend the
daycare facility

References

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Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Philadelphia, PA:
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Felton P, Lutfy-Clayton L, Gonen Smith L, Visintainer P, Rathlev N. A Retrospective
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J. Lance Lichtor, Maricarmen Roche Rodriguez, Nicole L. Aaronson, Todd Spock, T. Rob
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