Epiglottitis: Difference between revisions

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==Background==
==Background==
*Otolaryngologic emergency
*Inflammation and edema of the epiglottis and supraglottic structures
**Can lead to rapid onset of life-threatening airway obstruction
*A '''life-threatening airway emergency''' — can progress to complete obstruction within hours
*Most cases are seen in adults (since advent of H. flu vaccine)
*Incidence in children has decreased dramatically since Hib vaccine; now more common in adults<ref name="shah">Shah RK, et al. Epiglottitis in the Hemophilus influenzae type b vaccine era. ''Laryngoscope''. 2004;114(3):557-560. PMID 15091234.</ref>
*Etiology
*Common pathogens:
**Strep, staph, H. flu (unvaccinated)
**Children: Haemophilus influenzae type b (unvaccinated)
**Caustic burns
**Adults: Streptococcus, Staphylococcus, H. influenzae (non-typeable), polymicrobial
*Non-infectious causes: thermal injury, caustic ingestion, foreign body, crack cocaine


==Clinical Features==
==Clinical Features==
*Three D's:
===Adults===
**Drooling
*Severe sore throat (out of proportion to pharyngeal exam findings)
**Dysphagia
*Odynophagia (pain with swallowing), dysphagia, drooling
**Distress
*Muffled or "hot potato" voice
*Pain with gentle palpation of larynx and upper trachea
*Stridor (late finding — suggests impending obstruction)
*Stridor
*Fever
*Respiratory distress
*Anterior neck tenderness ("thyroid cartilage tenderness")


==Diagnosis==
===Children (Classic Presentation)===
*Bedside nasopharyngoscopy for direct visualization
*Abrupt onset high fever, toxic appearance
*Imaging only required if diagnosis uncertain
*Tripod positioning (sitting forward, neck extended, chin protruding)
*Lateral neck x-ray
*Drooling, stridor, refusal to swallow
**Obliteration of vallecula
*Anxiety, air hunger
**Edema of prevertebral and retropharyngeal soft tissues
*'''Do NOT agitate the child''' (crying/agitation may precipitate complete obstruction)
**"Thumb sign" (enlarged epiglottis)
 
==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


==Treatment==
*Emergent ENT consult
*O2 (humidified)
*IVF (hydration minimizes crusting in the airway)
*Nebulized [[Epinephrine]] to reduce edema
===Antibiotics===
===Antibiotics===
;Empiric coverage for Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae
*Ceftriaxone 2 g IV (or Cefotaxime) PLUS
*[[Ceftriaxone]] 2gm IV is first line
*Vancomycin if MRSA concern or critically ill<ref name="syed">Syed MI, et al. Adult epiglottitis: trends in the current era. ''Eur Arch Otorhinolaryngol''. 2012;269(10):2269-2274. PMID 22218491.</ref>
**Consider [[Vancomycin]] in patients at risk for [[MRSA]]<ref>Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.</ref>
*Alternative: Ampicillin-sulbactam 3 g IV


===Steroids===
===Adjuncts===
[[Methylprednisolone]] 125mg IV
*Dexamethasone 10 mg IV (or methylprednisolone) — may reduce edema (limited evidence)
*IV fluids (patients often dehydrated due to inability to swallow)
*Humidified oxygen


===Airway Managment<ref>Katori H, Tsukuda M. Acute epiglottitis: analysis of factors associated with airway intervention. J Laryngol Otol. Dec 2005;119(12):967-72</ref>===
==Disposition==
*First line therapy is fiberoptic [[Intubation]]
*Admit all patients with epiglottitis
*Preparation should be made for simultaneous [[Cricothyrotomy|cricothyrotomy]] incase intubation fails
*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


==Disposition==
==See Also==
*Admit with ENT notification
*[[Croup]]
*[[Peritonsillar abscess]]
*[[Retropharyngeal abscess]]
*[[Airway management]]
*[[Cricothyrotomy]]


==Source==
==References==
*Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. Aug 2008;122(8):818-23
<references/>
<references/>
[[Category:Peds]]
 
[[Category:ID]]
[[Category:Head and Neck]]
[[Category:ENT]]
[[Category:Pediatrics]]
[[Category:Infectious Disease]]

Latest revision as of 09:31, 22 March 2026

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

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

See Also

References

  1. ↑ Shah RK, et al. Epiglottitis in the Hemophilus influenzae type b vaccine era. Laryngoscope. 2004;114(3):557-560. PMID 15091234.
  2. ↑ Syed MI, et al. Adult epiglottitis: trends in the current era. Eur Arch Otorhinolaryngol. 2012;269(10):2269-2274. PMID 22218491.
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