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
• 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
• 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

• Croup
• Peritonsillar abscess
• Retropharyngeal abscess
• Airway management
• Cricothyrotomy