Epiglottitis

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Epiglottitis\: acute in
caused by H a e m o p h i l u s i n
Hib vaccine\: signi
S t r e p t o c o c c u s p n e u m o n i a e , g r o u p A s t r e p t o c o c c i , S t a p h y l o c o c c u s a u r e u s , viral (HSV), and fungal infections (Candida).
Risk factors\: non-immunisation against Hib, immunocompromised status, diabetes; typically a
with comorbidities in vaccinated regions.
Symptoms\: severe sore throat, mu
odynophagia), often following an upper respiratory tract infection (URTI).
Clinical
of accessory muscles, cyanosis), inspiratory stridor, hypoxia, tachycardia, fever.
Di
Sore throat\: acute tonsillitis, acute pharyngitis, peritonsillar abscess (quinsy), deep neck space infection.
Stridor\: laryngotracheobronchitis (croup), foreign body inhalation, anaphylaxis, laryngitis.
Investigations\: avoid initial investigations unless the patient is stable. Main priority is to secure the airway.
First-line\: direct
Second-line (stable patients)\: lateral neck radiograph (‘thumbprint sign’), blood tests (FBC, CRP, LFTs, U&Es, blood cultures),
culture swab from epiglottis.
Management\:
Initial\: secure the airway (endotracheal intubation or surgical airway), upright positioning, senior support, ENT and
anaesthetics involvement.
Additional\: nebulised adrenaline, high-
corticosteroids (e.g., dexamethasone),
Complications\: epiglottic abscess, deep neck space infections (e.g., retro- and parapharyngeal abscesses), mediastinitis.
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A comprehensive topic overview

Introduction

Epiglottitis is acute in
associated with signi
It is most commonly caused by the bacteria H a e m o p h i l u s i n
introduction of the Hib vaccine in the early 1990s, the incidence of epiglottitis has dropped signi

Aetiology

AnatomyThe epiglottis is a cartilaginous
(glottis) during swallowing. This prevents food or liquids from passing into the trachea and the lungs.
Figure 1. The location of the epiglottis
Given its location within the larynx, any in
Causes of epiglottitis
The most common cause of epiglottitis is infection.
While H a e m o p h i l u s i n
reduced its incidence. 1,2
Other causative organisms include S t r e p t o c o c c u s p n e u m o n i a e , g r o u p A s t r e p t o c o c c i a n d
s t a p h y l o c o c c u s a u r e u s .
1
Other less common and rare infectious causes of epiglottitis are viral causes (for example, herpes simplex virus (HSV) and
infectious mononucleosis) 1 3
and fungal infections, such as candida.
Non-infectious causes include thermal injuries, chemical burns from caustic agents and foreign body ingestion.
1

Risk factors

Given the e
against Haemophilus in
Immunocompromised individuals are at greater risk of acquiring a bacterium that can lead to epiglottitis, including those
with diabetes.
In vaccinated areas, the patient most commonly a
morbidities.
4

Clinical features

History
Typical symptoms of epiglottitis include\:
2,3,5
Severe and acute onset of sore throat
Mu
Drooling
Inspiratory stridor
Di
Most patients also report a recent upper respiratory tract infection (URTI).
Compared to paediatric patients, adults often present with a slower onset of symptoms, which are less severe.
3
Clinical examination
In a child with epiglottitis, no action should be taken to stimulate or irritate them, as this may trigger laryngospasm in an
already critical airway. This includes examination of the oral cavity, any form of instrumentation in the airway, and even
separating the child from their parent.
1,2,3Typical clinical
1,2,3
Mu
Tripod position\: sitting up on hands, with the mouth open and head forward to increase air
children)
Drooling (more common in children)
Signs of respiratory distress\: dyspnoea, tachypnoea, use of accessory muscles and cyanosis are severe
indicate impending respiratory failure (seen in both children and adults)
Inspiratory stridor\: can sometimes be a late
Hypoxia
Tachycardia
Fever

Di

Di
1,3
Acute tonsillitis
Acute pharyngitis
Peri-tonsillar abscess (quinsy)\: usually presents with fever, sore throat, trismus, and mu
Deep neck space infection\: severe sore throat that can present with neck swelling (and possibly stridor)
Distridor include\:
1,3
Laryngotracheobronchitis (Croup)
Foreign body inhalation
Anaphylaxis
Laryngitis

Investigations

Investigations in the immediate period are avoided as the condition is time critical, unless the patient is stable.
The main priority is to avoid further agitating the patient and precipitating airway obstruction, particularly in children.
The diagnosis of epiglottitis is mainly clinical. Therefore, it is crucial to have senior support early on, including those with
advanced airway skills.
If there is a strong clinical suspicion of epiglottitis in an unstable patient, they will likely be taken to a controlled
environment, such as the operating theatre, for examination of the airway plus endotracheal intubation or a surgical
airway.
1
Only once the airway is secure can other investigations be performed, such as blood tests, blood culture and a culture
swab from the epiglottis.
First-line investigations in the stable patient
The
performed by ENT, this con
structures.
1,3
This should only be performed in a controlled setting, such as an operating theatre, with anaesthetics and ENT present.
This will allow for an airway to be secured if required, either via endotracheal intubation or an emergency surgical airway
(i.e. tracheostomy).
1,3Figure 2. A swollen epiglottis seen on laryngoscopy via
scope
Other investigations
Other investigations can be carried out once the airway is secure.
Second-line imaging
1,3
A lateral neck radiograph is usually only carried out in a stable adult patient or a stable, cooperative child if there is
diagnostic uncertainty. The child should not be sent unaccompanied for the examination.
It may reveal a severely swollen epiglottis, called the ‘thumbprint sign’
.
Imaging may not be necessary if the diagnosis is made with clinical examination and laryngoscopy.
Laboratory investigations
1,3
Blood tests are only performed in a stable patient or once the airway is secure. No blood tests should be attempted in a
child until the airway is secure.
Relevant laboratory investigations include\:
Full blood count\: raised white cells can indicate infection
CRP\: often raised in acute infection
Liver function tests
Urea & electrolytes
Blood cultures\: to help guide future antibiotic choices.
Culture swab from epiglottis\: to identify the causative organism and guide antibiotic choice. Only performed by senior
members of sta

Management

The main priority is to secure the airway in a controlled environment, as patients (particularly children) can deteriorate
quickly. Involve senior members of sta
epiglottitis.
Once the patient is stable, they will be managed in critical care with monitoring, IV antibiotics and subsequent extubation
in a controlled setting.
Take no action that may stimulate a child with epiglottitis. Similar caution should be used in adults with acute severe
epiglottitis.
Approach the patient with suspected epiglottitis with an ABCDE approach, bearing in mind this is an airway emergency. No
other procedures or clinical examination should delay control of the airway.
Initial management
Manage the patient in an upright position (lying a patient supine can worsen airway obstruction).
3
Have the airway assessed and secured by a relevant specialist (ENT or anaesthetics). This can take two main forms\:
1,3
Endotracheal intubation
Surgical airway if intubation is not possible (e.g. tracheostomy or cricothyroidotomy).Additional management
Additional management of epiglottitis includes\:
Nebulised adrenaline\: can be used back-to-back if required.
High-
Intravenous broad-spectrum antibiotics\: a third-generation cephalosporin (e.g. ceftriaxone or cefuroxime) is often used
but always follow local empirical antibiotic guidelines. 2
Antibiotic therapy can be tailored once culture results are known.
Corticosteroids (e.g., dexamethasone)\: usually given as a stat dose on acute presentation. Administered orally in children
to avoid cannulation but could be intravenous in adults if stable. Then, it is continued regularly whilst the patient
recovers (IV or oral). Whilst not proven in clinical trials, corticosteroids may help reduce supraglottic in
Fluid replacement therapy\: given orally in children to avoid cannulation
Analgesia

Complications

Complications of epiglottitis include\:
1,3,6
Epiglottic abscess\: may require drainage
Deep neck space infections\: may occur if the infection extends beyond the epiglottis. This can be cellulitis or an
abscess, such as retro- and parapharyngeal abscesses
Mediastinitis\: as the epiglottis involves the retropharyngeal space, the infection can spread to the mediastinum (a life-
threatening condition)

References

Guerra AM, Waseem M. 2022. Epiglottitis. S t a t P e a r l s . Available from\: [LINK]
Lindquist B, Zachariah S, Kulkarni A. 2017. Adult Epiglottitis\: A Case Series. Perm J. 21\:16-089. doi\: 10.7812/TPP/16-089.
BMJ Best Practice. Epiglottitis. BMJ Publishing Group. Last updated 2023. Available from\: [LINK]
Shah R K, Stocks C. 2010. Epiglottitis in the United States\: national trends, variances, prognosis, and management.
Laryngoscope. 120(6)\:1256-62. doi\: 10.1002/lary.20921.
National Institute for Health and Care Excellence. Sore Throat – Acute. CKS Health Topic. Available from\: [LINK]
Ito K, Chitose H, Koganemaru M. 2011. Four cases of acute epiglottitis with a peritonsillar abscess. A u r i s N a s u s L a r y n x .
38(2)\:284-8
Image references
Figure 1. Prof. Squirrel / Arcadian. H e a d n e c k v s p h i n c t e r . License\: [Public domain]
Figure 2. 藤澤孝志.Epiglottitis endoscopy. License\: [CC BY-SA]

Reviewer

Miss Lucy Li
ST4 Otolaryngology

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Contents

Introduction
Aetiology
Risk factors
Source\: geekymedics.com