Overview
Epiglottitis
Topic Overview
Summary
Epiglottitis is acute inflammation of the epiglottis and surrounding supraglottic structures. In adults, it is most commonly bacterial (Haemophilus influenzae, Streptococci, Staphylococci). It presents with severe sore throat, odynophagia, muffled voice, drooling, and in severe cases, stridor and airway obstruction. This is an ENT emergency — airway compromise can occur rapidly. Treatment is IV antibiotics, dexamethasone, and close airway monitoring with readiness for emergency intubation or surgical airway.
Key Facts
- Aetiology: H. influenzae (decreasing with Hib vaccine), Strep, Staph
- Presentation: Severe sore throat, odynophagia, muffled voice, drooling
- Key risk: Airway obstruction — can be rapid and fatal
- Diagnosis: Clinical + flexible nasendoscopy (NOT direct laryngoscopy in ED)
- Treatment: IV antibiotics, dexamethasone, airway monitoring/intervention
Clinical Pearls
In adults, epiglottitis may lack classic "cherry-red epiglottis" — diagnosis is clinical
Do NOT examine the pharynx aggressively or lie the patient flat — may precipitate complete obstruction
Stridor is a late sign — do not wait for it to act
Why This Matters Clinically
Epiglottitis is a true airway emergency. Rapid recognition, avoiding interventions that may worsen obstruction, and preparedness for emergency airway management are life-saving.
Visual Summary
Visual assets to be added:
- Lateral soft tissue neck X-ray (thumb sign)
- Nasendoscopy showing swollen epiglottis
- Tripod position illustration
- Airway management algorithm
Epidemiology
Incidence
- Decreasing in children (Hib vaccination)
- Increasing proportion in adults
- 1-2 per 100,000/year in adults
Demographics
- Adults: Peak 40-50 years
- Children: Rare since Hib vaccination
- Male predominance
Risk Factors
| Factor | Notes |
|---|---|
| Immunocompromise | |
| Diabetes | |
| Lack of Hib vaccination | (children) |
| Recent URI |
Organisms
| Organism | Notes |
|---|---|
| Haemophilus influenzae | Classic; decreasing with vaccination |
| Streptococcus pneumoniae | |
| Staphylococcus aureus | |
| Group A Streptococcus | |
| Viral | Less common |
Pathophysiology
Mechanism
- Bacterial (or viral) infection of epiglottis
- Inflammation and oedema of epiglottis and aryepiglottic folds
- Supraglottic swelling
- Narrowing of airway
- Complete airway obstruction (if progressive)
Why Dangerous
- Epiglottis is small structure
- Small amount of oedema = significant airway compromise
- Can progress rapidly
Clinical Presentation
Symptoms
Signs
Classic vs Adult Presentation
| Feature | Children (Classic) | Adults |
|---|---|---|
| Onset | Rapid (hours) | More gradual (days) |
| Drooling | Common | May be present |
| Stridor | Common | Less common initially |
| Cherry-red epiglottis | Classic | May be less obvious |
Red Flags
| Finding | Significance |
|---|---|
| Stridor | Impending obstruction |
| Drooling | Cannot swallow — severe |
| Rapid progression | Urgent airway management |
| Respiratory distress | Critical |
Severe sore throat — often out of proportion to examination
Common presentation.
Odynophagia — painful swallowing
Common presentation.
Dysphagia — difficulty swallowing
Common presentation.
Drooling — cannot swallow secretions
Common presentation.
Muffled "hot potato" voice
Common presentation.
Fever
Common presentation.
Neck pain
Common presentation.
Clinical Examination
General
- Toxic appearance
- Sitting forward
- Drooling
- Stridor (listen)
Neck
- Tender anteriorly
- Lymphadenopathy
Oropharynx
- Often looks NORMAL — epiglottis is not visible on routine examination
- Do NOT use tongue depressor aggressively — may precipitate laryngospasm
Investigations
Clinical Diagnosis
- Primarily clinical
- Investigations should NOT delay treatment
Flexible Nasendoscopy
- Gold standard for visualisation
- Performed by ENT in controlled setting
- Shows swollen, inflamed epiglottis
Imaging
| Modality | Finding |
|---|---|
| Lateral soft tissue neck X-ray | "Thumb sign" (swollen epiglottis); NOT routine |
| CT neck | If diagnosis uncertain; shows supraglottic swelling |
Blood Tests
| Test | Purpose |
|---|---|
| FBC | Raised WCC |
| CRP | Elevated |
| Blood cultures | If septic |
Do NOT
- Examine throat aggressively
- Lay patient flat
- Delay treatment for investigations
Classification & Staging
By Severity
| Severity | Features |
|---|---|
| Mild | Sore throat, odynophagia, stable airway |
| Moderate | Muffled voice, drooling, mild stridor |
| Severe | Stridor at rest, respiratory distress, impending obstruction |
Management
Principles
- Keep patient calm
- Keep patient sitting upright
- Do NOT examine throat aggressively
- Prepare for emergency airway
Airway — Priority
| Status | Action |
|---|---|
| Stable | Close monitoring; ENT, anaesthetics on standby |
| Deteriorating/stridor | Emergency intubation (senior, experienced) |
| Cannot intubate | Surgical airway (tracheostomy/cricothyroidotomy) |
Intubation:
- Most senior available anaesthetist
- Awake fibreoptic if possible
- Have surgical airway equipment ready
Medical Management
IV Antibiotics:
- Ceftriaxone 2g IV (or co-amoxiclav)
- Add vancomycin if MRSA risk
Dexamethasone:
- 0.25-0.5 mg/kg (max 10 mg)
- Reduces oedema
Nebulised Adrenaline:
- May provide temporary relief
- 5 mg nebulised
- Not definitive treatment
Supportive Care
- High-flow oxygen (if tolerated)
- IV fluids
- Close monitoring (ICU/HDU)
Complications
Airway
- Complete airway obstruction
- Death
Infectious
- Epiglottic abscess
- Sepsis
- Pneumonia (aspiration)
Prognosis & Outcomes
Prognosis
- Excellent if airway secured and treated
- Mortality under 1% with treatment
- Higher if delayed
Recovery
- Most recover in 48-72 hours with antibiotics
- May need observation in ICU/HDU
Evidence & Guidelines
Key Guidelines
- No specific national guideline
- Management based on expert consensus
Key Evidence
- Early recognition and airway management are key
- Hib vaccination has reduced childhood epiglottitis dramatically
Patient & Family Information
What is Epiglottitis?
Epiglottitis is a serious infection of the flap at the back of the throat (epiglottis) that can swell and block the airway.
Symptoms
- Severe sore throat
- Difficulty swallowing
- Drooling
- Muffled voice
- Noisy breathing
Treatment
- Hospital admission
- Antibiotics through a drip
- Close monitoring of your breathing
- Sometimes a breathing tube is needed
Resources
References
Key Reviews
- Shah RK, et al. Acute epiglottitis in adults. Curr Opin Otolaryngol Head Neck Surg. 2007;15(3):175-180. PMID: 17483684
- Guardiani E, et al. Adult epiglottitis: trends, predictors, and management. Am J Otolaryngol. 2012;33(1):14-18. PMID: 21296444
Epidemiology
- Guldfred LA, et al. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122(8):818-823. PMID: 17892617