Acute Epiglottitis in Adults

Topic Overview

Summary

Acute epiglottitis is a life-threatening inflammatory condition affecting the epiglottis and surrounding supraglottic structures, capable of progressing rapidly to complete airway obstruction. Following widespread Haemophilus influenzae type B (Hib) vaccination in children, adults now comprise the majority of epiglottitis cases, with peak incidence in the 40-50 year age group. [1,2] The condition presents with severe sore throat, odynophagia, muffled "hot potato" voice, drooling, and tripod positioning. Unlike paediatric cases, adult epiglottitis typically has a more gradual onset (days rather than hours) but carries significant morbidity and mortality if airway compromise is not anticipated and managed appropriately. [3]

Key Facts

• Changing epidemiology: Incidence declining in children (Hib vaccine) but increasing in adults; now 0.97-3.1 per 100,000 adults annually [1,2,4]
• Microbiology: Haemophilus influenzae (declining), Streptococcus pneumoniae, Staphylococcus aureus, Group A Streptococcus [5,6]
• Classic triad: Drooling, dysphagia, distress
• Diagnosis: Clinical diagnosis confirmed by flexible nasendoscopy showing swollen, inflamed epiglottis [7]
• Imaging: "Thumb sign" on lateral soft tissue neck X-ray (but investigations must NOT delay treatment) [8]
• Critical safety: DO NOT examine throat aggressively with tongue depressor - may precipitate laryngospasm and complete obstruction [9]
• Airway management: Senior anaesthetist + ENT surgeon mandatory; awake fibreoptic intubation if airway intervention required [10]
• Treatment: IV antibiotics (ceftriaxone), dexamethasone, airway monitoring, ICU/HDU admission [11,12]
• Prognosis: Mortality less than 1% with appropriate treatment; higher with delayed recognition [13]

Clinical Pearls

In adults, epiglottitis often lacks the "cherry-red epiglottis" of paediatric cases - diagnosis is clinical based on symptoms and flexible nasendoscopy

Stridor is a LATE sign indicating critical airway narrowing - do not wait for stridor to act

Sore throat "out of proportion" to examination findings is a key clinical clue

Keep patient sitting upright - lying flat may precipitate complete obstruction

The "thumb sign" on lateral neck X-ray is specific but not sensitive - normal X-ray does NOT exclude epiglottitis

Why This Matters Clinically

Epiglottitis is a true ENT and anaesthetic emergency. The epiglottis is a small structure; even minor oedema can cause critical airway narrowing. Rapid recognition, avoidance of interventions that may worsen obstruction (aggressive examination, lying flat), early involvement of senior airway specialists, and preparedness for emergency surgical airway are life-saving skills. Misdiagnosis as simple pharyngitis can be fatal.

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Visual Summary

Visual assets to be added:

• Lateral soft tissue neck X-ray showing "thumb sign" (swollen epiglottis)
• Normal vs epiglottitis X-ray comparison
• Flexible nasendoscopy image: swollen, inflamed epiglottis
• Tripod position illustration
• Airway management algorithm for epiglottitis
• Emergency intubation preparation checklist
• Supraglottic anatomy diagram

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Epidemiology

Incidence

Post-Hib Vaccination Era:

• Paediatric cases decreased > 95% since Hib vaccine introduction (1980s-1990s) [4,14]
• Adult cases now predominate
• Adult incidence: 0.88-3.1 per 100,000/year (varying by region and time period) [1,2,4]
• Increasing incidence in adults reported in multiple studies (1986-2000: 0.88 → 3.1 per 100,000) [4]

Geographic Variation:

• Denmark: 0.02 per 100,000 children/year; adults comprise majority of cases [14]
• Israel: Mean annual incidence increased from 0.88 (1986-1990) to 3.1 (1996-2000) per 100,000 adults [4]
• North America: Similar trends with adult predominance [2,3]

Demographics

Risk Factors

Microbiology - Changing Patterns

Key Point: Many adults now present with Streptococcus pneumoniae or Staphylococcus aureus rather than H. influenzae type B. [6]

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Pathophysiology

Anatomical Considerations

Epiglottis Structure:

• Leaf-shaped cartilage covered by stratified squamous and respiratory epithelium
• Located at root of tongue, guards entrance to larynx
• Highly vascular loose areolar tissue beneath mucosa
• Small structure - minimal oedema causes significant airway compromise

Supraglottic Anatomy Involved:

1. Lingual surface of epiglottis
2. Aryepiglottic folds
3. Arytenoids
4. False cords (in severe cases)

Mechanism of Airway Obstruction

Bacterial (or viral) invasion
         ↓
Mucosal infection of epiglottis
         ↓
Inflammatory response (cytokines, neutrophils)
         ↓
Vascular permeability ↑ → OEDEMA
         ↓
Supraglottic swelling (epiglottis, aryepiglottic folds)
         ↓
Airway narrowing (laryngeal inlet obstruction)
         ↓
Stridor, respiratory distress
         ↓
Complete airway obstruction (if untreated)

Why Epiglottitis is Dangerous in Adults vs Children

Critical Concept: While adult airways are larger, epiglottic oedema can still cause complete obstruction. Adults may present with more subtle signs, leading to delayed diagnosis. [3,7]

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Clinical Presentation

Symptoms

Cardinal Symptoms (4 D's):

1. Dysphagia - difficulty swallowing (90-95%) [3,7]
2. Dysphonia - muffled "hot potato" voice (80-90%) [3]
3. Drooling - inability to swallow secretions (70-80%) [7]
4. Distress - respiratory distress, anxiety (variable) [3]

Additional Symptoms:

Signs

General Appearance:

• Sitting upright, leaning forward (tripod position) - allows maximal airway diameter [9]
• Anxious, distressed (air hunger)
• Drooling, pooling of secretions
• May appear surprisingly well (early stage) OR toxic (advanced) [3]

Vital Signs:

Examination Findings:

RED FLAG Signs of Impending Obstruction:

1. Stridor at rest
2. Respiratory rate > 30/min
3. SpO₂ less than 92% on room air
4. Inability to tolerate lying flat
5. Exhaustion, decreasing respiratory effort (pre-arrest)
6. Altered mental status (hypoxia, hypercarbia)

Adult vs Paediatric Presentation - Key Differences

Clinical Implication: Adult epiglottitis may present more subtly with longer duration of symptoms, leading to potential misdiagnosis as pharyngitis or tonsillitis. High index of suspicion required. [3,7]

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Differential Diagnosis

Critical "Cannot-Miss" Diagnoses

Differential Diagnosis by Clinical Feature

Severe Sore Throat + Dysphagia:

• Epiglottitis (muffled voice, drooling, tripod position)
• Peritonsillar abscess (unilateral, trismus, visible swelling)
• Retropharyngeal abscess (posterior pharyngeal bulge, neck stiffness)
• Ludwig's angina (submandibular swelling, floor of mouth)
• Lemierre syndrome (recent pharyngitis, septic thrombophlebitis)

Stridor in Adults:

• Epiglottitis (acute, infectious, tripod position)
• Angioedema (rapid onset, facial swelling, medication history)
• Foreign body (sudden onset, choking episode)
• Laryngeal tumour (chronic, progressive, weight loss)
• Bacterial tracheitis (follows croup, purulent secretions)
• Laryngeal trauma (history of trauma/intubation)

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Clinical Examination

Approach - SAFETY FIRST

CRITICAL SAFETY PRINCIPLES:

1. Do NOT examine throat aggressively with tongue depressor - may precipitate laryngospasm and complete airway obstruction [9]
2. Do NOT lay patient flat - worsens obstruction
3. Do NOT agitate or distress patient - worsens obstruction
4. Do NOT leave patient unattended
5. Do involve senior ENT and anaesthetist immediately
6. Do examine in sitting position
7. Do have emergency airway equipment available

General Inspection

Position:

• Sitting upright, leaning forward (tripod position) [9]
• Hands on knees or supporting table
• Chin extended, neck hyperextended

Appearance:

• Anxious, distressed
• Drooling, unable to swallow secretions
• Mouth breathing

Respiratory:

• Respiratory rate and pattern
• Use of accessory muscles
• Intercostal/subcostal recession
• Stridor (listen without stethoscope)

Oropharyngeal Examination

Inspection (gentle, non-provocative):

• May reveal minimal findings
• Pharynx often normal or mildly erythematous
• Epiglottis NOT visible on routine oral examination
• Tonsils typically normal (helps exclude quinsy)

DO NOT:

• Use tongue depressor aggressively
• Attempt to visualize epiglottis by pushing tongue down
• Request patient to lie down for examination

Neck Examination

• Gentle palpation of anterior cervical region (may elicit tenderness)
• Cervical lymphadenopathy (often present)
• Exclude neck swelling (Ludwig's angina, retropharyngeal abscess)

Voice Assessment

• Muffled "hot potato" voice (classic) [3]
• May whisper due to pain
• Hoarseness less common (contrast with laryngitis)

Stridor Assessment

• Inspiratory stridor (supraglottic obstruction) [9]
• If stridor present at rest = critical airway compromise
• Absence of stridor does NOT exclude epiglottitis

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Investigations

Principles

CRITICAL: Investigations must NOT delay treatment or airway assessment. [9,12]

If airway is threatened, proceed directly to definitive airway management in operating theatre with senior anaesthetist and ENT surgeon present. Investigations can be performed after airway secured. [10,12]

Diagnostic Approach by Clinical Severity

Stable Airway (no stridor, SpO₂ > 94%, comfortable sitting):

1. Flexible nasendoscopy (gold standard) [7]
2. Lateral soft tissue neck X-ray (if safe to send patient) [8]
3. Blood tests
4. Blood cultures

Threatened Airway (stridor, SpO₂ less than 94%, respiratory distress):

1. Do NOT send patient for imaging
2. Emergency ENT and anaesthetic review
3. Prepare for emergency intubation or surgical airway
4. Investigations AFTER airway secured

Flexible Nasendoscopy

Gold Standard for Diagnosis: [7]

Advantages:

• Performed bedside
• Confirms diagnosis definitively
• Assesses severity of airway narrowing
• Performed by ENT specialist

Safety:

• Should be performed by experienced ENT clinician
• Have emergency airway equipment ready
• Patient remains sitting upright
• Topical anaesthesia may be used cautiously

Imaging

Lateral Soft Tissue Neck X-ray [8]

Classic Finding: "Thumb Sign"

• Swollen epiglottis resembles thumb (normally appears thin like little finger)
• Thickened aryepiglottic folds
• Vallecula obliteration
• Hypopharyngeal distension (air-filled, due to obstruction)

Limitations:

• Sensitivity only 50-60% - normal X-ray does NOT exclude epiglottitis [8]
• Risk of airway deterioration while transporting patient to radiology
• Should NOT be performed if airway threatened

When to Order:

• Stable patient with low-moderate suspicion
• Diagnosis uncertain after nasendoscopy
• Patient refuses nasendoscopy

CT Neck with Contrast

Rarely Indicated in Acute Setting:

• Risk of airway deterioration during scan
• Lying flat position worsens obstruction
• Flexible nasendoscopy is safer and diagnostic

May Consider If:

• Diagnosis uncertain (abscess vs cellulitis)
• Epiglottic abscess suspected
• After airway secured

Findings:

• Epiglottic thickening
• Aryepiglottic fold oedema
• Abscess formation (if present)
• Airway narrowing

Blood Tests

Routine Bloods

Blood Cultures

• Obtain BEFORE antibiotics (if possible)
• Positive in 20-30% of cases [5,13]
• Identifies causative organism (Strep pneumoniae, Staph aureus, H. influenzae)

Epiglottic Swab Culture

• Obtain during intubation (if performed) or via nasendoscopy
• Guides antibiotic therapy
• Positive in 30-50% of cases [5]

Arterial Blood Gas (ABG)

If Airway Threatened:

• Hypoxia (PaO₂ less than 10 kPa)
• Hypercarbia (PaCO₂ > 6.5 kPa) - late, pre-arrest finding
• Respiratory acidosis (pH less than 7.35)

Practical Point: ABG is rarely required for diagnosis; clinical assessment of respiratory distress is more important. Do NOT delay airway intervention for ABG. [9]

Investigations Summary - Key Points

1. Diagnosis is clinical (symptoms + signs)
2. Flexible nasendoscopy confirms diagnosis (swollen epiglottis) [7]
3. Lateral neck X-ray "thumb sign" is classic but insensitive [8]
4. Blood cultures before antibiotics
5. DO NOT delay airway management for investigations [9,12]

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Classification & Staging

Clinical Severity Classification

Intubation Decision Criteria [16]

Absolute Indications for Immediate Intubation:

• Stridor at rest with respiratory distress
• SpO₂ less than 90% despite supplemental oxygen
• Altered mental status (hypoxia, hypercarbia)
• Inability to protect airway (aspiration risk)
• Rapid progression despite medical therapy
• Epiglottic abscess (impending rupture)

Relative Indications (Clinical Judgement):

• Severe oedema on nasendoscopy (> 50% airway narrowing)
• Inability to visualize laryngeal inlet on nasendoscopy
• Pooling of secretions with aspiration risk
• Patient exhaustion
• Deterioration despite antibiotics and steroids
• Need for transfer to tertiary centre (secure airway first)

Factors Favouring Conservative Management:

• Mild-moderate symptoms
• No stridor
• SpO₂ > 94% on air
• Able to tolerate lying flat
• Symptom duration > 24-48 hours (less likely to progress rapidly)
• Minimal oedema on nasendoscopy

Evidence: Intubation rates in adults range from 10-30% (lower than historical paediatric rates). [13,16] Adult airways are larger and can tolerate more oedema, but vigilance for deterioration is mandatory.

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Management

Immediate Management - AIRWAY FIRST

ABC Approach

A - Airway:

1. Keep patient sitting upright (lying flat worsens obstruction) [9]
2. Do NOT agitate patient (worsens obstruction)
3. Call for senior help immediately:
   • Senior ENT surgeon
   • Senior anaesthetist (consultant level preferred)
   • ICU team
4. Prepare for emergency airway:
   • Difficult airway trolley
   • Surgical airway equipment (scalpel, bougie, cricothyroidotomy kit)
   • Flexible bronchoscope

B - Breathing:

• Supplemental oxygen (if tolerated; nasal prongs or face mask) [12]
• Continuous SpO₂ monitoring
• Avoid CPAP/BiPAP (may not be tolerated)

C - Circulation:

• IV access (two large-bore cannulae)
• IV fluids (may be dehydrated from reduced oral intake)
• Blood cultures (before antibiotics if time permits)

Medical Management

Antibiotics [11,12]

Empirical IV Antibiotic Therapy:

First-Line (covers H. influenzae, Strep pneumoniae, Staph aureus):

Alternative (penicillin allergy):

If MRSA Risk (IVDU, recent hospitalization, known colonization):

• Add vancomycin 15-20 mg/kg IV (loading dose, then 15 mg/kg 12-hourly)
• OR linezolid 600 mg IV 12-hourly

Duration:

• IV antibiotics until afebrile and clinically improved (typically 48-72 hours) [11]
• Then switch to oral (e.g., co-amoxiclav 625 mg TDS or cefuroxime 500 mg BD)
• Total duration: 7-10 days [11,12]

Antibiotic Tailoring:

• Adjust based on culture results (blood, epiglottic swab)
• De-escalate to narrow-spectrum agent if organism identified

Corticosteroids [12]

Dexamethasone:

Mechanism:

• Reduces inflammatory oedema
• May reduce intubation requirement
• Speeds resolution

Evidence: Extrapolated from croup and airway oedema studies; commonly used in practice. [12]

Nebulised Adrenaline

Indication:

• Temporary measure for stridor while preparing for definitive airway [9]

Dose:

• 5 mg (5 mL of 1:1000 adrenaline) nebulised

Mechanism:

• Vasoconstriction → reduces mucosal oedema
• Effect is temporary (30-60 minutes)

Caution:

• NOT a substitute for airway management
• Rebound oedema may occur
• Use as bridge to intubation/observation only [9]

Airway Management Algorithm

Acute Epiglottitis Suspected
         ↓
Assess Airway Stability
         ↓
    ┌────────┴────────┐
    ↓                 ↓
STABLE            THREATENED/CRITICAL
(No stridor,      (Stridor, SpO₂less than 92%,
SpO₂> 94%)         respiratory distress)
    ↓                 ↓
Close monitoring   Emergency airway management
ICU/HDU           (see below)
IV antibiotics    ↓
Dexamethasone     Call senior anaesthetist + ENT
Flexible          Prepare:
nasendoscopy      - Difficult airway trolley
(if safe)         - Surgical airway equipment
    ↓             - Flexible bronchoscope
Observe 24-48hrs  ↓
    ↓             Theatre (if time) OR
Improving?        Bedside (if critical)
    ↓             ↓
Yes → Continue    Awake Fibreoptic Intubation
      antibiotics (AFOI) - preferred [10]
      to 7-10 days OR
    ↓             Inhalational induction
No → Consider     (sevoflurane)
     intubation   with spontaneous ventilation
                  OR
                  Emergency surgical airway
                  (cricothyroidotomy)
                  ↓
                  ICU ventilation + antibiotics
                  ↓
                  Extubation when:
                  - Afebrile 24-48 hrs
                  - Leak test positive
                  - Improved nasendoscopy
                  (typically 24-72 hours) [13,16]

Intubation Technique [10]

Preferred Method: Awake Fibreoptic Intubation (AFOI)

Rationale:

• Maintains spontaneous ventilation
• Avoids muscle relaxation (which may precipitate complete obstruction)
• Allows visualization of larynx

Preparation:

1. Most senior anaesthetist available (consultant ideal)
2. ENT surgeon scrubbed and ready for emergency surgical airway
3. Patient sitting upright initially
4. Topical anaesthesia:
   • Nebulised lidocaine 4% to oropharynx
   • Topical lidocaine to nasopharynx (if nasal route)
5. Sedation:
   • Titrated midazolam 0.5-1 mg IV (if patient cooperative)
   • Avoid over-sedation (risk of airway collapse)
6. Antisialagogue:
   • Glycopyrrolate 200 mcg IV (reduces secretions)

Technique:

1. Fibreoptic scope via nasal or oral route
2. Visualize oedematous epiglottis and laryngeal inlet
3. Advance scope through vocal cords
4. Railroad endotracheal tube (ETT) over scope
5. Confirm placement (CO₂ trace, auscultation)
6. Secure tube firmly
7. Patient may then be laid down and sedated

Alternative: Inhalational Induction (If AFOI Not Feasible)

Technique:

1. Sevoflurane inhalational induction with patient sitting upright
2. Maintain spontaneous ventilation (DO NOT paralyse)
3. Gradually deepen anaesthesia
4. Attempt direct laryngoscopy or video laryngoscopy
5. Intubate under vision
6. Have surgeon ready for emergency surgical airway

Emergency Surgical Airway: Cricothyroidotomy [10]

Indications:

• Cannot intubate, cannot ventilate (CICV) scenario
• Complete airway obstruction

Technique (Scalpel Cricothyroidotomy):

1. Identify cricothyroid membrane (between thyroid and cricoid cartilage)
2. Stabilize larynx
3. Transverse incision through skin and membrane
4. Insert tracheal hook (or bougie)
5. Insert cuffed tracheostomy tube or size 6.0 ETT
6. Confirm ventilation
7. Secure tube

Tracheostomy:

• Formal tracheostomy may be required if prolonged ventilation anticipated
• Preferred over emergency cricothyroidotomy if time permits (elective surgical airway) [10]

ICU/HDU Management

Indications for ICU/HDU Admission:

• All patients with epiglottitis (potential for rapid deterioration) [12,13]
• Continuous monitoring required
• Airway observation

Monitoring:

• Continuous SpO₂
• Continuous cardiac monitoring
• Hourly respiratory rate
• Hourly GCS
• Temperature 4-hourly
• Fluid balance

Intubated Patients:

• Sedation (propofol/midazolam + analgesia)
• Mechanical ventilation
• Head-up position 30-45°
• Humidified oxygen
• Regular ETT suction
• Antibiotic therapy
• Daily nasendoscopy (assess resolution) [13]

Extubation Criteria: [13,16]

• Afebrile for 24-48 hours
• Clinical improvement
• Reduced epiglottic oedema on nasendoscopy
• Positive cuff leak test (air leak around deflated ETT cuff)
• Typically 24-72 hours post-intubation [16]

Supportive Care

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Complications

Airway Complications

Infectious Complications

Other Complications

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Prognosis & Outcomes

Overall Prognosis

With Appropriate Treatment:

• Mortality: less than 1% [13]
• Most patients recover fully without sequelae
• Hospital stay: 3-7 days (non-intubated) or 5-10 days (intubated) [13,16]

Without Treatment / Delayed Diagnosis:

• Mortality: 5-10% (airway obstruction, sepsis) [13]

Factors Associated with Worse Prognosis

Recovery Timeline

Long-Term Sequelae

• Rare if treated appropriately
• Epiglottic scarring (very rare)
• Chronic dysphagia (very rare)
• Voice changes (very rare)

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Evidence & Guidelines

Key Evidence

Epidemiology:

1. Shepherd et al. demonstrated adult peak incidence 35-39 years (0.97-1.8 per 100,000), 2.5× higher than children post-Hib vaccination. [PMID: 14700569] [1]
2. Berger et al. showed rising adult incidence from 0.88 (1986-1990) to 3.1 (1996-2000) per 100,000. [PMID: 14608569] [4]

Microbiology: 3. Isakson et al. demonstrated Streptococcus pneumoniae replacing H. influenzae as major adult pathogen. [PMID: 21106138] [6]

Clinical Presentation: 4. Guldfred et al. confirmed adult presentation is more gradual (days vs hours in children). [PMID: 17892608] [14] 5. Solomon et al. (Toronto Hospital series, 57 patients) showed intubation rate 30% in adults. [PMID: 9857318] [13]

Airway Management: 6. Bridwell et al. (2022 review) emphasized avoiding supine positioning and aggressive examination. [PMID: 35489220] [9] 7. Pineau et al. identified intubation decision criteria based on clinical and endoscopic data. [PMID: 33358682] [16]

Guidelines

No Formal National Guidelines Exist for Adult Epiglottitis

Management is based on:

• Expert consensus
• Extrapolation from paediatric guidelines
• Case series and retrospective studies
• Anaesthetic society difficult airway guidelines

Relevant Guidance:

• Difficult Airway Society (DAS) guidelines for unanticipated difficult intubation [10]
• Society for Airway Management recommendations
• Local hospital protocols for ENT emergencies

Levels of Evidence

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Special Situations

Epiglottitis in Immunocompromised Patients

Risk Factors:

• HIV/AIDS (CD4 less than 200)
• Chemotherapy
• Solid organ transplant
• Immunosuppressive therapy (e.g., biologics)

Considerations:

• Atypical organisms (fungi - Candida, viruses - HSV) [15]
• More severe, prolonged course
• Higher risk of abscess formation
• Broader antibiotic cover may be required

Epiglottitis in Diabetic Patients

Considerations:

• Higher incidence [13]
• Slower resolution
• Optimize glycaemic control
• Monitor for complications

Pregnancy

Management Considerations:

• Avoid teratogenic agents (chloramphenicol)
• Ceftriaxone safe in pregnancy [11]
• Anaesthetic challenges (airway oedema, aspiration risk)
• Multidisciplinary team (ENT, anaesthetics, obstetrics)

Recurrent Epiglottitis

Rare but Reported:

• Investigate for immunodeficiency
• Consider chronic granulomatous disease
• Rule out anatomical abnormality
• Consider prophylactic Hib vaccination

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Patient & Family Information

What is Acute Epiglottitis?

Acute epiglottitis is a serious infection and swelling of the epiglottis - the small flap of tissue at the back of your throat that prevents food and drink going into your windpipe. When the epiglottis becomes infected and swollen, it can partially or completely block your airway, making it difficult to breathe. This is a medical emergency requiring immediate hospital treatment.

Symptoms to Watch For

• Severe sore throat (often described as the "worst sore throat ever")
• Difficulty and pain swallowing (odynophagia)
• Drooling (unable to swallow your saliva)
• Muffled voice (sounding like you have a "hot potato" in your mouth)
• Fever
• Difficulty breathing or noisy breathing (stridor)
• Sitting forward and leaning to help breathing

Seek Emergency Care Immediately If:

• You have severe sore throat with difficulty breathing
• You are drooling and cannot swallow
• You have stridor (noisy breathing)

What Causes Epiglottitis?

Epiglottitis is usually caused by bacteria, most commonly:

• Streptococcus pneumoniae (pneumococcus)
• Staphylococcus aureus
• Haemophilus influenzae type B (less common now due to childhood vaccination)

How is it Diagnosed?

• Clinical assessment by doctors (your symptoms and examination findings)
• Flexible nasendoscopy (a thin flexible camera passed through your nose to look at your throat) - this is the gold standard test
• Lateral neck X-ray may show a "thumb sign" (swollen epiglottis)
• Blood tests to check for infection

Important: You will NOT have your throat examined with a tongue depressor as this can worsen the swelling and obstruct your airway completely.

Treatment

Airway Management

The most important aspect of treatment is protecting your airway. You will be:

• Kept sitting upright (lying flat makes breathing harder)
• Monitored closely in ICU or High Dependency Unit
• Given oxygen to help breathing
• Some patients may need a breathing tube (intubation) if the airway becomes severely narrowed - this is usually temporary (24-72 hours)

Antibiotics

• You will receive intravenous (IV) antibiotics (through a drip) to treat the bacterial infection
• Commonly used: ceftriaxone
• Duration: 7-10 days total (first few days IV, then switch to oral tablets when improving)

Steroids

• Dexamethasone injection to reduce swelling in your throat

Supportive Care

• IV fluids if you cannot drink
• Pain relief (paracetamol)
• Monitoring (oxygen levels, heart rate, breathing rate)

What to Expect

Hospital Stay:

• Most patients stay 3-7 days if not intubated
• 5-10 days if breathing tube required

Recovery Timeline:

• 24-48 hours: Fever should settle, pain improves
• 48-72 hours: Able to swallow again
• 5-7 days: Discharge from hospital (if uncomplicated)
• 2-4 weeks: Full recovery

Prognosis:

• With prompt treatment, > 99% of patients recover fully
• Most people have no long-term problems after epiglottitis

Questions to Ask Your Doctor

1. Do I need a breathing tube (intubation)?
2. How long will I need to stay in hospital?
3. What bacteria caused my infection?
4. When can I start eating and drinking again?
5. Are there any long-term complications?
6. Should I have any vaccinations to prevent this in future?

When to Seek Further Help

After discharge, contact your doctor or return to hospital if:

• Fever returns
• Difficulty swallowing recurs
• Breathing becomes difficult again
• Severe pain not controlled by painkillers

Prevention

• Haemophilus influenzae type B (Hib) vaccination (routine in children; may be offered to high-risk adults)
• Pneumococcal vaccination (recommended for over-65s and high-risk groups)
• Good hand hygiene
• Avoid smoking

Resources

• NHS Epiglottitis Information
• ENT UK Patient Information
• British Lung Foundation - Airway Problems

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Examination Focus

MRCP PACES / Clinical Exam Scenarios

Station 5: Clinical Scenarios / Emergency Management

Scenario 1: Acute Presentation

"A 45-year-old man presents to the Emergency Department with severe sore throat, difficulty swallowing, and drooling. He is sitting forward and appears distressed. His oxygen saturations are 93% on room air. Please assess and manage."

Candidate Approach:

1. Immediate Assessment (ABC):

   • Recognize potential airway emergency
   • Keep patient sitting upright
   • Avoid aggressive examination
   • Call for senior help (ENT, anaesthetist)

2. History (Brief, Focused):

   • Duration of symptoms
   • Progression (rapid vs gradual)
   • Ability to swallow
   • Stridor, respiratory distress
   • Past medical history (diabetes, immunocompromise)
   • Medications

3. Examination (SAFE):

   • General inspection (tripod position, drooling, stridor)
   • Voice assessment (muffled "hot potato" voice)
   • Gentle neck examination (anterior tenderness)
   • DO NOT examine throat with tongue depressor
   • Respiratory assessment (rate, SpO₂, respiratory distress)

4. Differential Diagnosis:

   • Epiglottitis (most likely)
   • Peritonsillar abscess
   • Retropharyngeal abscess
   • Ludwig's angina
   • Angioedema

5. Investigations:

   • Flexible nasendoscopy (by ENT)
   • Blood tests (FBC, CRP, blood cultures)
   • Lateral soft tissue neck X-ray (if SAFE)
   • Do NOT send patient for CT if airway threatened

6. Management:

   • Airway: Senior ENT + anaesthetist; prepare for emergency intubation
   • Antibiotics: IV ceftriaxone 2 g
   • Steroids: IV dexamethasone 10 mg
   • Oxygen: Supplemental oxygen (nasal prongs)
   • Monitoring: ICU/HDU admission; continuous SpO₂
   • Nebulised adrenaline: If stridor (temporary measure)
   • Prepare for intubation: Awake fibreoptic intubation if airway deteriorates

Examiner Questions:

Q: Why do you not examine the throat with a tongue depressor? A: Aggressive examination can precipitate laryngospasm and complete airway obstruction in a patient with supraglottic swelling. The epiglottis is not visible on routine oral examination anyway - diagnosis is clinical and confirmed by flexible nasendoscopy.

Q: What is the "thumb sign" on X-ray? A: The "thumb sign" is seen on lateral soft tissue neck X-ray. The swollen, oedematous epiglottis appears thickened and rounded, resembling a thumb, in contrast to the normal thin epiglottis which resembles a little finger.

Q: How would you intubate this patient? A: The preferred technique is awake fibreoptic intubation (AFOI) performed by the most senior anaesthetist available, with an ENT surgeon scrubbed and ready for emergency surgical airway. The patient is kept sitting upright, given topical anaesthesia (nebulised lidocaine) and minimal sedation, and a flexible bronchoscope is used to visualize the larynx and railroad an endotracheal tube. This maintains spontaneous ventilation and avoids the risk of complete obstruction that can occur with muscle relaxation.

Q: What organisms cause adult epiglottitis? A: The microbiology has changed since Hib vaccination. Adults are now more commonly infected with Streptococcus pneumoniae, Staphylococcus aureus, and Group A Streptococcus, rather than Haemophilus influenzae type B which was historically the predominant organism in children.

Q: What are the indications for intubation? A: Absolute indications include stridor at rest with respiratory distress, SpO₂ less than 90% despite oxygen, altered mental status, inability to protect the airway, and rapid progression despite medical therapy. Intubation rates in adults are 10-30%, lower than historical paediatric rates, as adult airways are larger and can tolerate more oedema.

Viva Voce: Acute Airway Management

Examiner: "Tell me about the differences between adult and paediatric epiglottitis."

Candidate Answer:

Examiner: "What are the key safety principles when managing a patient with suspected epiglottitis?"

Candidate Answer:

1. Do NOT examine throat aggressively - may precipitate complete obstruction
2. Keep patient sitting upright - lying flat worsens obstruction
3. Do NOT agitate patient - distress worsens obstruction
4. Call for senior help early - consultant anaesthetist and ENT
5. Prepare for emergency airway - difficult airway trolley, surgical airway kit
6. Do NOT leave patient unattended - potential for rapid deterioration
7. Investigations must NOT delay treatment - if airway threatened, proceed directly to intubation

FRCA / Anaesthetics Exam

Scenario: Difficult Airway Management

"You are called to see a 50-year-old man in the Emergency Department with suspected epiglottitis. He is sitting forward, drooling, and has stridor. SpO₂ is 91% on 15L oxygen. Discuss your management."

Candidate Approach:

1. Initial Assessment:

   • This is a critically threatened airway
   • Summon senior help (consultant anaesthetist, ENT surgeon)
   • Do NOT attempt to lay patient flat
   • Prepare for emergency airway management

2. Preparation:

   • Difficult airway trolley
   • Surgical airway equipment (scalpel bougie cricothyroidotomy kit)
   • Flexible bronchoscope
   • Range of ETT sizes (may need smaller tube due to oedema)
   • Video laryngoscope

3. Team:

   • Most senior anaesthetist available (consultant)
   • ENT surgeon scrubbed for emergency surgical airway
   • Theatre ODP/nurse
   • ICU bed booked

4. Intubation Plan:

   Plan A: Awake Fibreoptic Intubation (AFOI)

   • Patient sitting upright initially
   • Topical anaesthesia: nebulised lidocaine 4%, nasal lidocaine
   • Antisialagogue: glycopyrrolate 200 mcg IV
   • Minimal sedation: titrated midazolam 0.5-1 mg (avoid over-sedation)
   • Fibreoptic scope (nasal or oral route)
   • Railroadendotracheal tube over scope
   • Confirm placement (CO₂, auscultation)

   Plan B: Inhalational Induction

   • Sevoflurane inhalational induction (sitting upright if possible)
   • Maintain spontaneous ventilation (DO NOT paralyse)
   • Attempt direct/video laryngoscopy
   • Intubate under vision

   Plan C: Cannot Intubate, Cannot Ventilate (CICV)

   • Emergency surgical airway
   • Scalpel cricothyroidotomy (ENT surgeon performs)

5. Post-Intubation:

   • ICU ventilation
   • IV antibiotics (ceftriaxone 2 g OD)
   • IV dexamethasone (10 mg, then 4 mg 6-hourly)
   • Daily nasendoscopy to assess resolution
   • Extubation when afebrile 24-48 hours + positive cuff leak test

Examiner: "Why not use muscle relaxation?" A: Muscle relaxation may cause complete airway collapse in a patient with critical supraglottic obstruction. The oedematous epiglottis can completely obstruct the laryngeal inlet when muscle tone is lost. Maintaining spontaneous ventilation throughout is safer, allowing the patient to maintain their own airway until it is definitively secured.

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References

Systematic Reviews & Key Literature

1. Shepherd M, Kidney E. Adult epiglottitis. Accid Emerg Nurs. 2004;12(1):28-30. PMID: 14700569 DOI: 10.1016/s0965-2302(03)00067-5

2. Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Adult epiglottitis. Am J Emerg Med. 2022;57:14-20. PMID: 35489220 DOI: 10.1016/j.ajem.2022.04.018

3. Westerhuis B, Bietz MG, Lindemann J. Acute epiglottitis in adults: an under-recognized and life-threatening condition. S D Med. 2013;66(8):309-11, 313. PMID: 24175495

Epidemiology

4. Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol. 2003;24(6):374-83. PMID: 14608569 DOI: 10.1016/s0196-0709(03)00083-8

5. Solomon P, Weisbrod M, Irish JC, Gullane PJ. Adult epiglottitis: the Toronto Hospital experience. J Otolaryngol. 1998;27(6):332-6. PMID: 9857318

6. Isakson M, Hugosson S. Acute epiglottitis: epidemiology and Streptococcus pneumoniae serotype distribution in adults. J Laryngol Otol. 2011;125(4):390-3. PMID: 21106138 DOI: 10.1017/S0022215110002446

7. Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010;120(6):1256-62. PMID: 20513043 DOI: 10.1002/lary.20921

Diagnosis

8. Ducic Y, Hebert PC, MacLachlan L, Neufeld JD, et al. Description and evaluation of the vallecula sign: a new radiologic sign in the diagnosis of adult epiglottitis. Ann Emerg Med. 1997;30(1):1-6. PMID: 9209213 DOI: 10.1016/s0196-0644(97)70102-7

Clinical Presentation & Management

9. Acevedo JL, Lander L, Choi S, Shah RK. Airway management in pediatric epiglottitis: a national perspective. Otolaryngol Head Neck Surg. 2009;140(4):548-51. PMID: 19328345 DOI: 10.1016/j.otohns.2008.12.037

10. Crumley RL. Airway management in croup and epiglottitis. West J Med. 1977;126(3):184-9. PMID: 349884 [PMC Free Article]

11. Lazoritz S, Saunders BS, Bason WM. Management of acute epiglottitis. Crit Care Med. 1979;7(6):285-90. PMID: 446064 DOI: 10.1097/00003246-197906000-00008

12. Sawyer SM, Johnson PD, Hogg GG, Robertson CF, Oppedisano F, MacIness SJ, Gilbert GL. Successful treatment of epiglottitis with two doses of ceftriaxone. Arch Dis Child. 1994;70(2):129-32. PMID: 8129435 [PMC Free Article] DOI: 10.1136/adc.70.2.129

13. Guardiani E, Bliss M, Harley E. Adult epiglottitis: trends, predictors, and management. Am J Otolaryngol. 2012;33(1):14-18. PMID: 21296444 DOI: 10.1016/j.amjoto.2010.12.002

14. Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122(8):818-23. PMID: 17892608 DOI: 10.1017/S0022215107000473

15. Luhana M, Karim J. The Adult Epiglottitis Enigma: A Case Report. Cureus. 2023;15(12):e49984. PMID: 38179346 [PMC Free Article] DOI: 10.7759/cureus.49984

Airway Management & Intubation

16. Pineau PM, Gautier J, Pineau A, Emam N, Laccourreye L, Boucher S. Intubation decision criteria in adult epiglottitis. Eur Ann Otorhinolaryngol Head Neck Dis. 2021;138(5):329-332. PMID: 33358682 DOI: 10.1016/j.anorl.2020.12.001

17. Ramawad HA, Seatherton R, Chineme J. Adult Epiglottitis as an Often Overlooked, Life-threatening Condition Requiring Special Airway Consideration; a Case Report. Arch Acad Emerg Med. 2024;12(1):e69. PMID: 39296522 [PMC Free Article] DOI: 10.22037/aaem.v12i1.2351

Complications

18. van Vugt R, van Leeuwen HJ, Tjan DH, van Zanten AR. Negative pressure pulmonary oedema. Eur J Anaesthesiol. 2007;24(12):1057-8. PMID: 18210657 DOI: 10.1017/s0265021507000555

Guidelines & Reviews

19. Benjamin B. Acute epiglottitis. Ann Acad Med Singap. 1991;20(5):696-9. PMID: 1781658

20. Wurtele P. Acute epiglottitis in children and adults: a large-scale incidence study. Otolaryngol Head Neck Surg. 1990;103(6):902-8. PMID: 2126123 DOI: 10.1177/019459989010300603

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