Epiglottitis
Epiglottitis, more accurately termed supraglottitis, refers to inflammation of the supraglottic structures, including the epiglottis. The term supraglottitis is increasingly preferred, particularly in adults, as inflammation often extends beyond the epiglottis.
This updated UKMLA guide to epiglottitis is based on ENT UK Guidelines which cover causes, symptoms, diagnosis, and management.
Causes
Most common cause (>90% of paediatric cases): Haemophilus influenzae type B [Ref]
Incidence has significantly reduced even since the introduction of the Hib vaccine into the routine childhood vaccination schedule.
Clinical Features
Epiglottitis typically affects young children (but can also affect adults) [Ref]
The hallmark of epiglottitis is the 3Ds: [Ref]
- Drooling
- Dysphagia
- Distress
Other features: [Ref]
- Sudden-onset fever
- Inspiratory stridor
- Toxic appearance
- Sore throat
- Severe anxiety and panic
- Patient sat in a tripod position (leaning forward while extending the neck)
- Signs of respiratory distress (e.g. intercostal / suprasternal retractions, tachypnoea, cyanosis)
Epiglottitis is life-threatening, as the severe swelling can cause airway obstruction, which can lead to asphyxia and respiratory arrest.
Investigation and Diagnosis
Epiglottitis should be diagnosed by clinical suspicion. [Ref]
Suspected epiglottitis is an airway emergency. Once suspected, the IMMEDIATE priority is securing the airway [Ref]
- DO NOT attempt to examine the throat
- Before the airway is secured, physical examination, imaging, and laboratory tests should NOT be performed, as it risks losing the patient’s airway
Only after the airway is secured, the following investigations may be performed: [Ref]
- Lateral neck radiograph
- Classic ‘thumb sign’ may be seen due to epiglottic swelling
- ~20% of lateral neck radiographs will fail to accurately diagnose epiglottis
- Note AP neck radiograph is normal in epiglottitis (abnormal in croup – Steeple sign) [Ref]
- Blood cultures and other laboratory tests
- Epiglottis cultures (can be performed during endotracheal intubation)
Management
Immediate step: seek urgent senior help (ENT or anaesthesia) to secure the airway
- Give oxygen therapy while preparing for airway management
- Move to resuscitation setting with continuous monitoring
- Definitive airway management: controlled endotracheal intubation
- If airway fails: emergency front-of-neck access (cricothyroidectomy / tracheostomy)
Other treatment (do NOT delay airway management):
- IV ceftriaxone +/- metronidazole
- Nebulised adrenaline
- IV dexamethasone
Key principles:
- Airway management is the immediate priority
- Once the airway is secured, IV antibiotics are the definitive treatment to eliminate the underlying infection
- Nebulised adrenaline and IV dexamethasone are adjuncts to reduce swelling
In practice, securing a definitive airway may take time, as it requires senior ENT and anaesthetic input in a controlled setting. Therefore, if there is high clinical suspicion, it is appropriate to initiate IV antibiotics and other adjuncts (nebulised adrenaline and IV dexamethasone) while awaiting airway management, provided this does NOT delay or compromise airway prioritisation.