Epiglottitis is a life-threatening condition caused by inflammation of the epiglottis and aryepiglottic folds 1, which can lead to acute airway obstruction. Hence, treatment should be urgent and performed by appropriately trained individuals, e.g. instrumentation of the trachea should be performed by a senior or a trained anaesthetist.
The traditional age of presentation is in children of 3 to 6 years, although this has been changing due to the routine vaccination against Haemophilus influenzae type B (Hib) introduced in most countries.
Hib used to be the most common responsible organism but group A beta-hemolytic Streptococci is becoming more common due to Hib vaccinations 4.
The presentation has a very rapid course beginning with a sore throat and leading to difficulty swallowing and drooling. However, other presenting symptoms include:
- difficulty speaking
- muffling or changes in the voice
- inspiratory stridor
- severe dysphagia
Lateral radiograph demonstrates thickening of the epiglottis and aryepiglottic folds, referred to as the thumb sign. This is the radiographic corollary of the omega sign. Hypopharynx may be over-distended.
CT is only rarely obtained, and usually when the diagnosis is unclear. Indeed, placing the child in the supine position can actually precipitate respiratory arrest. If a scan is obtained, marked oedema and thickening of the epiglottis and aryepiglottic folds may be seen with narrowing of the airway.
Treatment and prognosis
Treatment must be expeditious given the life-threatening nature of the condition:
- patients should be kept upright in a comfortable position
- airway management with oxygen therapy
- early tracheal intubation by specialist staff: if ET tube placement is impossible because of an inflamed epiglottis, emergency needle cricotracheostomy may need to be performed
- IV fluids
- IV steroids and antibiotics
- subglottic narrowing and ballooning of hypopharynx
- no epiglottis thickening
- inhaled foreign bodies
- peritonsillar abscess
- usually clinical following tonsillitis
- asymmetric subglottic narrowing (intraluminal membranes)
- 1. Raj PP, Larard DG, Diba YT. Acute epiglottitis in children. A respiratory emergency. Br J Anaesth. 1969;41 (7): 619-27. doi:10.1093/bja/41.7.619 - Pubmed citation
- 2. Stuart MJ, Hodgetts TJ. Adult epiglottitis: prompt diagnosis saves lives. BMJ. 1994;308 (6924): 329-30. BMJ (link) - Free text at pubmed - Pubmed citation
- 3. Grover C. Images in clinical medicine. "Thumb sign" of epiglottitis. N. Engl. J. Med. 2011;365 (5): 447. doi:10.1056/NEJMicm1009990 - Pubmed citation
- 4. Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi journal of anaesthesia. 6 (3): 279-81. doi:10.4103/1658-354X.101222 - Pubmed