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Epiglottitis
Other namesAcute supraglottitis
Neck X-ray showing thumbprint sign
SpecialtyOtolaryngology
SymptomsTrouble swallowing, drooling, changes to the voice, fever, increased breathing rate, stridor[1][2]
Usual onsetRapid[1][2]
CausesH. influenzae type b, burns, trauma to the area[1]
Diagnostic methodMedical imaging, looking at the epiglottis[3][1]
PreventionHib vaccine, rifampin[4][5]
TreatmentEndotracheal intubation, intravenous antibiotics, corticosteroids[1][2][4]
Prognosis5% risk of death[3]
Frequency~2 per 100,000 per year[1][6]

Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe).[7] Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate.[1][2] As the epiglottis is in the upper airway, swelling can interfere with breathing.[7] People may lean forward in an effort to open the airway.[1] As the condition worsens, stridor and bluish skin may occur.[1]

Epiglottitis was historically mostly caused by infection by H. influenzae type b (commonly referred to as "Hib").[1] Following the introduction of the Hib vaccine, pediatric cases of epiglottitis fell from 3.47 cases per 100,000 children in 1980 to 0.63 cases in 1990[8] such that it is now more often caused by other bacteria, most commonly Streptococcus pneumoniae, Streptococcus pyogenes, or Staphylococcus aureus.[1] Predisposing factors include burns and trauma to the area.[1] The most accurate way to make the diagnosis is to look directly at the epiglottis.[3] X-rays of the neck from the side may show a "thumbprint sign" but the lack of this sign does not mean the condition is absent.[1]

An effective vaccine, the Hib vaccine, has been available since the 1980s.[4] The antibiotic rifampicin may also be used to prevent the disease among those who have been exposed to the disease and are at high risk.[5] The most important part of treatment involves securing the airway, which is often done by endotracheal intubation.[1] Intravenous antibiotics such as ceftriaxone and possibly vancomycin or clindamycin is then given.[2][4] Corticosteroids are also typically used.[1] With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent.[3]

With the use of the Hib vaccine, the number of cases of epiglottitis has decreased by more than 95%.[9] Historically, young children were mostly affected, but it is now more common among older children and adults.[4] In the United States, pediatric cases of epiglottitis fell from 3.47 cases per 100,000 children in 1980 to 0.63 cases in 1990 following the introduction of the Hib vaccinae,[8] and it now affects about 1.3 per 100,000 children a year.[1] In adults, between 1 and 4 per 100,000 are affected a year.[6] It occurs more commonly in the developing world.[10] In children the risk of death is about 6%; however, if they are intubated early, it is less than 1%.[5]

Signs and symptoms

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Epiglottitis is associated with fever, throat pain, difficulty in swallowing, drooling, hoarseness of voice, and stridor.[11] Onset is typically over a day.[11] The throat itself may appear normal.[11]

Drawing (left image) and CT scan (right image) of the normal pharynx as a cross-section viewed from the side (sagittal view), including the normal epiglottis (orange arrow), opening to the esophagus (yellow arrow), and opening to the trachea (blue arrow). An infected epiglottis becomes swollen and causes issues with swallowing, speaking, and breathing due to its proximity to the esophagus and trachea. Other labeled structures include the tongue (pink arrow) and vertebral bodies of the cervical spine (grey arrow).

Stridor is a sign of upper airway obstruction and is a surgical emergency. The child often appears acutely ill, anxious, and will have very quiet shallow breathing often keeping the head held forward and insisting on sitting up in bed, commonly called the "tripod position."[12] The early symptoms are usually insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.[13]

Adults commonly present with less dramatic breathing symptoms than children due to them having wider airways to begin with, so their main symptoms are usually a severe sore throat and difficulty swallowing.[12] The back of the throat appears normal in 90% of adult patients, so epiglottitis should considered when there is pain out of proportion to exam or when pain is caused by pressing on the external windpipe.[12] Adult epiglottitis is often referred to as supraglottitis. In contrast to children, the symptoms are non-specific, sub-acute and can be unpredictable.[14]

Causes

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Epiglottitis is primarily caused by an acquired bacterial infection of the epiglottis.[1] Historically it was most often caused by Haemophilus influenzae type B, but with the availability of immunization this is no longer the case.[1] H. influenzae type B contains a capsule which helps it avoid being destroyed by macrophages and also contains surface proteins that allow it to stick to the lining of the upper respiratory tract.[15] Presently, the bacteria most often causing infection are other encapsulated organisms including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus.[1] These bacteria spread in respiratory droplets or aerosols produced from coughing and sneezing.[16][17] While the overall incidence of epiglottitis has decreased, the incidence of cases caused by Streptococcus pneumoniae has increased in adults.[18] The exact strains of Streptococcus pneumoniae are often those that are covered by the PPV-23 vaccine,[18] but there is no evidence that this vaccine prevents epiglottitis.

There have been many cases of epiglottitis reported in immunocompromised patients, including those undergoing cancer treatment and those who are HIV positive.[19] While a variety of different bacteria can cause disease in these patients, cases often involve the Candida species of fungus, though it is unknown if the fungus causes significant disease on its own.[19]

Alternate risk factors and causes associated with infection include burns and other trauma to the area.[1] Medical research has also identified a link between epiglottitis and crack cocaine usage.[20] Underlying disorders of the immune system, such as graft-versus-host disease and lymphoproliferative disorders, have also been identified as contributors of increased risk for developing the infection .[4]

Diagnosis

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Diagnosis may be confirmed by direct inspection using a laryngoscope, although this may provoke airway spasm.[21] If epiglottitis is suspected, attempts to visualize the epiglottis using a tongue depressor are discouraged for this reason; therefore, diagnosis is made on basis of indirect fiberoptic laryngoscopy carried out in a controlled environment like an operating room.[21] An infected epiglottis appears swollen and is described as having a "cherry-red" appearance.[22] Imaging is rarely useful, and treatment should not be delayed for this test to be carried out.[21]

  • CT imaging showing the "halloween sign"
    CT imaging showing the "halloween sign"
  • Left column: Normal epiglottis. Right column: Epiglottitis.
    Left column: Normal epiglottis. Right column: Epiglottitis.
  • Swollen epiglottis in laryngoscopy
    Swollen epiglottis in laryngoscopy
  • Normal appearance of epiglottis (label 3) as seen on laryngoscopy
    Normal appearance of epiglottis (label 3) as seen on laryngoscopy

Imaging

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On lateral C-spine X-ray, the thumbprint sign describes a swollen, enlarged epiglottis.[11] A normal X-ray, however, does not exclude the diagnosis.[11] An ultrasound may be helpful if specific changes are present, but its use (as of 2018) is in the early stages of study.[11]

On CT imaging, the "Halloween sign" describes an epiglottis of normal thickness. It can safely exclude the acute epiglottitis. Furthermore, CT imaging can help to diagnose other conditions such as peritonsillar abscess or retropharyngeal abscess which have similar clinical features.[23]

Necrotizing epiglottitis

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If there is visual or radiologic evidence that the infection has caused tissue destruction, the disease is called "necrotizing epiglottitis" (NE).[24] The feared complication of NE is the bacteria spreading to the surrounding neck muscles and causing cervical necrotizing fasciitis which is a surgical emergency.[24]

Differential diagnosis

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The differential diagnosis includes other infectious causes of acute airway obstruction, as well as acute or subacute mechanical causes. It includes, but is not limited to, the conditions below.[25][26]

Prevention

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An effective vaccine, the Hib vaccine, has been available since the 1980s.[4] Modern Hib vaccines are mainly conjugate vaccines, with the key component being the polysaccharide found in the bacteria's capsule which is its primary virulence factor.[27] Currently, the CDC recommends that children receive a two or three-dose primary series with an additional booster dose.[28] The countries of the world who have included the Hib vaccine in their immunization schedules typically begin the series at the age of two or three months with subsequent doses administered at four or eight week intervals.[29] Routine vaccination in these nations has led to a dramatic decrease in the incidence of invasive diseases caused by H. influenzae type b such as epiglottitis, meningitis and pneumonia.[29] It has been reported that epiglottitis cases have decreased by 95% since the 1980s following the introduction of the first Hib vaccine.[9]

The antibiotic rifampicin may also be used to prevent the disease among those who have been exposed to the disease and are at high risk.[5][22]

Management

[edit]

The most important part of treatment involves securing the airway.[1] Nebulized epinephrine may be useful to improve the situation temporarily.[11] Corticosteroids are also typically used.[1] However, there is poor evidence for whether steroids actually improve patient outcomes.[11] Epiglottitis may require urgent tracheal intubation to protect the airway.[1] Tracheal intubation can be difficult due to distorted anatomy and profuse secretions. Spontaneous respiration is ideally maintained until tracheal intubation is successful.[11] A surgical airway opening (cricothyrotomy) may be required if intubation is not possible.[11] The management of epiglottitis is different in adults compared to children.[14] Emergent tracheal intubation with general anesthesia (inhalational induction to preserve spontaneous ventilation) in the operating theater is standard.[14] However only 10% of adults require airway intervention, which means a selective approach is required.[14] Tracheal intubation is a high risk scenario with a 1 in 25 failure rate in adults.[14] Multiple airway management techniques have described for adults and include: awake tracheostomy, awake fibreoptic intubation, general anesthesia with spontaneous breathing preserved or ablated with paralysis.[14] The optimal technique is controversial and likely determined by contextual factors such as the severity of epiglottitis and the clinical location (ie emergency department or intensive care or the operating room).[14] Ideally airway intervention should occur in the operating room with an otolaryngology surgeon present to perform an emergency tracheostomy in the event of complete airway obstruction or failed intubation.[14]

Intravenous antibiotics such as ceftriaxone and possibly vancomycin or clindamycin are given once the airway is secure.[2][4] A third-generation cephalosporin such as ceftriaxone is usually sufficient since it is usually effective against H. influenzae and S. pneumoniae.[30] If S. aureus is suspected to be causing the disease, then the treatment should include ceftaroline or clindamycin as these would provide coverage against antibiotic resistant strains of that bacteria (MRSA).[30] Vancomycin can also be considered for its MRSA coverage, but it may be less safe than ceftaroline in children older than two months.[30] If the patient has a penicillin allergy, trimethoprim/sulfamethoxazole, clindamycin, or levofloxacin may be appropriate choices.[30][12]

Necrotizing epiglottitis is treated similarly to uncomplicated epiglottitis, but usually requires intubation in addition to standard IV antibiotic therapy.[24] If the tissue damage continues to spread and necrotizing fasciitis of the neck is suspected, patients are taken to the operating room for emergency debridement.[24]

Prognosis

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With appropriate treatment, the risk of death among children with the condition is about one percent and among adults is seven percent.[3] Elsewhere, it has been reported that only one percent of adults diagnosed with epiglottitis die from the disease.[12] Some people may develop pneumonia, lymphadenopathy, or septic arthritis.[31]

Between 1998 and 2006, there were an average of 36 deaths per year in the United States attributed to epiglottitis, giving a case-fatality rate of 0.89% during that time period.[32]

Patients who recover from necrotizing epiglottitis often regain their ability to swallow foods and liquids despite the tissue damage.[24]

Epidemiology

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While, historically, young children were mostly affected, it is now more common among older children and adults.[4] Before Haemophilus influenzae (Hib) immunization children of two to four were most commonly affected.[1] With immunization about 1.3 per 100,000 children are affected a year.[1] It has been reported that only 0.5 per 100,000 American children are diagnosed every year, while the incidence in American adults is about 1 to 4 per 100,000.[12] A 2010 retrospective study revealed the average age of patients admitted to American hospitals for epiglottitis was about 45, but patients under the age of 1 and over the age of 85 are also particularly vulnerable.[32]

Notable cases

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References

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Epiglottitis

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Epiglottitis is a rare but potentially life-threatening inflammation of the epiglottis—the flap of cartilage that covers the windpipe (trachea) during swallowing—and adjacent supraglottic structures in the upper throat, often caused by bacterial infection and leading to swelling that can obstruct the airway. Historically, epiglottitis primarily affected unvaccinated children under age 5, with over 90% of cases caused by Haemophilus influenzae type b (Hib), but widespread Hib vaccination since the 1980s has reduced pediatric incidence by more than 95% in vaccinated populations. In recent decades, the condition has become more common in adults, with an estimated annual incidence of 1 to 4 cases per 100,000 adults in developed countries (based on studies through the 2020s), often due to pathogens such as Haemophilus influenzae, Streptococcus species (including group A and pneumoniae), Staphylococcus aureus, or anaerobes. Risk factors in adults include diabetes mellitus, alcohol abuse, immunosuppression, and smoking, which impair local defenses and increase susceptibility. Symptoms typically onset abruptly over hours, beginning with high fever, severe (odynophagia), and painful swallowing (), progressing to drooling from inability to swallow saliva, muffled voice (dysphonia), , and respiratory distress. Affected individuals, especially children, often assume a characteristic —sitting forward with neck extended and hands on knees—to optimize airflow and relieve obstruction. Without intervention, swelling can cause complete airway closure, hypoxia, and death within hours. Diagnosis relies on clinical suspicion due to the urgency of airway protection; direct visualization via fiberoptic reveals a cherry-red, swollen , while lateral neck X-rays may show the classic "thumbprint sign" but are avoided if they delay care. cultures and swabs guide but are secondary to stabilization. Treatment prioritizes securing the airway through or, rarely, in severe cases, followed by empiric intravenous antibiotics (e.g., or ) targeting common , with steroids sometimes used to reduce . Hospitalization in an is standard, and most patients recover fully within 1–2 weeks with appropriate therapy, though mortality remains 1–5% in adults due to airway complications. Prevention centers on Hib vaccination for children, with adults at risk advised to maintain up-to-date immunizations against pneumococcus and .

Background

Definition

Epiglottitis is an acute inflammatory condition characterized by rapid swelling of the and adjacent supraglottic structures, which can obstruct the airway and pose a life-threatening risk if untreated. The functions as a protective flap covering the windpipe during swallowing to direct food toward the . This inflammation typically progresses swiftly, often over hours, leading to potential respiratory compromise. The condition is classified primarily as infectious, with bacterial etiologies being the most common, though viral and fungal infections can also cause it. Non-infectious forms arise from causes such as trauma, including injuries or caustic ingestion. In the post-vaccine era, non-infectious cases, including autoimmune and idiopathic etiologies, have become more relatively prominent due to the decline in bacterial infections. Allergic reactions, such as , may occasionally contribute to similar supraglottic swelling. Historically, epiglottitis was a major pediatric emergency, predominantly affecting children aged 2 to 5 years due to type b infections, with high mortality rates before modern interventions. The introduction of the in the late 1980s led to a dramatic decline in pediatric cases, reducing incidence by over 99% in vaccinated populations. Consequently, adult cases have become more prominent, often involving different pathogens like species. The term supraglottitis is frequently used interchangeably, particularly to describe the broader involvement of supraglottic tissues in adults.

Anatomy of the Epiglottis

The is a leaf-shaped structure composed primarily of , providing flexibility essential for its role in protecting the airway. It is located at the superior aspect of the , projecting posterosuperiorly behind the tongue base, posterior to the and anterior to the laryngeal inlet. The narrow, stem-like base, known as the petiolus or stalk, attaches to the midline of the inner surface of the via the thyroepiglottic , while its free superior edge and lateral margins connect to the aryepiglottic folds, which extend to the arytenoid cartilages. Additionally, indirect attachments via the hyoepiglottic link it to the , facilitating coordinated movement during . The surface of the is covered by a that varies by region to accommodate its exposure to food and air. The anterior (lingual) surface and the apical portion of the posterior (laryngeal) surface are lined with non-keratinized , offering protection against mechanical abrasion from swallowed materials. In contrast, the lower posterior surface transitions to ciliated , typical of the , which supports . Beneath the lies a rich in elastic fibers and minor salivary glands, surrounding the central core that imparts resilience and shape. Blood supply to the epiglottis arises mainly from the superior laryngeal artery, a of the , which nourishes the supraglottic region including the epiglottis and adjacent mucosa. Venous drainage follows the thyroid veins into the . Sensory innervation of the epiglottic mucosa is provided by the internal branch of the (cranial nerve X), which supplies the area above the vocal folds, ensuring reflex responses to protect the airway. Motor control of associated muscles, such as the aryepiglottic muscles, is mediated by the , also from the .

Pathophysiology

Inflammatory Mechanisms

Epiglottitis is typically initiated by bacterial invasion of the epiglottic mucosa, such as by Haemophilus influenzae (including nontypeable strains), Streptococcus species, or Staphylococcus aureus, which colonizes the nasopharynx and spreads locally to trigger an acute immune response. This invasion leads to the activation of resident immune cells, such as macrophages and epithelial cells, resulting in the release of proinflammatory cytokines including tumor necrosis factor-alpha (TNF-α) and interleukin-1β (IL-1β). These cytokines induce vasodilation and enhance vascular permeability in the mucosal tissues, facilitating fluid extravasation and the initial formation of edema. Bacterial components, such as endotoxins like (LPS) from (e.g., H. influenzae) or exotoxins and components from , play a critical role in amplifying the inflammatory process by directly stimulating production from immune and epithelial cells. This activation promotes the recruitment and infiltration of neutrophils and other inflammatory cells into the epiglottic tissues, increasing local inflammation and contributing to tissue swelling. The inflammatory response begins as localized in the supraglottic region, characterized by diffuse of the , aryepiglottic folds, and adjacent structures. As and signaling intensifies, along with ongoing cellular infiltration, the process progresses rapidly to supraglottic , with marked swelling that can compromise the loose connective tissues of the area. This progression reflects the robust lymphatic drainage and of the , which accelerate the spread of . Rarely, non-bacterial triggers such as thermal injury from inhaling hot or exposure to caustic substances can initiate analogous inflammatory mechanisms through direct epithelial damage, prompting release and immune cell recruitment that culminate in . In these cases, the initial tissue or ulceration serves as the nidus for a secondary inflammatory cascade similar to that seen in infectious etiologies.

Airway Obstruction Development

Epiglottitis progresses to airway obstruction through escalating stages of inflammatory swelling in the supraglottic region, as outlined in Friedman's classification system for respiratory distress. In the initial mild stage (stage I), develops in the without compromising airway patency, allowing normal ventilation despite the onset of . As the condition advances to the moderate stage (stage II), partial narrowing occurs due to accumulating , though significant airflow limitation remains absent, marking the transition from non-obstructive to potentially restrictive pathology. Further progression to severe stages (stages III and IV) involves substantial supraglottic swelling that reduces the glottic —the critical narrow point in the upper airway—leading to turbulent airflow, heightened respiratory effort, and risk of complete occlusion. This biomechanical compromise increases negative intrathoracic pressure during inspiration, exacerbating through fluid shifts and potentially culminating in hypoxia and if the inflammatory response, often triggered by bacterial invasion, is unchecked. Several factors accelerate this obstructive progression, notably in young children where proportionally smaller airway diameters amplify the impact of even modest , causing rapid compared to adults. Additionally, assuming a can intensify dependent in the , hastening airway closure due to gravitational effects on swollen tissues. In advanced cases, histopathological alterations such as deposition of fibrinous on the mucosal surface and localized tissue further distort the epiglottic structure, promoting adherence of inflammatory debris and worsening luminal narrowing. These changes reflect severe suppurative responses in bacterial epiglottitis, contributing to the potential for irreversible airway compromise.

Clinical Presentation

Signs and Symptoms in Children

Epiglottitis in children typically presents with a classic tetrad of symptoms including sudden-onset high fever, severe , accompanied by , and tripod positioning where the child leans forward with the neck extended and mouth open to maintain airway patency. These manifestations arise rapidly, often progressing within hours to a few days, reflecting the acute inflammatory swelling of the . Respiratory distress is a hallmark, featuring inspiratory due to partial airway obstruction, along with intercostal and suprasternal retractions as the child labors to breathe; in advanced stages, may develop as hypoxia worsens. Prior to widespread type b (Hib) vaccination, the condition most commonly affected children aged 2 to 7 years, with peak incidence around 3 years, though incidence has since declined dramatically. Behavioral cues further indicate distress, such as refusal to lie down because positioning exacerbates airway compromise, heightened anxiety with a toxic appearance, and a muffled "hot potato" voice resulting from painful phonation and pharyngeal .

Signs and Symptoms in Adults

Epiglottitis in adults typically presents with a more insidious onset compared to children, often developing over several days rather than hours, allowing for a potentially delayed recognition of the condition. The most common initial symptoms include (painful swallowing), which affects nearly all cases, along with and a that progressively worsens. Voice changes, such as dysphonia or a muffled "hot potato" voice, occur in over half of patients and may accompany these pharyngeal complaints. Fever is frequently present, though it may be low-grade in some instances, contributing to the subacute progression. Respiratory symptoms in adults are generally less dramatic than in children due to larger airway dimensions, with being uncommon but hoarseness and dyspnea possible as the advances. Throat often radiates to the ears, exacerbating discomfort during swallowing or speaking. Systemic manifestations include and or tenderness, which can mimic other upper respiratory infections and further delay . Adults face a higher of complications such as epiglottic formation, which can intensify local and swelling. Certain atypical features are associated with adult epiglottitis, particularly in individuals with risk factors like or , which may lead to postponed seeking of medical care due to the subtle initial symptoms. These comorbidities can exacerbate the inflammatory response and contribute to a more protracted course.

Signs Requiring Immediate Emergency Medical Attention

Individuals experiencing symptoms suggestive of epiglottitis should seek immediate emergency medical care if breathing becomes increasingly difficult or gasping; if there is difficulty swallowing, drooling, or slurred speech; if breathing sounds become more prominent, especially high-pitched inspiratory stridor; if there is a persistent high fever, severe throat pain, or chest tightness; or if symptoms rapidly worsen within hours. These signs indicate potential airway compromise and require urgent evaluation to prevent life-threatening complications.

Etiology and Risk Factors

Primary Causes

Epiglottitis is primarily caused by bacterial infections, with Haemophilus influenzae type b (Hib) historically being the predominant in children prior to widespread vaccination. In the pre-vaccine era, over 90% of pediatric cases were attributed to Hib, a gram-negative bacterium that leads to acute of the . Following the introduction of the in the 1980s and 1990s, there has been a significant shift in , particularly after the 2000s, with non-typeable H. influenzae (NTHi) emerging as a more common cause alongside other bacteria such as , , , and anaerobes. In adults, these streptococcal species, S. aureus, and anaerobes are frequently implicated, reflecting a broader of pathogens in vaccinated populations. Non-bacterial causes are rare but include viral infections such as varicella-zoster virus, fungal pathogens like Candida species in immunocompromised individuals, and traumatic injuries from procedures like or . Bacterial transmission typically occurs through respiratory droplets from coughing or sneezing by infected individuals, particularly in unvaccinated or closely exposed populations.

Predisposing Factors

Epiglottitis susceptibility is heightened by various immunological deficiencies that impair the body's ability to combat bacterial infections. Lack of against type b (Hib) significantly increases risk, particularly in unvaccinated populations where invasive Hib disease, including epiglottitis, remains prevalent. , whether functional or anatomic, compromises immune clearance of encapsulated bacteria like Hib, elevating the incidence of epiglottitis among affected individuals. Similarly, infection weakens host defenses, leading to a higher rate of invasive Hib-related illnesses such as epiglottitis. Demographic characteristics also play a key role in predisposing individuals to epiglottitis. In the pre-Hib vaccine era, children aged 2 to 4 years experienced the peak incidence of the condition, with rates estimated at 13 per 100,000 in this group due to immature immunity and exposure patterns. Among adults, middle-aged males, particularly those of Caucasian descent, show a higher , often compounded by factors. Environmental influences contribute to epiglottitis risk through increased bacterial exposure and seasonal patterns. Close contact with infected individuals, such as in household crowding or childcare settings, facilitates transmission of causative agents, amplifying susceptibility. Cases tend to peak during winter months, correlating with higher rates of respiratory infections that may serve as entry points for pathogens. Certain comorbidities further predispose individuals by altering local defenses or . A recent upper respiratory often precedes epiglottitis, providing a nidus for bacterial in the . In adults, additional factors like diabetes mellitus, impair and increase tissue propensity, while and suppress mucosal immunity and promote bacterial adherence.

Diagnosis

Clinical Assessment

The clinical assessment of suspected epiglottitis prioritizes rapid, non-invasive evaluation to identify airway compromise while minimizing manipulation that could exacerbate obstruction. History taking focuses on the acute onset of symptoms, typically within 24 to 48 hours, including high fever, severe , , and , which are reported in over 90% of cases. Patients may describe a prodromal upper respiratory , progressive difficulty handling secretions leading to , and voice changes such as a muffled or "hot potato" quality. A thorough oropharyngeal examination is contraindicated at the bedside in unstable patients, as it risks inducing and complete airway closure; instead, the history guides suspicion toward epiglottitis in those with rapid progression and absence of , which differentiates it from other upper airway illnesses. Physical examination emphasizes and external observation to gauge distress without internal airway inspection. , ( often exceeding 30 breaths per minute in children), and fever above 39°C are common, reflecting and compensatory efforts. External signs include a toxic or anxious appearance, tripod positioning with neck extension, use of accessory respiratory muscles, and inspiratory in up to 50% of cases; gentle anterior cervical may reveal tender . The patient should remain in a position of comfort, and any agitation avoided to prevent . Red flags signaling imminent airway threat include inability to swallow oral secretions (manifesting as drooling), severe respiratory distress with retractions or , and altered mental status from hypoxia. These warrant immediate airway intervention over further diagnostic maneuvers. Clinical severity is assessed based on , external signs of distress, and the presence of red flags to guide urgency. If the patient is stable, lateral radiography may be referenced briefly for confirmation, but only after securing the airway.

Imaging Techniques

Lateral neck radiography serves as the primary imaging modality for confirming suspected epiglottitis in hemodynamically stable patients, allowing visualization of epiglottic swelling without invasive procedures. The lateral view classically reveals the "thumb sign," characterized by a thickened, rounded epiglottis projecting posteriorly from the anterior pharyngeal wall, often measuring greater than 7 mm in anteroposterior diameter in adults. This technique is indicated when clinical suspicion is high but direct laryngoscopy is not immediately feasible, aiding in rapid bedside or emergency department assessment. However, it is contraindicated in unstable patients, as the required neck extension and positioning can precipitate airway compromise or distress. Computed tomography (CT) of the neck with intravenous contrast is reserved for evaluating potential complications, such as abscess formation or extension into adjacent spaces, particularly in cases refractory to initial therapy or with atypical presentations. Key findings include diffuse hypodensity within the edematous epiglottis and aryepiglottic folds, with possible rim-enhancing fluid collections indicating , often accompanied by pre-epiglottic space obliteration. Contrast enhancement helps delineate vascularized inflammatory tissue from necrotic or purulent areas, with sensitivity approaching 100% for detecting supraglottic involvement. (MRI) offers superior soft-tissue resolution for similar complications but is infrequently used due to longer acquisition times and limited availability in acute settings. Bedside ultrasound has emerged as a noninvasive, radiation-free alternative for assessing supraglottic , particularly in pediatric or emergency contexts where may be challenging. Transverse and longitudinal views of the reveal a hypoechoic, thickened exceeding 3 mm in anteroposterior dimension, sometimes described as the "alphabet P sign" due to the curved shape of the swollen structure. This modality enables quick, serial evaluations at the point of care, with high accuracy in detecting comparable to direct visualization. Despite their utility, imaging techniques carry limitations that must be weighed against diagnostic benefits. from X-rays and CT poses cumulative risks, especially in children, where even low-dose exposures can contribute to long-term effects. Additionally, radiographic studies require patient cooperation for optimal positioning, which may be impossible in agitated or young individuals, potentially leading to nondiagnostic images. These factors underscore the need for imaging to be performed only after initial clinical assessment confirms stability.

Differential Diagnosis

Epiglottitis must be differentiated from other conditions presenting with acute upper airway obstruction, , or to ensure prompt and accurate management. Common airway emergencies that mimic epiglottitis include , bacterial tracheitis, and . Croup, typically viral and affecting the subglottic region, often occurs in younger children (aged 6 months to 3 years) with a more gradual onset over days and a characteristic barking , contrasting with the rapid progression and in epiglottitis. Bacterial tracheitis presents with a toxic appearance, high fever, and productive due to purulent secretions, differentiating it from the nonproductive and supraglottic focus of epiglottitis. Foreign body aspiration is suggested by a history of sudden , particularly in toddlers, and may cause asymmetric breath sounds or unilateral findings on , unlike the symmetric of epiglottitis. Nonemergent conditions such as and can simulate epiglottitis but are distinguished by localized features. typically causes unilateral and with deviation of the , often in older children or adolescents. is associated with posterior , , and bulging of the posterior pharyngeal wall, commonly in younger children under 5 years. Key diagnostic discriminators include patient age (epiglottitis now more frequent in adults post-vaccination), the speed of symptom onset (hours in epiglottitis versus days in ), and absence of response to racemic epinephrine, which improves symptoms in but worsens or has no effect in epiglottitis due to its supraglottic location. Rare mimics such as and involve rapid-onset swelling without fever or , often linked to allergen exposure or use, and lack the infectious etiology of epiglottitis. Lateral neck radiographs may briefly aid distinction, revealing the classic thumbprint sign in epiglottitis versus the in .

Management

Airway Protection

Airway protection is the cornerstone of managing epiglottitis, as progressive swelling of the and surrounding structures can lead to complete airway obstruction, a life-threatening . The primary goal is to secure a airway rapidly while minimizing manipulation that could exacerbate . In both children and adults, is indicated in cases of severe respiratory distress, such as , retractions, , or inability to handle oral secretions, with approximately 10% of adult cases requiring intervention despite overall declining rates.00129-6/fulltext) Procedures should occur in a controlled environment, ideally an operating room (OR) with an experienced anesthesiologist and otolaryngologist () specialist present to facilitate immediate surgical backup if needed. Intubation techniques prioritize gentle, atraumatic approaches to avoid precipitating total obstruction. Orotracheal or nasotracheal intubation is preferred, often performed under controlled conditions with spontaneous ventilation maintained until the airway is secured; fiberoptic bronchoscopy may be employed for visualization in difficult cases, particularly in adults where allows. Direct should be minimized to prevent epiglottal trauma, and rapid sequence intubation is generally avoided due to the risk of loss of airway patency. If fails despite these measures, emergency surgical airways are essential: provides immediate access via incision through the cricothyroid membrane, while tracheostomy offers a more definitive route, especially in pediatric patients where limits cricothyrotomy feasibility. Following successful , post-intubation care focuses on maintaining airway stability and patient comfort to reduce the risk of accidental extubation. Sedation with agents like or is administered to minimize agitation and coughing, which could dislodge the tube, while continuous monitoring ensures adequate ventilation and oxygenation. The endotracheal tube is typically left in place for 48-72 hours or until resolves, confirmed by flexible , after which extubation is attempted in a controlled setting. Once the airway is protected, antibiotic therapy is initiated to address the underlying .

Antibiotic Therapy

Antibiotic therapy is a cornerstone of epiglottitis management, targeting the underlying bacterial infection once airway stability has been ensured. Empiric intravenous antibiotics are typically administered promptly after obtaining blood and epiglottic cultures to cover common pathogens such as Haemophilus influenzae type b (Hib), Streptococcus species, and other gram-positive and gram-negative organisms. The recommended first-line regimen includes a third-generation cephalosporin, such as ceftriaxone (1-2 g IV every 24 hours) or cefotaxime (1-2 g IV every 6-8 hours), which provides broad-spectrum coverage including Hib. For patients with penicillin or allergies, alternative regimens are necessary to avoid while maintaining coverage against potential pathogens. In such cases, a combination of (15-20 mg/kg IV every 8-12 hours) and clindamycin (600-900 mg IV every 8 hours) is often used, providing activity against gram-positive organisms including methicillin-resistant Staphylococcus aureus (MRSA) and some anaerobes. Other options include a fluoroquinolone like levofloxacin (750 mg IV daily) combined with clindamycin for broader coverage in severe allergies. In adults, where polymicrobial infections involving anaerobes are more common due to potential aspiration or oral involvement, regimens should include anaerobic coverage. inhibitor combinations, such as ampicillin-sulbactam (1.5-3 g IV every 6 hours) or piperacillin-tazobactam (3.375-4.5 g IV every 6 hours), are preferred for in this population to address beta-lactamase-producing anaerobes alongside aerobes. Therapy duration is generally 7-10 days, with guided by culture results and clinical improvement to minimize resistance and side effects. The use of adjunctive corticosteroids, such as low-dose dexamethasone (4-10 mg IV bolus followed by 4 mg every 6 hours), remains controversial for reducing airway in epiglottitis. While some guidelines suggest it may help in select cases with significant , evidence is limited, and it is not routinely recommended due to potential risks of masking symptoms or delaying .36175-5/fulltext)

Supportive Interventions

Supportive interventions for epiglottitis focus on maintaining physiological stability, alleviating discomfort, and facilitating recovery alongside primary treatments such as antibiotics. Oxygen therapy is a cornerstone, with supplemental humidified oxygen delivered via face mask or nasal cannula to maintain oxygen saturation above 92-94% and prevent hypoxemia, particularly in patients with respiratory distress but without immediate airway compromise. Continuous pulse oximetry monitoring is essential during administration to guide adjustments and detect early desaturation. Hydration and are managed conservatively to address and reduce aspiration risk. Intravenous fluids, typically isotonic solutions like normal saline or lactated Ringer's, are administered to maintain euvolemia and support metabolic needs, especially in children or adults unable to safely. If is prolonged and oral intake remains restricted, a nasogastric tube may be placed for enteral to provide calories and prevent , though this is done cautiously to avoid further airway irritation. Pain management aims to control throat discomfort and fever without compromising respiratory function. Acetaminophen is preferred for mild to moderate pain and antipyresis, dosed at 10-15 mg/kg every 4-6 hours in children or 650-1000 mg every 6 hours in adults, as it avoids the respiratory depression associated with opioids. Opioids such as morphine may be used sparingly for severe pain (e.g., 0.05-0.1 mg/kg IV), but only under close supervision to minimize sedation risks. All patients require intensive monitoring in an ICU setting for at least 24-48 hours, regardless of intubation status, to allow for rapid response to deterioration. Serial clinical examinations, including assessment and indirect every 4-6 hours, track epiglottal swelling resolution and guide of care. This vigilant observation, combined with antibiotic therapy, supports overall recovery and reduces complication rates.

Prevention

Vaccination

The type b (Hib) serves as the primary strategy for preventing epiglottitis, which was historically a leading cause of invasive Hib in children. The standard recommends a primary series administered at 2, 4, and 6 months of age, followed by a at 12 to 15 months. This regimen has demonstrated efficacy greater than 95% in reducing invasive Hib , including epiglottitis, through the induction of robust immune memory against the bacterial capsule. The introduction of Hib conjugate vaccines in the late 1980s and their widespread adoption in routine childhood programs during the led to a dramatic decline in pediatric epiglottitis cases, with incidence rates dropping by over 90% in children under 5 years in vaccinated populations. Prior to vaccination, epiglottitis accounted for a significant portion of Hib-related hospitalizations, but post-vaccination has shown near-elimination of Hib-associated cases in immunized communities. For at-risk groups, catch-up vaccination is recommended, particularly for unvaccinated older children and adults with conditions such as functional or anatomic , including those with or undergoing . In these individuals, a single dose of is advised to provide protection against invasive disease. While the Hib vaccine targets the predominant pathogen, other vaccines offer partial cross-protection against non-Hib causes of epiglottitis. Pneumococcal conjugate vaccines reduce the risk from , a common alternative , by covering serotypes associated with supraglottic infections. Similarly, meningococcal vaccines may mitigate cases linked to , though their role remains supplementary to Hib . For adults at risk, such as those with , , or history, maintaining up-to-date pneumococcal (PCV15, PCV20, or PCV21 followed by PPSV23 if indicated) and annual is recommended to lower the risk of bacterial superinfections following viral illnesses that can lead to epiglottitis.

Hygiene and Prophylaxis

Hygiene practices play a crucial role in preventing the transmission of bacterial pathogens that cause epiglottitis, particularly through droplet spread. Regular handwashing with soap and water for at least 20 seconds, especially after contact with respiratory secretions or contaminated surfaces, reduces the risk of infection. Respiratory etiquette, such as covering the mouth and nose with a tissue or elbow when coughing or sneezing and promptly disposing of tissues, further minimizes the dispersal of infectious droplets. Using alcohol-based hand sanitizers when soap is unavailable provides an additional barrier against pathogen transfer. Prophylactic antibiotics are recommended for close contacts of individuals diagnosed with epiglottitis due to type b (Hib) to eradicate nasopharyngeal carriage and prevent secondary cases. Rifampin, administered orally at 20 mg/kg per day (maximum 600 mg) for four days, is the standard regimen for household members and other intimate contacts, including children under 4 years and adults in high-risk settings. This chemoprophylaxis has demonstrated high efficacy in reducing invasive Hib disease risk among treated contacts, with studies showing eradication of carriage in over 95% of recipients. Avoiding throat irritants and promptly treating upper respiratory infections (URIs) can help mitigate the risk of epiglottitis, especially in susceptible populations. is advised, as tobacco smoke irritates the upper airway and may exacerbate leading to epiglottic swelling. Early intervention for URIs, including hydration, , and over-the-counter analgesics to manage symptoms, prevents bacterial that could progress to epiglottitis. In contexts, such as daycare centers, outbreak management involves coordinated rifampin prophylaxis for all classroom contacts of an to interrupt transmission chains. Enhanced hygiene protocols, including surface disinfection and exclusion of symptomatic children until cleared by a healthcare provider, are implemented to contain spread in these high-density environments. While the remains the primary preventive measure against Hib-related epiglottitis, these non-immunological strategies complement it by addressing environmental and contact-based risks.

Prognosis and Outcomes

Short-term Prognosis

With prompt recognition and appropriate followed by antibiotic therapy, the for epiglottitis is less than 1% in children and approximately 7% in adults. Historically, prior to the use of artificial airways and antibiotics, mortality rates approached 100%, reflecting the high risk of airway obstruction without intervention. In adults, the elevated mortality risk stems from factors such as delayed and comorbidities, underscoring the need for rapid intervention. Patients typically show clinical improvement within 48 to 72 hours of and supportive care, with full resolution of symptoms often occurring within one week. Early is a critical factor in achieving favorable short-term outcomes, as it minimizes the incidence of complications like hypoxia or secondary infections. Conversely, diagnostic delays heighten the risk of asphyxiation, potentially leading to emergent airway compromise. Successful short-term recovery is gauged by extubation criteria, including the presence of an air leak around the deflated endotracheal tube cuff, resolution of fever, and alleviation of or , often confirmed via nasolaryngoscopy. Discharge planning typically follows 4 to 7 days of hospitalization, contingent on clinical stability and completion of an initial course, with mean stays around 4 days in uncomplicated cases.

Long-term Complications

While epiglottitis is typically managed successfully with prompt intervention, long-term complications can arise in a minority of cases, primarily due to the need for or the severity of the initial obstruction. One potential airway sequela is , resulting from trauma associated with or tracheostomy during acute treatment. This narrowing of the subglottic region occurs due to scar tissue formation and , with reported cases following epiglottitis , though the overall incidence remains low with short intubation durations typical in epiglottitis, reported at up to 11% in broader post- pediatric studies. Infectious complications may persist or recur post-recovery, including recurrent episodes of epiglottitis or residual scarring from associated abscesses. Recurrent acute infectious epiglottitis has been documented in approximately 4.2% of cases, often linked to underlying immune factors or incomplete resolution of initial , potentially leading to chronic supraglottic changes such as scar tissue that impairs or increases susceptibility to future infections. Epiglottic abscesses, a known extension of untreated epiglottitis, can leave fibrotic scars that contribute to long-term airway irregularities if not fully drained. Neurological effects are rare but severe, primarily manifesting as hypoxic brain injury from prolonged airway obstruction leading to oxygen deprivation before medical intervention. In pediatric cases, this can result in permanent deficits such as cognitive impairment or motor delays, with isolated reports of survivors experiencing lasting neurological damage following cardiorespiratory arrest. Such outcomes underscore the critical need for rapid airway securing to prevent cerebral hypoxia. Psychological impacts, particularly anxiety disorders, may affect survivors, especially children who endure the traumatic acute phase involving intensive care and airway procedures. While specific data on epiglottitis is limited, the intense fear and helplessness during obstruction can contribute to post-traumatic stress symptoms or heightened anxiety around and medical settings in the long term, as observed in broader studies of pediatric airway emergency survivors.

Epidemiology

Global Incidence

Prior to the introduction of the type b ( in the late 1980s, epiglottitis occurred at rates of 2 to 5 cases per 100,000 children annually in developed countries, primarily affecting those under 5 years old and caused predominantly by Hib. Following widespread Hib vaccination, pediatric incidence declined dramatically to less than 0.5 cases per 100,000 children per year in regions with high coverage, reflecting the vaccine's efficacy in preventing Hib-related invasive disease. In unvaccinated or low-vaccination regions, such as parts of where Hib vaccine uptake remains limited, epiglottitis rates have persisted at higher levels than in vaccinated areas. incidence, unaffected by childhood Hib vaccination, has remained stable or shown a slight increase, ranging from 0.7 to 3.2 cases per 100,000 adults per year, often due to other pathogens like species. As of 2025, epiglottitis cases among children in vaccinated populations have become minimal, with the disease shifting predominantly to adults in high-income countries, where and other streptococci now account for the majority of infections, potentially linked to post-pandemic increases in group A activity. This highlights the success of Hib while emphasizing the need for surveillance of non-Hib etiologies globally.

Demographic Variations

Epiglottitis exhibits a bimodal age distribution, with peaks among toddlers aged 2 to 6 years and adults over 40 years, while cases are rare in infants under 1 year and adolescents. In recent years, the condition has become three times more common in adults than in children due to the protective effect of type b (Hib) vaccination on pediatric populations, resulting in a mean adult age at of approximately 45 years. There is a slight male predominance in epiglottitis cases, with a male-to-female of about 1.5:1, particularly evident in adult patients. Geographically, epiglottitis incidence is higher in regions with low Hib coverage, such as developing countries, where pediatric cases remain more prevalent compared to vaccinated high-income nations. Socioeconomic factors can exacerbate risk in underserved populations through barriers to and increased exposure. This overall decline in incidence from is most pronounced in high-resource settings, underscoring the role of equitable access in demographic patterns.

History

Pre-vaccination Era

In the late 19th and early 20th centuries, epiglottitis emerged as a frequent and lethal pediatric condition, often ranking among the leading causes of acute supraglottic airway obstruction and in young children. Primarily affecting children aged 2 to 4 years, it was characterized by rapid of the and adjacent supraglottic structures, leading to severe respiratory distress and if untreated. of the era documented it as a major infectious threat, with cases frequently reported in hospital records and findings as a "frequent pediatric killer" due to its swift progression and limited therapeutic options. The incidence of epiglottitis in the pre-vaccination period was substantial, accounting for up to 15 cases per 100,000 children under 5 years annually in regions with reliable surveillance, and representing 10 to 20% of all invasive type b (Hib) infections, which themselves caused thousands of severe illnesses yearly. Mortality rates were alarmingly high, ranging from 20 to 50% in untreated cases or those without timely airway intervention such as , as the swelling could cause complete obstruction within hours. Even with , fatality approached 25% due to complications like secondary infection or procedural risks. Hib, the predominant etiologic agent, was first isolated in the 1890s—specifically in 1892 by Richard Pfeiffer during an outbreak—though its role in epiglottitis was not fully elucidated until later bacteriological studies in the mid-20th century. Vaccines against Hib were not developed until the 1970s and 1980s, with the first vaccine licensed in 1985 and conjugate versions following shortly thereafter, marking the beginning of effective prevention. Treatment in the pre-antibiotic era relied heavily on non-pharmacologic measures and surgical urgency, evolving from passive observation and symptomatic relief—such as steam inhalation or positioning to ease breathing—to aggressive airway management. Early approaches emphasized close monitoring in a controlled environment, but recognition of the imminent risk of asphyxia led to tracheotomy as the cornerstone intervention, performed in up to 30% of cases to bypass the obstructed supraglottis. This procedure, though lifesaving, carried significant morbidity, including hemorrhage, infection, and long-term scarring, and was often delayed due to diagnostic challenges or limited surgical access. The absence of antibiotics meant that supportive care, including hydration and fever control, provided minimal benefit against the underlying bacterial invasion, underscoring the high stakes of the condition before antimicrobial therapy became available in the 1940s.

Notable Cases

One of the most historically significant cases of epiglottitis is that of , the first , who died on December 14, 1799, at age 67 after a rapid onset of throat infection following exposure to cold weather. Contemporary accounts and modern analyses describe symptoms including sore throat, hoarseness, and difficulty breathing, consistent with acute bacterial epiglottitis caused by , which led to airway obstruction and despite and other period treatments. This case underscores the lethality of untreated epiglottitis in the pre-antibiotic era, with Washington's death occurring within 24 hours of symptom onset. In modern times, comedian Sarah Silverman experienced a severe episode of epiglottitis in June 2016, initially dismissed as a minor sore throat but progressing to life-threatening airway swelling that required five days in intensive care at Cedars-Sinai Medical Center. She described the condition as a "freak case" involving inflammation of the epiglottis cartilage, treated with intubation and antibiotics, highlighting the risks of delayed diagnosis in adults where symptoms can mimic less severe infections. Similarly, television host Jeannie Mai was hospitalized in November 2020 with epiglottitis, forcing her withdrawal from Dancing with the Stars and necessitating emergency surgery to secure her airway after symptoms of throat pain and swelling emerged suddenly. Her case, managed with surgical intervention and antibiotics, emphasized the potential for rapid deterioration even in otherwise healthy adults, with full recovery following weeks of rehabilitation. During the COVID-19 pandemic in the 2020s, several documented cases linked epiglottitis to SARS-CoV-2 infection, often as a bacterial superinfection complicating viral illness. A 2021 case report detailed a patient with severe COVID-19 who developed acute epiglottitis post-extubation, presenting with hoarseness, dysphagia, and stridor, requiring urgent airway management to prevent obstruction. A systematic review of 14 such cases from 2020–2022 found common symptoms including sore throat, odynophagia, and dyspnea, with most involving adults and treatment via steroids, antibiotics, and intubation, illustrating how viral inflammation can predispose to secondary bacterial epiglottitis. These instances highlight the importance of vigilance for airway complications in COVID-19 patients, where delays in recognizing epiglottitis contributed to intensive care needs in over half of reported cases.

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