Version May 2024
INTRODUCTION — The pathogenesis, etiology, and clinical features of epiglottitis (also called supraglottitis) will be reviewed here. The treatment and prevention of epiglottitis are discussed separately. (See "Epiglottitis (supraglottitis): Management".)
DEFINITION — Epiglottitis refers to inflammation of the epiglottis and adjacent supraglottic structures, primarily due to infection [1]. Without treatment, epiglottitis can progress to life-threatening airway obstruction. A rapid overview of the recognition and management of epiglottitis in children is provided in the table (table 1).
ANATOMY — The epiglottis forms the posterior wall of the vallecular space inserting at the base of the tongue (figure 1). It is connected by ligaments to the thyroid cartilage and hyoid bone and consists of a thin cartilage that is covered anteriorly by a stratified squamous epithelial layer. This squamous layer also covers the superior third of the posterior surface, where it merges with respiratory epithelium that extends into the larynx. The epithelium and lamina propria beneath are tightly adherent on the posterior (laryngeal) surface and loosely attached on the anterior (lingual) surface. This creates a potential space on the lingual surface for edema fluid to collect.
PATHOGENESIS — Epiglottitis is most frequently caused by infection, although caustic ingestion, thermal injury, and local trauma are important noninfectious etiologies. Infectious epiglottitis is a cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissues. It results from bacteremia and/or direct invasion of the epithelial layer by the pathogenic organism [2,3]. The posterior nasopharynx is the primary source of pathogens in epiglottitis. Microscopic trauma to the epithelial surface (eg, mucosal damage during a viral infection or from food during swallowing) may be a predisposing factor. Less frequently, noninfectious conditions cause local burns or ecchymosis of the epiglottis and adjacent structures.
For both infectious and noninfectious etiology, swelling of the epiglottis results from edema and accumulation of inflammatory cells in the potential space between the squamous epithelial layer and the epiglottal cartilage. The lingual surface of the epiglottis and periepiglottic tissues have abundant networks of lymphatic and blood vessels that facilitate spread of infection and the subsequent inflammatory response. Once infection begins, swelling rapidly progresses to involve the entire supraglottic larynx (including the aryepiglottic folds and arytenoids) [3,4]. The subglottic regions generally are not affected; swelling is halted by the tightly bound epithelium at the level of the vocal cords.
Supraglottic swelling reduces the caliber of the upper airway, causing turbulent airflow during inspiration (stridor) [3]. Additional mechanisms of airflow obstruction may include posterior and inferior curling of the epiglottis (which acts as a ball-valve, obstructing airflow during inspiration but permitting exhalation) and aspiration of oropharyngeal secretions [2,3].
Airway obstruction, which may result in cardiopulmonary arrest, can be rapidly progressive. The signs of severe upper airway obstruction (eg, stridor/stertor, intercostal and suprasternal retraction, tachypnea, and cyanosis) may be absent until late in the disease process, when airway obstruction is nearly complete [5,6]. Out-of-hospital respiratory arrests from acute airway obstruction, with ultimate death, have been reported in children and adults [7,8].
ETIOLOGY
Infectious — Epiglottitis may be caused by a number of bacterial, viral, and fungal pathogens (table 2):
●Bacterial pathogens – Bacterial pathogens are the most frequently identified infectious etiology for epiglottitis. Despite the rapid decline in infectious epiglottitis among immunized children in the post-conjugate vaccine era, Haemophilus influenzae type b (Hib) remains an important etiology, primarily in unvaccinated or incompletely immunized children. Furthermore, based upon small case series, Hib may still be isolated in fully immunized children and adults [9-13].
In addition to Hib, bacterial isolates from immunocompetent patients with epiglottitis also include:
•Staphylococcus aureus (including methicillin-resistant strains [14-16])
•Streptococcus pneumoniae [16,17]
•Streptococcus pyogenes and other streptococci [16,18,19]
•Neisseria meningitidis [16,20,21]
•Pasteurella multocida [16]
For immunocompromised hosts, in addition to the bacterial etiologies as above, isolates include Pseudomonas aeruginosa, Serratia spp, Enterobacter spp, and anaerobic flora.
●Viral pathogens – Viral infections may rarely cause epiglottitis or enable bacterial superinfection. Reported isolates in patients with epiglottitis include:
•Influenza, type a [22]
•Influenza, type b [23]
•Herpes simplex virus, types 1 and 2 [24-26]
•Parainfluenza virus, type 3 [23]
•Epstein-Barr virus [27]
•Human immunodeficiency virus (HIV) [28]
•SARS-CoV-2 [29-33]
●Fungal pathogens – Fungal infections (Candida species and Histoplasma capsulatum) as a cause of epiglottitis are rare and appear to primarily occur in immunocompromised patients [34-36]. A probable case of Candida epiglottitis in an apparently healthy child has been described [37].
Necrotizing epiglottitis may complicate upper airway infections and can be seen in immunocompromised hosts (including children [28,38]) and, rarely, in immunocompetent hosts [38,39].
Noninfectious — Epiglottitis can accompany smoke inhalation (see "Inhalation injury from heat, smoke, or chemical irritants"). Otherwise, noninfectious epiglottitis tends to be rare. Case reports and case series describe epiglottitis complicating the following conditions:
●Local airway trauma such as:
•Thermal injury from:
-Ingestion of hot beverages or food [40-43]
-E-cigarette use [44] or inhalation of heated objects during use of illicit drugs such as crack cocaine [45]
•Direct trauma to the epiglottis [46,47]
•Caustic ingestion or inhalation [47,48]
●Lymphoproliferative disease or graft-versus-host disease after bone marrow or solid organ transplantation [49-51]
●Chronic granulomatous disorders including polyangiitis, sarcoidosis, systemic lupus erythematosus, relapsing polychondritis, and immunoglobulin G4 (IgG4)-related disease [52,53]
Granulomatous involvement of the supraglottic airway, with progressive airway obstructive features over several months, has been described as the initial overt manifestation of Crohn disease in a case report [54].
EPIDEMIOLOGY — Since the introduction of vaccines against H. influenzae type b (Hib), epiglottitis has mostly become a disease observed in adults with an estimated annual incidence of 0.6 to 1.9 cases per 100,000 [16,55] and an overall mean age of 45 to 49 years [56,57] (see 'Infectious' above). Epiglottitis has been associated with a number of comorbid conditions, including hypertension, diabetes mellitus, end-stage kidney disease, substance abuse, and immune deficiency [58-64]. Furthermore, body mass index (BMI) >25, diabetes mellitus, concurrent pneumonia, and presence of an epiglottic cyst at admission appear to be factors associated with a greater severity of epiglottitis [65].
The annual incidence of epiglottitis among children has declined dramatically since the introduction of Hib vaccines, with the estimated annual incidence of Hib as low as two cases per 10 million children in populations with high rates of immunization [55,66-74]. In addition, as Hib has become a less frequent cause of epiglottitis in children, it has become more common among school-age children and adolescents than preschool children (<5 years of age) [9,75].
CLINICAL PRESENTATION — The clinical features of epiglottitis differ with age, severity, and etiology:
●Young children (<5 years of age) with H. influenzae type b (Hib) epiglottitis may present with respiratory distress, anxiety, and the characteristic "tripod" or "sniffing" posture (picture 1 and picture 2) in which they assume a sitting position with the trunk leaning forward, neck hyperextended, and chin thrust forward in an effort to maximize the diameter of the obstructed airway [6]. They may be reluctant to lie down [2]. However, the presentation may be subtle (picture 3). Drooling is often present. Cough is typically absent.
●Older children, adolescents, and adults with infectious or noninfectious epiglottitis may present with a severe sore throat, dysphagia, and drooling; a relatively normal oropharyngeal examination; and minimal respiratory distress.
Acute (fever and stridor) — Abrupt onset and rapid progression (within hours) of upper airway obstruction are hallmarks of bacterial epiglottitis due to Hib [6,76-80]. This classic presentation of Hib epiglottitis is rare but may still occur among young children (<5 years of age) in communities with large numbers of unimmunized patients. Acute presentations of epiglottitis with abrupt airway compromise may also occur with (see 'Etiology' above):
●Infections by other pathogens
●Thermal injury to the upper airway (eg, smoke inhalation, ingestion of hot beverages, or inhalation of heated objects during use of illicit drugs)
●Caustic ingestion or inhalation
Clinical findings of acute epiglottitis include [6,58,81]:
●Toxic appearance and distress (agitation, restlessness, irritability (picture 2))
●Sudden onset of high fever (between 38.8 and 40.0°C)
●Stridor
●Drooling
●Change in voice (muffled, "hot potato" voice)
●Severe sore throat and dysphagia
Patients with epiglottitis and impending complete airway obstruction may also assume the "tripod" posture (picture 1), a sitting position with the trunk leaning forward, neck hyperextended, and chin thrust forward in an effort to maximize the diameter of the obstructed airway.
Children with epiglottitis generally lack hoarseness of the voice or cough, which are more characteristic of croup. (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Clinical presentation'.)
Necrotizing epiglottitis occurs rarely and has been described in immunocompromised and immunocompetent children with a variety of associated microbial etiologies [82].
Subacute (severe sore throat) — Among immunized populations, infectious epiglottitis is caused by other oro- and nasopharyngeal bacterial pathogens including S. pneumoniae, S. pyogenes and other streptococci, S. aureus (including methicillin-resistant strains), and non-typable H. influenzae; Hib epiglottitis is much less common. In addition, rare cases of viral and fungal epiglottitis are described. (See 'Infectious' above.)
As a result, a subacute presentation of infectious epiglottitis predominates and consists of [5,55,58,83,84]:
●Progressively painful sore throat
●Low-grade fever
●Muffled ("hot potato") or hoarse voice
●Difficulty with swallowing
●Drooling
Stridor occurs in a minority of these patients. In addition, sudden airway obstruction is far less common but remains a possibility [56,85]. Thus, epiglottitis has become an important consideration in older children, adolescents, and adults seeking care for acute infectious pharyngitis. (See "Evaluation of acute pharyngitis in adults" and "Evaluation of sore throat in children".)
Rare noninfectious causes of subacute epiglottitis, predominantly seen in immunocompromised patients, include lymphoproliferative disease, graft-versus-host disease, chronic granulomatous disease, and necrotizing epiglottitis. (See 'Noninfectious' above.)
AIRWAY MANAGEMENT — For patients with signs of impending complete airway obstruction, securing the airway is the focus of treatment as described in the rapid overview (table 1). In these patients, airway management necessarily precedes diagnostic evaluation [3]. (See "Epiglottitis (supraglottitis): Management" and "Technique of emergency endotracheal intubation in children" and "Overview of advanced airway management in adults for emergency medicine and critical care".)
EXAMINATION — The approach to diagnosing epiglottitis, including which patients should undergo attempts at direct visualization, depend upon the patient's presentation and the clinician's suspicion for epiglottitis (algorithm 1).
Visualization of the epiglottis confirms the clinical diagnosis [13]; a soft-tissue lateral radiograph of the neck is an alternative approach that has reasonable sensitivity and specificity. (See 'Imaging' below.)
Signs of impending airway obstruction — There are rare reports of cardiorespiratory arrest in children with acute presentations of epiglottitis during attempts to visualize the epiglottis [86]. These arrests have been attributed to functional airway obstruction (resulting from increased respiratory effort secondary to increased anxiety), aggravation of airway obstruction caused by supine positioning, and/or laryngospasm.
Presumably, the patients who have arrested after visualization have had pre-existing, nearly complete obstruction. These patients would typically have fairly definitive signs of epiglottitis (eg, severe respiratory distress, anxiety, "sniffing" position (picture 2); signs of upper airway involvement, particularly stridor, drooling, or "tripod" posture (picture 1); and no cough). (See 'Acute (fever and stridor)' above.)
Emergency involvement of airway experts (eg, otolaryngologists and anesthesiologists with pediatric expertise) to evaluate and to secure the airway should occur prior to any attempts at visualization in these patients. (See 'Diagnostic confirmation' below.)
Severe sore throat — In patients with sore throat and drooling in whom epiglottitis is a possibility but for whom other diagnoses are also likely (table 3), cautious examination of the throat is appropriate to determine the best management. These patients should have [87]:
●Normal mental status
●Absent or minimal of stridor
●No or minimal increase in symptoms during agitation or exertion
●No cyanosis
The patient should be permitted to take a position of comfort in the upright position. Younger children may be held by the caregiver to reduce anxiety that could provoke increased respiratory distress. If the child develops increased respiratory distress during the attempt to examine the throat, this effort should be discontinued.
Use of a head lamp permits better visualization of oropharyngeal structures and facilitates more precise and gentler placement of the tongue blade during examination. On examination of the oral cavity and oropharynx in patients with epiglottitis, pooled secretions may be noted [3]. Occasionally, a swollen, red epiglottitis may be visible. The laryngotracheal complex may be tender on neck palpation, particularly in the region of the hyoid bone [88-90].
However, the oropharyngeal examination is normal in the majority of patients with epiglottitis [5,83,91]. When oropharyngeal examination fails to permit visualization of the epiglottis, clinicians may proceed to either plain radiography or laryngoscopy. (See 'Diagnostic confirmation' below.)
Nasolaryngoscopy, plain radiography, or visualization during direct laryngoscopy under general anesthesia in the operating room is frequently necessary to confirm the diagnosis. (See 'Diagnosis' below.)
DIAGNOSIS
Clinical suspicion — Epiglottitis typically presents in one of two ways:
●Progressive, severe sore throat over several days – Epiglottitis should be suspected in older children, adolescents, and adults in whom the severity of sore throat is out of proportion to the findings on oropharyngeal examination, particularly if significant dysphagia and drooling are present [5]. These patients are appropriate candidates for confirmation by direct visualization of the upper airway or soft-tissue radiograph of the lateral neck.
●Abrupt onset of fever, stridor, and respiratory distress over 24 hours – Acute epiglottitis with severe airway obstruction should be suspected in patients, especially those who are un- or under-immunized against H. influenzae type b (Hib), who present with the characteristic clinical features including:
•"Tripod" position (picture 1)
•Anxiety (picture 2)
•Sore throat
•Stridor
•Drooling
•Dysphagia
•Severe respiratory distress
Because of the potential for rapid progression to complete airway obstruction, the threshold for suspicion of epiglottitis should be low. These patients should undergo definitive airway management. Direct visualization should be avoided. Soft-tissue radiograph of the lateral neck (portable if possible) may be helpful, but necessary personnel and equipment to manage an acute airway event must remain with the patient at all times during the imaging process. Furthermore, imaging should not delay definitive airway management.
Diagnostic confirmation — The diagnostic approach to patients with suspected epiglottitis varies based upon clinical findings (algorithm 1).
Visualization of the epiglottis — Maintenance of the airway is the mainstay of treatment in patients with suspected epiglottitis. In patients with signs of total or near-total upper airway obstruction, airway control necessarily precedes diagnostic evaluation (algorithm 2), and confirmation is made by direct visualization. (See "Epiglottitis (supraglottitis): Management".)
Visualization of the epiglottis without performing endotracheal intubation should only be attempted in a setting where the airway can be secured immediately if necessary (eg, the emergency department, intensive care unit, or operating room) and, whenever possible, by the appropriate airway experts (eg, anesthesiology and otolaryngologist or airway expert with similar expertise). Methods include fiberoptic nasolaryngoscopy and/or indirect laryngoscopy with a 70-degree endoscope [87,92,93].
Examination findings that confirm epiglottitis include inflammation and edema of the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoid cartilages) (picture 4 and picture 5) [5]. The false vocal cords may also be involved [83]. Estimated airway obstruction of ≥50 percent is an indication for endotracheal intubation or establishment of a surgical airway.
Imaging
Plain radiographs — Soft-tissue lateral neck radiographs can confirm the diagnosis of epiglottitis but are not necessary in many cases in which the likelihood of epiglottitis is sufficiently low (eg, immunized children with a hoarse voice and characteristic cough of croup), such that no imaging is indicated, or high, in which case direct visualization during airway management in the operating suite is preferred.
Radiographs are most helpful in the evaluation of patients in whom epiglottitis is a possibility, but other conditions are more likely (table 3) [94] (see 'Differential diagnosis' below). Diagnosis may also be confirmed by radiography if direct visualization appears unsafe or is unsuccessful. Radiographs should be deferred if they increase the patient's level of anxiety or will delay definitive airway management [58,72]. If it is necessary for the patient with more than a low likelihood of epiglottitis to be transported to the radiology department (ie, if portable radiographs cannot be obtained), the patient must be accompanied by personnel skilled with advanced airway management and with proper equipment and medications. (See 'Visualization of the epiglottis' above.)
Radiographic features of epiglottitis include [2,95]:
●An enlarged epiglottis protruding from the anterior wall of the hypopharynx (the "thumb sign", (image 1 and image 2)). In adults with epiglottitis, the width of the epiglottis is usually >8 mm [96].
●Loss of the vallecular air space, a finding that may be underappreciated.
●Thickened aryepiglottic folds (image 2). In adults with epiglottitis, the width of the aryepiglottic folds is usually >7 mm [96].
●Distended hypopharynx (nonspecific).
●Straightening or reversal of the normal cervical lordosis (nonspecific).
Based upon case series in adults, lateral neck films are abnormal (generally showing the classic "thumb sign") in 77 to 88 percent of patients with epiglottitis [13,59]. False-negative radiographic findings appear to be more common when patients have received prior oral antimicrobial therapy [97]. If radiographs are negative or equivocal, but clinical suspicion for epiglottitis remains high, then the provider should proceed with visualization during airway management (patients with signs of severe upper airway obstruction) or fiberoptic nasolaryngoscopy and/or indirect laryngoscopy in a setting where the airway can be secured immediately. (See 'Visualization of the epiglottis' above.)
Ultrasonography — Bedside ultrasound evaluation of the epiglottis in adults has been described, but its role in diagnosing epiglottitis is unclear [98,99]. The ultrasonographic appearance of epiglottitis in adults has been described as an "alphabet P sign" formed by an acoustic shadow of the swollen epiglottis and hyoid bone at the level of the thyrohyoid membrane when imaged in longitudinal orientation [98]. An evaluation of ultrasound in 15 adults with epiglottitis and 15 healthy controls found that an increased anteroposterior diameter of the epiglottis at either lateral edge may also discriminate between those with and without epiglottitis. The lower limit of the diameter in adults with epiglottitis was 3.6 versus 3.2 mm upper limit in the controls [100]. No pediatric experience with ultrasound has as yet been reported.
Laboratory studies — Laboratory studies should not be performed in young children with imminent complete airway obstruction until the airway is secured because agitation caused by pain may worsen respiratory distress and precipitate sudden respiratory arrest.
In older children, adolescents, and adults with suspected epiglottitis, laboratory evaluation includes:
●Complete blood count with differential
●Blood culture
●In intubated patients, epiglottal culture
Most patients with epiglottitis have an elevated white blood cell count [5], but this finding is nonspecific.
The yield of blood and epiglottal cultures is discussed below. (See 'Microbiology' below.)
The immunologic evaluation for a child who develops Hib epiglottitis or pneumococcal epiglottitis despite having been immunized is discussed separately. (See "Epiglottitis (supraglottitis): Management", section on 'Additional evaluation'.)
Microbiology — The etiologic diagnosis is sometimes made by culture of a pathogenic organism from the blood or the surface of the epiglottis.
Blood and epiglottic cultures should be obtained after the airway is secure [6,88]. Swabbing the epiglottis is difficult, potentially dangerous, and contraindicated in patients who are not intubated [72,101].
Epiglottal cultures are positive in 33 to 75 percent of patients with epiglottitis [83,84,101,102].
Blood cultures are positive in approximately 70 percent of children with epiglottitis caused by Hib [103]. In children immunized against Hib, the yield of blood cultures is likely lower. In adult case series, the yield of blood cultures ranges from 0 to 17 percent [5].
DIFFERENTIAL DIAGNOSIS — Epiglottitis is an important consideration in older children, adolescents, and adults seeking care for sore throat as discussed separately. (See "Evaluation of acute pharyngitis in adults" and "Evaluation of sore throat in children".)
The diagnostic approach (algorithm 3) and emergency evaluation of acute upper airway obstruction in children are discussed separately. (See "Emergency evaluation of acute upper airway obstruction in children".)
In young children (<5 years of age), the differential diagnosis of epiglottitis includes other causes of acute upper airway obstruction (table 3):
●Croup – Epiglottitis is distinguished from croup by the absence of "barking" cough and the presence of anxiety and drooling. Children with croup generally are comfortable in the supine position and have a normal-appearing epiglottis, when visualized, on examination. If obtained, lateral neck radiographs in patients with croup may demonstrate distention of the hypopharynx during inspiration, subglottic haziness, and a normal epiglottis (image 3). (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Clinical presentation'.)
●Bacterial tracheitis – Bacterial tracheitis may be a complication of viral laryngotracheitis (croup) or a primary bacterial infection. Primary bacterial tracheitis may present with acute onset of upper airway obstruction, fever, and toxic appearance, similar to epiglottitis. However, radiographs may demonstrate intraluminal membranes and irregularities of the tracheal wall, as well as a normal epiglottis and supraglottic region (image 4). Direct tracheoscopy may be necessary for diagnosis (picture 6). (See "Bacterial tracheitis in children: Clinical features and diagnosis", section on 'Clinical features'.)
●Peritonsillar or retropharyngeal infection – Children with peritonsillar or retropharyngeal cellulitis/abscess, or other painful infections of the oropharynx, may present with drooling and neck extension [104]. Children with these infections usually are not as toxic appearing or anxious as those with acute epiglottitis. Peritonsillar cellulitis or abscess is readily identified on inspection of the oropharynx. For patients with a retropharyngeal abscess, a soft-tissue lateral neck radiograph may be helpful in confirming or excluding the presence of epiglottitis. (See "Peritonsillar cellulitis and abscess" and "Retropharyngeal infections in children".)
●Foreign bodies – Foreign bodies in the larynx or trachea can cause complete or partial airway obstruction that requires immediate treatment. Foreign bodies lodged in the upper esophagus can cause tissue edema that compresses the airway, causing partial airway obstruction (picture 7). Symptoms are likely to have an abrupt onset, and fever is absent. (See "Emergency evaluation of acute upper airway obstruction in children", section on 'Foreign body' and "Foreign bodies of the esophagus and gastrointestinal tract in children".)
●Angioedema (anaphylaxis or hereditary) – Allergic reaction or acute angioneurotic edema has rapid onset without antecedent cold symptoms or fever. The primary manifestations are swelling of the lips and tongue, urticarial rash, dysphagia without hoarseness, and sometimes inspiratory stridor [105,106]. There may be a history of allergy or a previous attack. (See "Anaphylaxis: Emergency treatment".)
●Congenital anomalies and laryngeal papillomas – Congenital anomalies of the upper airway and laryngeal papillomas sometimes cause symptoms similar to those of epiglottitis. However, these conditions have a chronic course and generally do not cause fever (unless symptoms are due to exacerbation of airway narrowing due to a concomitant viral infection). (See "Congenital anomalies of the larynx".)
●Diphtheria – The clinical presentation of diphtheria can be similar to that of epiglottitis. The onset of symptoms is typically gradual. Sore throat, malaise, and low-grade fever are the most common presenting symptoms. A diphtheritic membrane (gray and sharply demarcated, (picture 8)) may be present. Diphtheria is exceedingly rare in countries with high rates of immunization for diphtheria, tetanus, and pertussis. (See "Epidemiology and pathophysiology of diphtheria" and "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Other bacterial infections'.)
●Other causes of epiglottic enlargement – Other causes of epiglottic enlargement, such as neck radiation therapy, trauma, or thermal injury, generally can be elucidated by history [40,107,108]. Laryngopyocele, an infectious complication of laryngoceles (which are uncommon, abnormal air sacs in the larynx), also may mimic epiglottitis both in clinical presentation and on lateral neck radiographs [109].
●Uvulitis – Patients with epiglottitis may also have uvulitis (picture 9), although uvulitis can be caused by other oropharyngeal infections such as streptococcal pharyngitis [110-112].
SUMMARY AND RECOMMENDATIONS
●Definition – Epiglottitis (supraglottitis) refers to inflammation of the epiglottis and adjacent supraglottic structures. Without treatment, epiglottitis can progress to life-threatening airway obstruction. A rapid overview of the recognition and management of epiglottitis is provided in the table (table 1). (See 'Definition' above.)
●Etiology – Since the introduction of vaccines against H. influenzae type b (Hib), epiglottitis has mostly become an adult disease that is caused by oro- and nasopharyngeal bacterial pathogens other than Hib (table 2). Immunocompromised patients may develop epiglottitis caused by opportunistic microorganisms. Hib epiglottitis remains a potential etiology in unvaccinated or incompletely immunized children. (See 'Etiology' above.)
●Clinical presentation:
•Acute – Young children with Hib epiglottitis present with fever, stridor, drooling, respiratory distress, anxiety, and the characteristic "sniffing" posture (picture 2), but the presentation may be more subtle (picture 3). (See 'Acute (fever and stridor)' above.)
•Subacute – Older children, adolescents, and adults may present with a severe sore throat, dysphagia, drooling, and anterior neck pain but a relatively normal oropharyngeal examination and mild respiratory distress. (See 'Subacute (severe sore throat)' above.)
●Diagnostic approach – The diagnostic approach for patients with suspected epiglottitis is provided in the algorithm (algorithm 1). For the patient with abrupt onset of fever, stridor, and respiratory distress, airway management is the primary focus (algorithm 2); the clinician should obtain emergency assistance from airway specialists (eg, anesthesiologist/critical care specialist and an otolaryngologist) when possible. Visualization of the epiglottis during definitive airway management confirms the diagnosis. (See 'Clinical suspicion' above and "Epiglottitis (supraglottitis): Management", section on 'Approach to airway management'.)
For the patient with sore throat and drooling in whom epiglottitis is a possibility but for whom other diagnoses are also likely (table 3), cautious examination of the throat is appropriate. Pooled secretions may be noted and, occasionally, a swollen, red epiglottitis may be visible. If the swollen epiglottis is not seen on routine oropharyngeal examination, diagnosis of epiglottitis is confirmed by (see 'Visualization of the epiglottis' above and 'Imaging' above):
•Fiberoptic nasolaryngoscopy or indirect laryngoscopy – Swelling and redness of the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoid cartilages) (picture 4 and picture 5) on fiberoptic nasolaryngoscopy and/or indirect laryngoscopy with a 70-degree endoscope. Visualization of the epiglottis should occur in a setting where the airway can be secured immediately if necessary. (See 'Diagnosis' above and 'Examination' above.)
•Plain radiographs – In cases when visualization is not performed, soft-tissue lateral neck plain radiographs may be diagnostic (generally showing the classic "thumb sign" (image 1 and image 2)). (See 'Plain radiographs' above.)
Plain radiography is most helpful in the evaluation of patients in whom epiglottitis is a possibility, but other conditions are more likely (table 3) (see 'Differential diagnosis' above). Diagnosis may also be confirmed by radiography if direct visualization appears unsafe or is unsuccessful. (See 'Imaging' above and 'Differential diagnosis' above.)
Although plain radiography can confirm the diagnosis of epiglottitis, it is not necessary in many cases in which the likelihood of epiglottitis is sufficiently low (eg, immunized children with a hoarse voice and characteristic cough of croup), such that no imaging is indicated, or high, in which case direct visualization during airway management in the operating suite is preferred.
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