Epiglottitis

What to do right now

1. Call 911 or your local emergency number.
2. Keep the person upright in whatever position helps them breathe. Do not lay them down.
3. Keep them calm. Crying and distress in children can worsen the obstruction.
4. Do not examine the throat or put anything in the mouth, as this can trigger complete airway blockage.
5. Do not give food or drink.

How epiglottitis happens

The epiglottis is a leaf-shaped flap at the base of the tongue. During swallowing, it folds over the opening of the voice box to stop food entering the airway. Infection or injury causes it and the surrounding tissues (the supraglottis) to swell quickly. Because the airway at that level is narrow, especially in children, even moderate swelling can block breathing.

Causes

• Bacteria: Haemophilus influenzae type b (Hib) was the main cause in children before routine vaccination in the late 1980s. Today, Streptococcus species, Staphylococcus aureus (including MRSA), non-type b H. influenzae and others are more common.
• Viruses and fungi: in people with weakened immunity.
• Thermal injury: swallowing very hot liquids or inhaling hot gases.
• Chemical injury: swallowing caustic substances.
• Trauma: a direct blow to the throat or a foreign object.

Risk factors

• not being vaccinated against Hib
• weakened immune system (diabetes, cancer treatment, HIV)
• adult men are affected more often than women

Symptoms

In children

• sudden high fever
• severe sore throat
• drooling because swallowing is too painful
• noisy breathing (stridor)
• sitting forward with the neck extended (tripod position)
• anxiety and restlessness
• a muffled voice; cough is usually absent, unlike croup

Symptoms in children can progress over just a few hours.

In adults

Symptoms often develop over 1 to 2 days:

• severe sore throat and pain on swallowing, often out of proportion to a normal-looking throat
• difficulty swallowing
• muffled voice or hoarseness
• fever
• tenderness of the front of the neck
• stridor and breathing difficulty in more severe cases

Epiglottitis vs croup

Diagnosis

Diagnosis takes place in a controlled setting with airway experts present. Doctors may:

• examine the throat carefully with a flexible camera through the nose (nasopharyngoscopy) in adults who are stable
• examine children in the operating room, ready to secure the airway
• take a lateral neck X-ray, which may show a swollen epiglottis (the "thumb sign"), only if the patient is stable
• take blood tests and cultures

Treatment

• Airway protection: the first priority. Many children and some adults need a breathing tube placed by an anesthesiologist or ENT surgeon, sometimes in the operating room. Rarely, an emergency surgical airway is needed.
• Intravenous antibiotics: usually a third-generation cephalosporin such as ceftriaxone, with vancomycin or similar added if MRSA is a concern.
• Steroids: sometimes used to reduce swelling, though evidence is limited.
• Monitoring in intensive care until swelling subsides, typically 1 to 3 days.

Close household contacts of someone with Hib epiglottitis may need preventive antibiotics.

Complications

• airway blockage and lack of oxygen
• abscess of the epiglottis
• pneumonia and spread of infection (meningitis, sepsis)

Outlook

With rapid airway management and antibiotics, most people recover fully within a week. Delayed treatment can be fatal.

Prevention

• Hib vaccine: given to babies in a series starting at 2 months. It has made epiglottitis in children rare in countries with routine vaccination.
• Avoid very hot drinks and be careful with young children around hot liquids.

Frequently asked questions

What are the first signs of epiglottitis?

Early signs are a severe sore throat, fever and pain on swallowing that worsen quickly. Drooling, a muffled voice, noisy breathing and sitting forward to breathe are warning signs of airway blockage that need emergency care.

Is epiglottitis still common in children?

No. Since the Hib vaccine was introduced, epiglottitis has become rare in children in countries with routine vaccination. It is now more common in adults, though unvaccinated children remain at risk.

How is epiglottitis different from strep throat?

Strep throat causes a sore throat and fever, but breathing and the voice are normal and drooling is uncommon. Epiglottitis causes severe pain on swallowing, drooling, a muffled voice and potentially breathing difficulty, and the throat may look surprisingly normal.

Can adults get epiglottitis?

Yes. Adults now account for most cases. They usually have a severe sore throat and painful swallowing over 1 to 2 days, sometimes with a muffled voice and drooling. Adults with these symptoms should go to the ER.