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Emergency And Acute Medicine - Adult Epiglottitis
Basic description
Epiglottitis is a rapidly progressive inflammation of the epiglottis and surrounding supraglottic tissues that can lead to acute airway compromise. Although often more indolent in adults than in children, adults may still deteriorate abruptly with complete airway obstruction. While the incidence of pediatric epiglottitis has declined, adult cases are increasing.
Inflammation primarily involves the epiglottis, where edema poses the greatest airway risk, but may also extend to adjacent structures including the vallecula and arytenoids. The incidence in adults is approximately 1–4 per 100,000 per year and is rising. It is more common in men, with a ratio of 3:1, and most frequently affects patients in their fifth decade of life. Adult mortality is approximately 7%, compared with less than 1% in children.
Immunocompromised patients may present with fulminant disease, minimal early symptoms, and atypical organisms such as Candida or Pseudomonas aeruginosa. Potential complications include total airway obstruction, retropharyngeal abscess, acute respiratory distress syndrome, pneumonia, and empyema.
Etiology
Infectious causes include Haemophilus influenzae type B as well as type A and nontypeable strains, Haemophilus parainfluenzae, Streptococcus pneumoniae, Staphylococcus aureus, group A Streptococcus, Neisseria meningitidis, herpes simplex virus, cytomegalovirus, and Pseudomonas aeruginosa.
Noninfectious causes include chemical or thermal burns, toxic or illicit drug inhalation, trauma, and airway instrumentation.
Diagnosis – signs and symptoms
History
General symptoms include fever and upper respiratory tract complaints, though a prodrome may be absent. Head and neck symptoms commonly include dysphagia, muffled or “hot potato” voice, hoarseness, foreign body sensation in the throat, drooling, and associated tonsillar, peritonsillar, or uvular findings. Respiratory complaints include a subjective sense of airway obstruction and shortness of breath.
Physical examination
Patients may appear toxic and febrile and often sit upright in a tripod position. The classic “cherry red” epiglottis may be seen, though up to half of patients have a pale, edematous epiglottis instead. Gentle palpation of the hyoid or thyroid cartilage may be painful, and lateral movement of the larynx (“tracheal rock”) can elicit pain. Cervical lymphadenopathy may be present. Respiratory findings include stridor, accessory muscle use, and sudden airway loss.
Alert
Any patient with respiratory distress is at high risk for rapid progression to complete airway obstruction. Emergent surgical airway management may be required.
Essential workup
In patients with significant respiratory distress, invasive diagnostic procedures should be avoided. Management should prioritize empiric antibiotics and airway control before further diagnostic evaluation.
Diagnosis tests and interpretation
Laboratory studies
Obtain a complete blood count with differential and blood cultures. Pharyngeal cultures should be obtained only if there are no signs of respiratory distress.
Imaging
In patients with moderate to severe respiratory distress, airway control must precede imaging. A portable lateral soft tissue neck radiograph may show the epiglottic “thumb sign,” loss of the normal vallecular contour, swelling of the arytenoids or aryepiglottic folds, and prevertebral soft tissue swelling. False-negative rates are significant; negative imaging does not exclude the diagnosis.
CT imaging is reserved for cases in which laryngoscopy cannot be performed or when complications such as abscess are suspected.
Diagnostic procedures
Nasopharyngoscopy or indirect laryngoscopy may confirm the diagnosis but should not be performed prior to securing the airway if stridor or respiratory distress is present.
Differential diagnosis
Croup, airway foreign body, anaphylaxis, paradoxical vocal cord dysfunction, angioedema, laryngitis, pharyngitis, peritonsillar or retropharyngeal abscess, bacterial tracheitis, congenital airway anomalies, and meningitis.
Treatment – prehospital
Transport the patient in a position of comfort. Provide supplemental oxygen as tolerated while minimizing anxiety. Intubation should be attempted only in severe respiratory distress, as airway manipulation carries a high risk of worsening obstruction. Inhaled agents, racemic epinephrine, and β-agonists have no proven benefit.
Initial stabilization and therapy
Follow airway, breathing, and circulation priorities. Be fully prepared for definitive airway management, including surgical airway capability, from first contact until the diagnosis is excluded or the patient is transferred to intensive care. Airway examination itself can precipitate obstruction.
Orotracheal intubation is indicated for patients with significant respiratory distress or impending airway failure. Early ENT or surgical consultation is recommended when feasible. Needle jet ventilation may be a life-saving temporizing measure if intubation fails and a surgical airway is not immediately available.
Emergency department treatment
Provide humidified oxygen, establish IV access, and initiate empiric intravenous antibiotics. The role of corticosteroids remains controversial.
Medication
First line
Cefotaxime 2 g IV every 8 hours
or
Ceftriaxone 2 g IV every 24 hours
Second line or alternative regimens
Ampicillin–sulbactam 3 g IV initially, then 200–300 mg/kg/day in four divided doses plus vancomycin 1 g IV every 12 hours
Trimethoprim–sulfamethoxazole 320 mg IV initially, then 4–5 mg/kg IV every 12 hours
Additional coverage for Staphylococcus aureus
Nafcillin 150–200 mg/kg/day IV in four divided doses
or
Clindamycin 600–900 mg IV every 8 hours
Prophylaxis for close contacts
Rifampin 600 mg PO daily for 4 days in adults
Follow-up and disposition
Admission criteria
All patients with suspected or confirmed epiglottitis require admission to an intensive care unit for airway monitoring and intravenous antibiotics.
Discharge criteria
Patients should not be discharged unless epiglottitis has been definitively excluded by direct visualization of the supraglottic structures by an experienced clinician.
Issues for referral
Early otolaryngology consultation is recommended in all suspected cases.
Clinical pearls and common missteps
Delayed airway control is the most common cause of poor outcome. Avoid unnecessary interventions until the airway is secured. Adult epiglottitis carries a mortality rate of approximately 7%, underscoring the need for early recognition and decisive management.
Basic description
Epiglottitis is a rapidly progressive inflammation of the epiglottis and surrounding supraglottic tissues that can lead to acute airway compromise. Although often more indolent in adults than in children, adults may still deteriorate abruptly with complete airway obstruction. While the incidence of pediatric epiglottitis has declined, adult cases are increasing.
Inflammation primarily involves the epiglottis, where edema poses the greatest airway risk, but may also extend to adjacent structures including the vallecula and arytenoids. The incidence in adults is approximately 1–4 per 100,000 per year and is rising. It is more common in men, with a ratio of 3:1, and most frequently affects patients in their fifth decade of life. Adult mortality is approximately 7%, compared with less than 1% in children.
Immunocompromised patients may present with fulminant disease, minimal early symptoms, and atypical organisms such as Candida or Pseudomonas aeruginosa. Potential complications include total airway obstruction, retropharyngeal abscess, acute respiratory distress syndrome, pneumonia, and empyema.
Etiology
Infectious causes include Haemophilus influenzae type B as well as type A and nontypeable strains, Haemophilus parainfluenzae, Streptococcus pneumoniae, Staphylococcus aureus, group A Streptococcus, Neisseria meningitidis, herpes simplex virus, cytomegalovirus, and Pseudomonas aeruginosa.
Noninfectious causes include chemical or thermal burns, toxic or illicit drug inhalation, trauma, and airway instrumentation.
Diagnosis – signs and symptoms
History
General symptoms include fever and upper respiratory tract complaints, though a prodrome may be absent. Head and neck symptoms commonly include dysphagia, muffled or “hot potato” voice, hoarseness, foreign body sensation in the throat, drooling, and associated tonsillar, peritonsillar, or uvular findings. Respiratory complaints include a subjective sense of airway obstruction and shortness of breath.
Physical examination
Patients may appear toxic and febrile and often sit upright in a tripod position. The classic “cherry red” epiglottis may be seen, though up to half of patients have a pale, edematous epiglottis instead. Gentle palpation of the hyoid or thyroid cartilage may be painful, and lateral movement of the larynx (“tracheal rock”) can elicit pain. Cervical lymphadenopathy may be present. Respiratory findings include stridor, accessory muscle use, and sudden airway loss.
Alert
Any patient with respiratory distress is at high risk for rapid progression to complete airway obstruction. Emergent surgical airway management may be required.
Essential workup
In patients with significant respiratory distress, invasive diagnostic procedures should be avoided. Management should prioritize empiric antibiotics and airway control before further diagnostic evaluation.
Diagnosis tests and interpretation
Laboratory studies
Obtain a complete blood count with differential and blood cultures. Pharyngeal cultures should be obtained only if there are no signs of respiratory distress.
Imaging
In patients with moderate to severe respiratory distress, airway control must precede imaging. A portable lateral soft tissue neck radiograph may show the epiglottic “thumb sign,” loss of the normal vallecular contour, swelling of the arytenoids or aryepiglottic folds, and prevertebral soft tissue swelling. False-negative rates are significant; negative imaging does not exclude the diagnosis.
CT imaging is reserved for cases in which laryngoscopy cannot be performed or when complications such as abscess are suspected.
Diagnostic procedures
Nasopharyngoscopy or indirect laryngoscopy may confirm the diagnosis but should not be performed prior to securing the airway if stridor or respiratory distress is present.
Differential diagnosis
Croup, airway foreign body, anaphylaxis, paradoxical vocal cord dysfunction, angioedema, laryngitis, pharyngitis, peritonsillar or retropharyngeal abscess, bacterial tracheitis, congenital airway anomalies, and meningitis.
Treatment – prehospital
Transport the patient in a position of comfort. Provide supplemental oxygen as tolerated while minimizing anxiety. Intubation should be attempted only in severe respiratory distress, as airway manipulation carries a high risk of worsening obstruction. Inhaled agents, racemic epinephrine, and β-agonists have no proven benefit.
Initial stabilization and therapy
Follow airway, breathing, and circulation priorities. Be fully prepared for definitive airway management, including surgical airway capability, from first contact until the diagnosis is excluded or the patient is transferred to intensive care. Airway examination itself can precipitate obstruction.
Orotracheal intubation is indicated for patients with significant respiratory distress or impending airway failure. Early ENT or surgical consultation is recommended when feasible. Needle jet ventilation may be a life-saving temporizing measure if intubation fails and a surgical airway is not immediately available.
Emergency department treatment
Provide humidified oxygen, establish IV access, and initiate empiric intravenous antibiotics. The role of corticosteroids remains controversial.
Medication
First line
Cefotaxime 2 g IV every 8 hours
or
Ceftriaxone 2 g IV every 24 hours
Second line or alternative regimens
Ampicillin–sulbactam 3 g IV initially, then 200–300 mg/kg/day in four divided doses plus vancomycin 1 g IV every 12 hours
Trimethoprim–sulfamethoxazole 320 mg IV initially, then 4–5 mg/kg IV every 12 hours
Additional coverage for Staphylococcus aureus
Nafcillin 150–200 mg/kg/day IV in four divided doses
or
Clindamycin 600–900 mg IV every 8 hours
Prophylaxis for close contacts
Rifampin 600 mg PO daily for 4 days in adults
Follow-up and disposition
Admission criteria
All patients with suspected or confirmed epiglottitis require admission to an intensive care unit for airway monitoring and intravenous antibiotics.
Discharge criteria
Patients should not be discharged unless epiglottitis has been definitively excluded by direct visualization of the supraglottic structures by an experienced clinician.
Issues for referral
Early otolaryngology consultation is recommended in all suspected cases.
Clinical pearls and common missteps
Delayed airway control is the most common cause of poor outcome. Avoid unnecessary interventions until the airway is secured. Adult epiglottitis carries a mortality rate of approximately 7%, underscoring the need for early recognition and decisive management.
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