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Emergency And Acute Medicine - Epiglottitis, Pediatric
Basic description
Pediatric epiglottitis is an inflammation of the epiglottis and nearby supraglottic tissues that can become rapidly fatal because of progressive upper-airway obstruction. Children are especially vulnerable because their upper airway has a smaller cross-sectional diameter, the mucosa is more loosely attached and highly vascular (so swelling develops quickly), and the airway can collapse dynamically during distress.
After widespread Haemophilus influenzae type b (Hib) vaccination, childhood epiglottitis became far less common; however, rare cases can still occur, including vaccine failure. In the post-Hib era, the average age has shifted upward, and the condition is now seen more often in adolescents and adults than in toddlers or young school-aged children. Cases may occur year-round.
Alert
Any child with suspected epiglottitis requires continuous intensive monitoring and urgent readiness for airway intervention because obstruction can progress suddenly.
Etiology
Infectious causes include H. influenzae type b, Streptococcus pneumoniae, group A β-hemolytic Streptococcus, Staphylococcus aureus, and viruses. Less common pathogens include Klebsiella, Pseudomonas, and Candida.
Noninfectious causes include caustic injury, thermal injury, trauma, post-transplant lymphoproliferative disorder, and hereditary angioedema.
Diagnosis – signs and symptoms
History
Presentation is typically abrupt and severe without a preceding viral prodrome. Common features include irritability, intense throat pain (often described as the worst sore throat), fever, noisy breathing, and rapidly worsening toxicity or respiratory distress. Adolescents may resemble adult presentations, including repeated prior visits before diagnosis.
Physical examination
Children often appear toxic with high fever and quickly progressive symptoms. Key throat findings include drooling, dysphagia, and a muffled “hot potato” voice. Respiratory distress may evolve rapidly; the child usually prefers to sit upright, leaning forward with the mouth open (tripod/sniffing position) to optimize airflow. Stridor may be subtle early and progress later. Severe complications include complete airway obstruction, epiglottic abscess, pneumonia, and atelectasis.
Essential workup
Epiglottitis is primarily a clinical diagnosis. Attempts to directly visualize the epiglottis in an awake child (including indirect laryngoscopy) should be avoided unless performed in a controlled environment with full airway capability. In adolescents without impending obstruction, fiberoptic nasopharyngoscopy may be appropriate. If infection is suspected, cultures of the epiglottis should be obtained during laryngoscopy only after the airway is secured.
Diagnosis tests and interpretation
Laboratory studies
Defer lab tests until the airway is controlled. After stabilization, obtain throat cultures and blood cultures (blood cultures are often positive when Hib is the cause).
Imaging
Lateral soft tissue neck radiographs are usually unnecessary and can be dangerous because they may delay airway control, agitate the child, and remove the patient to a less controlled setting. If imaging is obtained, the child must be accompanied and airway equipment and skilled personnel must be immediately available. Possible findings include a normal film, epiglottic swelling (“thumbprint sign”), supraglottic swelling, a ballooned hypopharynx, obliteration of the vallecula, and an epiglottic width to C3 vertebral body width ratio greater than 0.5.
Diagnostic procedures
Laryngoscopy should be performed in a controlled setting whenever possible. The epiglottis typically appears swollen, erythematous, and inflamed. Cultures obtained after airway control can help target therapy.
Differential diagnosis
Bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, croup (with age overlap), pertussis, mononucleosis, Ludwig angina, diphtheria, anaphylaxis with angioedema, hereditary angioedema, upper-airway foreign body, laryngeal trauma, laryngospasm, toxic inhalation/aspiration (e.g., hydrocarbons), airway burns, hyperventilation, and CNS disorders.
Treatment – prehospital
Intervention should match the degree of obstruction, transport time, and provider capability. Notify the receiving facility early and coordinate transport with minimal agitation of the child.
Initial stabilization and therapy
Prioritize airway management if the child is in extremis. Bag-valve-mask ventilation with 100% oxygen and cricoid pressure may provide adequate ventilation and time to move to a controlled setting (often the operating room).
For intubation, use an endotracheal tube one to two sizes smaller than usual for age/length. Gentle anterior neck compression may help identify air bubbles at the narrowed glottic opening. Difficult-airway adjuncts may be needed.
If oral intubation fails, proceed to emergent surgical airway options: cricothyrotomy or needle cricothyrotomy may be used in older children (typically >10–12 years), while needle cricothyrotomy is preferred in younger children.
Emergency department treatment
Provide 100% oxygen as tolerated. Keep the child in the position of comfort and avoid forcing supine positioning. While not definitively proven, nebulized racemic epinephrine or L-epinephrine may temporarily reduce symptoms while definitive airway planning proceeds, but use cautiously to avoid agitation.
Avoid agitating procedures such as IV placement and blood draws until airway plans are finalized. Consider early definitive airway management for rapidly worsening distress, increasing tachypnea, escalating throat pain, tachycardia, hypoxemia, or in children at high risk of sudden obstruction (e.g., immunodeficiency).
When possible, intubate in the operating room or similarly controlled environment by the most experienced clinician, often using inhalational anesthesia. Have multiple tube sizes available. Surgical backup must be present or immediately available for emergent tracheotomy or cricothyrotomy.
Start IV antibiotics promptly; second- or third-generation cephalosporins are effective against β-lactamase–producing H. influenzae. Steroids are controversial but often used, especially for chemical or thermal causes.
Medication
First line
Ampicillin/sulbactam 200–300 mg/kg/day IV divided every 6 hours
or
Cefotaxime 150 mg/kg/day IV divided every 6–8 hours
or
Ceftriaxone 100 mg/kg/day IV divided every 12 hours
Second line and selected options
Ampicillin 100–200 mg/kg/day IV divided every 6 hours plus chloramphenicol
Chloramphenicol 75–100 mg/kg/day IV divided every 6 hours
Meropenem 120 mg/kg/day IV divided every 8 hours (maximum 6 g/day)
Dexamethasone 0.6 mg/kg/day IV (maximum 10 mg); use remains controversial
Racemic epinephrine 0.05 mL/kg (maximum 0.5 mL) in 2.5 mL normal saline via nebulizer every 30 minutes as needed
L-epinephrine 1:1,000 at 0.5 mL/kg (maximum 5 mL) via nebulizer every 30 minutes as needed
Rifampin for household contact prophylaxis: 20 mg/kg (maximum 600 mg) daily for 4 days
If hereditary angioedema is suspected: C1 esterase inhibitor concentrate (or fresh frozen plasma if unavailable) with expert consultation
Follow-up and disposition
Admission criteria
All suspected or confirmed cases require ICU admission after airway stabilization, antibiotics, and supportive care.
Discharge criteria
Patients are not discharged from the ED with suspected epiglottitis. Public health actions and prophylaxis may be required for close contacts when Hib is confirmed, especially in households with infants under 12 months, unimmunized or incompletely immunized children, or immunosuppressed contacts. Child care contacts may need prophylaxis when multiple cases occur within 60 days. Invasive H. influenzae disease should be reported to local or state public health authorities.
Issues for referral
Critical care consultation is required; pulmonary and ENT involvement is commonly appropriate depending on local practice and airway course.
Clinical pearls and common missteps
This is a true airway emergency. The child must be continuously monitored and never left unattended, including during transport or any imaging, and must always be accompanied by personnel capable of immediate airway stabilization.
Basic description
Pediatric epiglottitis is an inflammation of the epiglottis and nearby supraglottic tissues that can become rapidly fatal because of progressive upper-airway obstruction. Children are especially vulnerable because their upper airway has a smaller cross-sectional diameter, the mucosa is more loosely attached and highly vascular (so swelling develops quickly), and the airway can collapse dynamically during distress.
After widespread Haemophilus influenzae type b (Hib) vaccination, childhood epiglottitis became far less common; however, rare cases can still occur, including vaccine failure. In the post-Hib era, the average age has shifted upward, and the condition is now seen more often in adolescents and adults than in toddlers or young school-aged children. Cases may occur year-round.
Alert
Any child with suspected epiglottitis requires continuous intensive monitoring and urgent readiness for airway intervention because obstruction can progress suddenly.
Etiology
Infectious causes include H. influenzae type b, Streptococcus pneumoniae, group A β-hemolytic Streptococcus, Staphylococcus aureus, and viruses. Less common pathogens include Klebsiella, Pseudomonas, and Candida.
Noninfectious causes include caustic injury, thermal injury, trauma, post-transplant lymphoproliferative disorder, and hereditary angioedema.
Diagnosis – signs and symptoms
History
Presentation is typically abrupt and severe without a preceding viral prodrome. Common features include irritability, intense throat pain (often described as the worst sore throat), fever, noisy breathing, and rapidly worsening toxicity or respiratory distress. Adolescents may resemble adult presentations, including repeated prior visits before diagnosis.
Physical examination
Children often appear toxic with high fever and quickly progressive symptoms. Key throat findings include drooling, dysphagia, and a muffled “hot potato” voice. Respiratory distress may evolve rapidly; the child usually prefers to sit upright, leaning forward with the mouth open (tripod/sniffing position) to optimize airflow. Stridor may be subtle early and progress later. Severe complications include complete airway obstruction, epiglottic abscess, pneumonia, and atelectasis.
Essential workup
Epiglottitis is primarily a clinical diagnosis. Attempts to directly visualize the epiglottis in an awake child (including indirect laryngoscopy) should be avoided unless performed in a controlled environment with full airway capability. In adolescents without impending obstruction, fiberoptic nasopharyngoscopy may be appropriate. If infection is suspected, cultures of the epiglottis should be obtained during laryngoscopy only after the airway is secured.
Diagnosis tests and interpretation
Laboratory studies
Defer lab tests until the airway is controlled. After stabilization, obtain throat cultures and blood cultures (blood cultures are often positive when Hib is the cause).
Imaging
Lateral soft tissue neck radiographs are usually unnecessary and can be dangerous because they may delay airway control, agitate the child, and remove the patient to a less controlled setting. If imaging is obtained, the child must be accompanied and airway equipment and skilled personnel must be immediately available. Possible findings include a normal film, epiglottic swelling (“thumbprint sign”), supraglottic swelling, a ballooned hypopharynx, obliteration of the vallecula, and an epiglottic width to C3 vertebral body width ratio greater than 0.5.
Diagnostic procedures
Laryngoscopy should be performed in a controlled setting whenever possible. The epiglottis typically appears swollen, erythematous, and inflamed. Cultures obtained after airway control can help target therapy.
Differential diagnosis
Bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, croup (with age overlap), pertussis, mononucleosis, Ludwig angina, diphtheria, anaphylaxis with angioedema, hereditary angioedema, upper-airway foreign body, laryngeal trauma, laryngospasm, toxic inhalation/aspiration (e.g., hydrocarbons), airway burns, hyperventilation, and CNS disorders.
Treatment – prehospital
Intervention should match the degree of obstruction, transport time, and provider capability. Notify the receiving facility early and coordinate transport with minimal agitation of the child.
Initial stabilization and therapy
Prioritize airway management if the child is in extremis. Bag-valve-mask ventilation with 100% oxygen and cricoid pressure may provide adequate ventilation and time to move to a controlled setting (often the operating room).
For intubation, use an endotracheal tube one to two sizes smaller than usual for age/length. Gentle anterior neck compression may help identify air bubbles at the narrowed glottic opening. Difficult-airway adjuncts may be needed.
If oral intubation fails, proceed to emergent surgical airway options: cricothyrotomy or needle cricothyrotomy may be used in older children (typically >10–12 years), while needle cricothyrotomy is preferred in younger children.
Emergency department treatment
Provide 100% oxygen as tolerated. Keep the child in the position of comfort and avoid forcing supine positioning. While not definitively proven, nebulized racemic epinephrine or L-epinephrine may temporarily reduce symptoms while definitive airway planning proceeds, but use cautiously to avoid agitation.
Avoid agitating procedures such as IV placement and blood draws until airway plans are finalized. Consider early definitive airway management for rapidly worsening distress, increasing tachypnea, escalating throat pain, tachycardia, hypoxemia, or in children at high risk of sudden obstruction (e.g., immunodeficiency).
When possible, intubate in the operating room or similarly controlled environment by the most experienced clinician, often using inhalational anesthesia. Have multiple tube sizes available. Surgical backup must be present or immediately available for emergent tracheotomy or cricothyrotomy.
Start IV antibiotics promptly; second- or third-generation cephalosporins are effective against β-lactamase–producing H. influenzae. Steroids are controversial but often used, especially for chemical or thermal causes.
Medication
First line
Ampicillin/sulbactam 200–300 mg/kg/day IV divided every 6 hours
or
Cefotaxime 150 mg/kg/day IV divided every 6–8 hours
or
Ceftriaxone 100 mg/kg/day IV divided every 12 hours
Second line and selected options
Ampicillin 100–200 mg/kg/day IV divided every 6 hours plus chloramphenicol
Chloramphenicol 75–100 mg/kg/day IV divided every 6 hours
Meropenem 120 mg/kg/day IV divided every 8 hours (maximum 6 g/day)
Dexamethasone 0.6 mg/kg/day IV (maximum 10 mg); use remains controversial
Racemic epinephrine 0.05 mL/kg (maximum 0.5 mL) in 2.5 mL normal saline via nebulizer every 30 minutes as needed
L-epinephrine 1:1,000 at 0.5 mL/kg (maximum 5 mL) via nebulizer every 30 minutes as needed
Rifampin for household contact prophylaxis: 20 mg/kg (maximum 600 mg) daily for 4 days
If hereditary angioedema is suspected: C1 esterase inhibitor concentrate (or fresh frozen plasma if unavailable) with expert consultation
Follow-up and disposition
Admission criteria
All suspected or confirmed cases require ICU admission after airway stabilization, antibiotics, and supportive care.
Discharge criteria
Patients are not discharged from the ED with suspected epiglottitis. Public health actions and prophylaxis may be required for close contacts when Hib is confirmed, especially in households with infants under 12 months, unimmunized or incompletely immunized children, or immunosuppressed contacts. Child care contacts may need prophylaxis when multiple cases occur within 60 days. Invasive H. influenzae disease should be reported to local or state public health authorities.
Issues for referral
Critical care consultation is required; pulmonary and ENT involvement is commonly appropriate depending on local practice and airway course.
Clinical pearls and common missteps
This is a true airway emergency. The child must be continuously monitored and never left unattended, including during transport or any imaging, and must always be accompanied by personnel capable of immediate airway stabilization.
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