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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical, however some people find that they add depth to the patient information leaflets. You may find the abbreviations record helpful.
Epiglottitis
Post your experience| Patients still die of epiglottitis and a high index of suspicion is required. Any patients with a severe sore throat, not tolerating oral fluids, should be referred for urgent assessment. |
The term acute epiglottitis is used to describe a condition in which there is inflammation of the epiglottis and commonly the soft tissues surrounding the epiglottis. The condition is rare, but can be life-threatening, as inflammation of the epiglottis and surrounding tissues may lead to the complete obstruction of the upper respiratory tract.
- Acute epiglottitis is most common in children between the ages of 2 and 8, although it can occur at any age
- Males are more commonly affected than females with a ratio of 2.5:11
- In adults, smoking and reduced levels of immunity appear to be risk factors, and there is some evidence to suggest an increased risk in diabetics2
- Since the advent of vaccination against Hib in children, the incidence of acute epiglottitis in children has reduced
- Over the last few years the presence of epiglottitis in adults is being increasingly seen1,3
- Haemophilus influenzae type b (Hib) (most common)
- Pneumococci
- Group A beta-haemolytic streptococci
- Pseudomonas spp.
- Mycobacterium tuberculosis
- Viruses
- Local trauma, e.g. following inhalation of foreign bodies or post intubation
Many of the signs and symptoms associated with acute epiglottitis are common, and may occur in many less serious disorders. Patients with epiglottitis may present with any of the following, and the symptoms may evolve very quickly over a period of a few hours.4
Commonest symptoms
- Sore throat
- Odynophagia
- Muffled voice
- Drooling
- Fever
- Anterior neck tenderness
Other features
- Irritability
- Cough
- Ear pain
- Cervical lymphadenopathy
- The " tripod sign" - patient leans forward on outstretched arms to move inflamed structures forward thereby easing the upper airway obstruction2
With more severe epiglottitis
The differential diagnosis will depend on the presenting symptoms and age of the patient, but generally include:
- Pharyngitis
- Laryngitis
- Inhaled foreign body
- Croup
- Retropharyngeal abscess
| Patients who are suspected of having acute epiglottitis should not have their throat examined with the aid of a tongue depressor, due to the risk of laryngeal obstruction, but should be urgently referred for laryngoscopy. |
- Fibreoptic laryngoscopy remains the "gold standard" for diagnosing epiglottitis, as the epiglottis can be seen directly. Laryngoscopy in these patients should only be performed in areas such as operating theatres which are prepared for intubation or tracheostomy in the event of upper airway obstruction.
- Lateral neck X-ray may be useful if laryngoscopy is not possible. Soft-tissue radiograph of the neck may show the "thumbprint sign".5
- Throat swabs may be taken when the airway is secure, or when intubation/tracheostomy facilities are at hand. Streptococci are becoming the major pathogens in acute epiglottitis now.6
- Blood cultures may be taken if the patient is systemically unwell.
- CT or MRI scans may be performed if abscess formation is suspected.
- Intubation is required in over 30% of all cases of acute epiglottitis, and prophylactic intubation may be carried out in patients with dyspnoea or stridor, as deterioration in symptoms may be rapid (usually if >50% airway obstruction present).7
- Treatment with antibiotics should be initiated without waiting for swab/blood culture results. The chosen antibiotic should have a broad spectrum of action which covers both Haemophilus influenzae type b and Streptococcus spp. Due to increasing resistance to ampicillin, third generation cephalosporins such as cefotaxime are now preferred as first line agents.
- Corticosteroids are often given for their anti-inflammatory properties, although there is as yet little evidence that their use influences the course of the disease.2
- Surgical tracheostomy may be required in patients with severe airway obstruction in whom intubation has not been possible.
- Abscess formation is being increasingly seen as epiglottitis cases in adults increase.8 Drainage may be required in some patients.
Epiglottitis, if not adequately treated, may occasionally result in
- Abscess formation
- Meningitis
- Septicaemia
- Pneumothorax
- Pneumo-mediastinitis (very rare)
The great majority of patients will make a complete recovery with no sequelae if early and appropriate treatment are given. Death may occur rapidly if the condition is not recognised and complete airway obstruction occurs.9
Vaccination against Hib has dramatically reduced the incidence of acute epiglottitis in children in those countries in which the vaccination is included in the routine vaccination protocol for children.
It is becoming increasingly obvious that vaccination of children with Hib is resulting in resurgence of Hib-associated infections in older age patients. This requires further observation and surveillance methods to determine how best to manage this.10
Document references
- Sack JL, Brock CD; Identifying acute epiglottitis in adults. High degree of awareness, close monitoring are key. Postgrad Med. 2002 Jul;112(1):81-2, 85-6. [abstract]
- Wong EY, Berkowitz RG; Acute epiglottitis in adults: the Royal Melbourne Hospital experience. ANZ J Surg. 2001 Dec;71(12):740-3. [abstract]
- Price IM, Preyra I, Fernandes CM, et al; Adult epiglottitis: a five-year retrospective chart review in a major urban centre. CJEM. 2005 Nov;7(6):387-90. [abstract]
- Parsons DS, Smith RB, Mair EA, et al; Unique case presentations of acute epiglottic swelling and a protocol for acute airway compromise. Laryngoscope. 1996 Oct;106(10):1287-91. [abstract]
- Tan CK, Chan KS, Cheng KC; Adult epiglottitis. CMAJ. 2007 Feb 27;176(5):620.
- Faden H; The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. 2006 Jun;22(6):443-4. [abstract]
- Hafidh MA, Sheahan P, Keogh I, et al; Acute epiglottitis in adults: a recent experience with 10 cases. J Laryngol Otol. 2006 Apr;120(4):310-3. [abstract]
- Berger G, Landau T, Berger S, et al; The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol. 2003 Nov-Dec;24(6):374-83. [abstract]
- Berg S, Trollfors B, Nylen O, et al; Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden. Scand J Infect Dis. 1996;28(3):261-4. [abstract]
- McVernon J, Trotter CL, Slack MP, et al; Trends in Haemophilus influenzae type b infections in adults in England and Wales: surveillance study. BMJ. 2004 Sep 18;329(7467):655-8. [abstract]
Document ID: 2106
Document Version: 22
Document Reference: bgp531
Last Updated: 22 Jul 2009
Planned Review: 22 Jul 2011
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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