Epiglottitis is a rare, life-threatening condition caused by inflammatory edema of the epiglottis and surrounding supraglottic tissues, with potential for rapid airway occlusion. In the post-Hib vaccine era, it now predominantly affects adults (mean age ~50 years, male predominance ~2:1), with an incidence that has been rising approximately 9% per year over the past decade. [1-3] Mortality ranges from 1–20% in adults, primarily from failed airway management. [4]
1. History
- Sore throat — most common symptom in adults (79–93%) and often the chief complaint [2][5-6]
- Dysphagia/odynophagia — present in 48–85%; severe, disproportionate to pharyngeal exam findings [6-7]
- Onset and progression — adults typically present subacutely over 1–2 days; children present acutely within hours [1][8]
- Voice changes — muffled "hot potato" voice (39–75%) [7-8]
- Drooling/hypersalivation — high sensitivity (0.79) and specificity (0.94) for epiglottitis vs. croup in children [9]
- Dyspnea — reported in 6–14% but strongly associated with need for airway intervention [2][5]
- Ask about: fever, inability to swallow secretions, positional preference (sitting upright/tripod), preceding URI, recent caustic/thermal ingestion, immunization history, immunosuppression, smoking, prior episodes [1][10]
2. Alarm Features
- Stridor — uncommon (3.6%) but strongly predicts airway intervention [5-6]
- Dyspnea, tachypnea, respiratory distress [6-7]
- Hypoxia — strong predictor of airway compromise [3]
- Inability to swallow secretions / drooling [9-10]
- Rapid symptom progression (hours) [7]
- Sitting upright, refusing to lie down ("sniffing" position) — classic in children [8]
- Epiglottic abscess on imaging or visualization — independent predictor of airway intervention [10]
3. Medications
- First-line antibiotics: IV third-generation cephalosporin (ceftriaxone) or ampicillin/sulbactam; add vancomycin if MRSA suspected [1][8]
- Corticosteroids: Early systemic steroids (within 24 hours) associated with 52% lower risk of intubation (RR 0.48) and shorter ICU/hospital stays. Widely used (98% of patients in some series) [2-3][7]
- Nebulized racemic epinephrine: Controversial but may be considered as temporizing measure [1]
- Avoid: Sedatives or anxiolytics that may compromise airway protective reflexes; avoid agitating the patient (especially children) as this can precipitate complete obstruction
- IV ampicillin alone has also been shown effective as empiric monotherapy in some series [11]
4. Diet
- NPO on presentation — patients are often unable to swallow and may require airway intervention
- IV fluid resuscitation for dehydration from poor oral intake
- Advance diet as swallowing improves (typically within 24–48 hours of treatment)
- No specific long-term dietary considerations
5. Review of Systems
- ENT: Sore throat, voice change, drooling, trismus, ear pain (referred otalgia)
- Respiratory: Dyspnea, stridor, positional breathing preference, cough (notably absent in epiglottitis vs. croup) [9]
- Constitutional: Fever, malaise, rigors
- GI: Dysphagia, odynophagia, inability to tolerate secretions
- Skin: Rash (consider angioedema, anaphylaxis as mimics)
- Immunologic: Recent illness, immunosuppression, HIV status
6. Collateral History and Family History
- Immunization status — Hib vaccination history (especially in children and unvaccinated adults) [8]
- Prior episodes — recurrent epiglottitis is more common in males and associated with more severe course and higher rates of airway intervention [6]
- Immunocompromised state — HIV, chemotherapy, transplant (consider fungal etiologies) [1]
- Substance use — smoking is an independent risk factor for airway intervention; crack cocaine or inhalational drug use (thermal/caustic injury) [10]
- Exposure history — sick contacts, recent intubation or instrumentation
7. Risk Factors
- Male sex (~60–67% of cases) [2][4][6]
- Age 40–60 years (peak incidence in adults); steepest rise in adults aged 60–74 [2-3]
- Diabetes mellitus — present in 11–14% of cases; hyperglycemia predicts more severe course [4][6]
- Smoking — independent predictor of airway intervention [10]
- Immunosuppression [1]
- Incomplete Hib vaccination [8]
- History of recurrent episodes [6]
- Comorbidities — present in ~33% of patients [2]
8. Differential Diagnosis
- Peritonsillar abscess — unilateral tonsillar swelling, trismus, uvular deviation; can coexist
- Retropharyngeal/parapharyngeal abscess — neck stiffness, posterior pharyngeal swelling on lateral neck film; CT with contrast for delineation [12]
- Croup (laryngotracheobronchitis) — barking cough (high sensitivity/specificity for croup), absence of drooling; typically ages 6 months–3 years [9][13]
- Bacterial tracheitis — toxic-appearing child with croup-like symptoms unresponsive to standard therapy
- Angioedema — rapid onset, no fever, may have urticaria; consider ACE inhibitor-related or hereditary
- Foreign body aspiration — sudden onset, no prodrome, no fever [12]
- Anaphylaxis — urticaria, hypotension, exposure history
- Ludwig angina — floor-of-mouth swelling, dental source
- Laryngeal/supraglottic malignancy — chronic progressive symptoms, weight loss, smoking history
- Laryngeal diphtheria — unimmunized patients, pharyngeal membrane [12]
9. Past Medical History
- Prior episodes of epiglottitis (recurrence rate ~5%; associated with worse outcomes) [6]
- Diabetes mellitus — most common comorbidity [4][14]
- History of nasopharyngeal carcinoma or head/neck radiation [14]
- Prior difficult airway or intubation
- Immunodeficiency states
- Autoimmune conditions (rare cause of non-infectious epiglottitis) [1]
10. Physical Exam
- Vitals: Fever (variable, 11–55% of adults), tachycardia, tachypnea, hypoxia [2][7][15]
- General: Anxious, sitting upright/tripod position, toxic appearance
- Oropharynx: Often appears deceptively normal — pharyngeal exam may be unremarkable despite severe supraglottic disease [1]
- Voice: Muffled/"hot potato" quality
- Drooling — inability to manage secretions
- Stridor — late and ominous sign indicating significant airway narrowing
- Cervical lymphadenopathy — associated with need for airway intervention [15]
- Pearl: In children, do NOT examine the oropharynx aggressively or lay the child supine — this can precipitate complete airway obstruction [8]
11. Lab Studies
- CBC with differential: Leukocytosis with left shift; relative neutrophilia correlates with severity [6]
- CRP: Elevated; higher levels associated with ICU admission and airway intervention [5-6]
- Blood glucose: Hyperglycemia is a predictor of aggressive disease course [5-6]
- Blood cultures: Preferred specimen for microbiologic diagnosis (positive in ~27% of adults, up to 70% of children); obtain before antibiotics [16]
- Lactate, BMP: Assess for sepsis and dehydration
- Throat/epiglottic swab cultures: Only if airway is secured — risk of precipitating obstruction if attempted on an unsecured airway [16]
12. Imaging
- Lateral soft-tissue neck radiograph:
- "Thumbprint sign" — swollen, rounded epiglottis (vs. normal thin "little finger" shape)
- Thickened aryepiglottic folds
- Quick and useful but can be falsely negative — should not delay definitive visualization [1][17]
- Only obtain if the patient is stable; do not send an unstable patient to radiology
- CT neck with IV contrast: Useful if abscess is suspected (epiglottic abscess, deep neck space infection) or diagnosis is uncertain [18]
- Imaging is unnecessary if direct visualization confirms the diagnosis and the patient is stable
13. Special Tests
- Flexible nasopharyngolaryngoscopy (FNL): Gold standard for diagnosis — direct visualization of a swollen, erythematous, "cherry-red" epiglottis [1-2]
- In adults, bedside FNL is generally safe and well-tolerated
- In children, perform only in a controlled setting with airway equipment immediately available
- Fiber optic laryngoscopy (FOL) every 12 hours in ICU — serial improvement on FOL accurately predicts absence of need for intubation and can guide early ICU discharge [19]
- No validated clinical scoring system specific to epiglottitis severity exists
14. ECG
- Not routinely indicated unless:
- Hemodynamic instability or sepsis
- Pre-intubation assessment
- Cardiac comorbidities
- No specific ECG findings associated with epiglottitis
15. Assessment
Severity stratification based on clinical features: [6-7]
- Mild/moderate: Sore throat, dysphagia, low-grade fever, no respiratory distress — majority of adult cases
- Severe/high-risk: Stridor, dyspnea, tachypnea, hypoxia, drooling, epiglottic abscess, rapid progression
High-risk profile (warrants aggressive management): Male, dyspnea/stridor, edema of epiglottis AND aryepiglottic folds, elevated CRP, hyperglycemia, history of recurrent episodes [6]
Complications to consider
- Complete airway obstruction and death
- Failed intubation requiring surgical airway (cricothyroidotomy/tracheostomy) — occurred in 5.7% of all patients in one series [4]
- Epiglottic abscess
- Sepsis
- Anoxic brain injury from prolonged hypoxia [2][4]
- Pneumonia, mediastinitis (rare extension)
16. Treatment Plan
Initial stabilization
- Airway first — keep the patient calm, upright, and in a position of comfort; have difficult airway equipment at bedside
- Supplemental humidified oxygen
- Avoid agitation, unnecessary procedures, or laying the patient supine
Medications
- IV antibiotics (within 24 hours, ideally immediately):
- Ceftriaxone 2g IV daily (or cefotaxime) OR ampicillin/sulbactam 3g IV q6h [8]
- Add vancomycin 15–20 mg/kg IV q8–12h if MRSA is suspected [8]
- IV corticosteroids: Dexamethasone 10 mg IV or methylprednisolone — early steroids associated with 52% reduction in intubation risk; corticosteroid use was also associated with shorter ICU and overall hospital stays [3][7]
- Nebulized racemic epinephrine: Consider as temporizing measure for impending obstruction [1]
Airway intervention (if needed)
- Preferred approach: Awake flexible intubating endoscopy or video laryngoscopy with anesthesia and/or ENT at bedside [1]
- Surgical airway (cricothyroidotomy or tracheostomy) as rescue — needed in ~3–7% of those requiring intervention [2][4]
- In children: nasotracheal intubation under controlled conditions in the OR remains the standard approach
17. Disposition
- All patients with confirmed epiglottitis require hospital admission [1]
- ICU admission for:
- Any signs of respiratory distress, stridor, dyspnea, or hypoxia
- Intubated patients
- High-risk features (see severity stratification above)
- ICU admission rates range from 10–76% across series [6][15]
- Monitored floor bed may be appropriate for stable adults with mild symptoms, no respiratory distress, and improving serial laryngoscopy [19]
- Serial FOL every 12 hours — improvement on FOL accurately predicts safe course and can guide early ICU discharge (median ICU stay 1 day for non-intubated patients) [19]
- Consult ENT/otolaryngology early for all cases; anesthesia consultation for airway management planning [1]
18. Follow Up / Return Precautions
- Follow-up: ENT follow-up within 1–2 weeks for repeat laryngoscopy to confirm resolution
- Average hospital stay: 3–4 days [2][7]
- Expected course: Most patients improve within 24–48 hours of IV antibiotics and steroids; transition to oral antibiotics when tolerating PO and clinically improving
- Return precautions — instruct patients to return immediately for:
- Worsening sore throat or difficulty swallowing
- New or worsening difficulty breathing
- Drooling or inability to manage secretions
- Fever recurrence
- Voice changes
- Recurrence: Occurs in ~5% of patients; recurrent episodes tend to be more severe. Counsel patients about recognizing early symptoms [6]
- Hib vaccination — ensure up-to-date immunization in unvaccinated patients and close contacts (especially children) [8]
References
1. High Risk and Low Prevalence Diseases: Adult Epiglottitis. — Bridwell RE, Koyfman A, Long B. The American Journal of Emergency Medicine. 2022.
2. Epidemiology, Presentation, Management and Outcomes of Patients With Acute Epiglottitis - A 10-Year Retrospective Study Based on a Tertiary Hospital in Northern China. — Fan Z, Qiao T, Shi S, et al. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies : Affiliated With the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2025.
3. Association of Early Steroid and Antibiotic Therapy With Airway Outcomes in Adult Epiglottitis: A 10-Year Multicenter Retrospective Cohort Study. — O'Brien J, Muccio DR, Schrock JW. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2026.
4. A Retrospective Cohort Study of Acute Epiglottitis in Adults. — Felton P, Lutfy-Clayton L, Smith LG, Visintainer P, Rathlev NK. The Western Journal of Emergency Medicine. 2021.
5. Acute Upper Airway Obstruction. — Eskander A, de Almeida JR, Irish JC. The New England Journal of Medicine. 2019.
6. Adult Acute Supraglottitis: Analysis of 358 Patients for Predictors of Airway Intervention. — Shapira Galitz Y, Shoffel-Havakuk H, Cohen O, Halperin D, Lahav Y. The Laryngoscope. 2017.
7. Supraglottitis in the Era Following Widespread Immunization Against Haemophilus Influenzae Type B: Evolving Principles in Diagnosis and Management. — Guardiani E, Bliss M, Harley E. The Laryngoscope. 2010.
8. Antibiotic Use in Acute Upper Respiratory Tract Infections. — Sur DKC, Plesa ML. American Family Physician. 2022.
9. Symptoms and Signs Differentiating Croup and Epiglottitis. — Tibballs J, Watson T. Journal of Paediatrics and Child Health. 2011.
10. Acute Infectious Supraglottitis in Adult Population: Epidemiology, Management, Outcomes and Predictors of Airway Intervention. — Penella A, Mesalles-Ruiz M, Portillo A, et al. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies : Affiliated With the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2022.
11. Clinical Evaluation of Intravenous Ampicillin as Empirical Antimicrobial Treatment of Acute Epiglottitis. — Kjaerulff AMG, Rusan M, Klug TE. Acta Oto-Laryngologica. 2018.
12. Croup. — Bjornson CL, Johnson DW. Lancet. 2008.
13. Croup. — Cherry JD. The New England Journal of Medicine. 2008.
14. Acute Epiglottitis in Adults: A Retrospective Review of 106 Patients in Hong Kong. — Ng HL, Sin LM, Li MF, Que TL, Anandaciva S. Emergency Medicine Journal : EMJ. 2008.
15. Review of Epiglottitis in the Post Haemophilus Influenzae Type-B Vaccine Era. — Baird SM, Marsh PA, Padiglione A, et al. ANZ Journal of Surgery. 2018.
16. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). — Miller JM, Binnicker MJ, Campbell S, et al. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2024.
17. Imaging Acute Airway Obstruction in Infants and Children. — Darras KE, Roston AT, Yewchuk LK. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2015.
18. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. — Marin JR, Lyons TW, Claudius I, et al. Pediatrics. 2024.
19. The Management of Acute Supraglottitis Patients at the Intensive Care Unit. — Shaul C, Levin PD, Attal PD, et al. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies : Affiliated With the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2022.