Abstract:
Epiglottitis should be considered in
the differential diagnosis of any
child with acute upper airway ob-
struction, although the incidence
has decreased dramatically since
the introduction of the conjugate
Haemophilus influenzae type b vac-
cine. Despite this decline, there are
still more than 3000 admissions
per year for this disease. Recent
attention toward the potential for
noncompliance with vaccination
guidelines suggests that this inci-
dence may increase. Airway man-
agement takes precedence over all
other interventions and requires
multidisciplinary coordination be-
tween emergency medicine, an-
esthesiology, and otolaryngology
providers. An immediate diagnosis,
treatment, and prophylaxis for close
contacts greatly improve recovery
time, increase survival rate, and, in
turn, reduce overall cost of disease
management and patient care. The
potential lethality of this disease
mandates that all health care pro-
viders remain acutely aware of how
to immediately and effectively
triage and intervene with a patient
with epiglottitis.
Keywords:
bacteremia; bacterial infection;
children; epiglottitis; H influenzae
type b; inflammation; laryngeal/
airway obstruction; pediatric;
supraglottitis; swelling; vaccine
*Department of Otolaryngology and
Communication Enhancement, Boston
Children's Hospital, Boston, MA;
†Department of Otology and Laryngology,
Harvard Medical School, Boston, MA;
‡Division of Otolaryngology, Children's
National Medical Center, Washington, DC.
Reprint requests and correspondence:
Rahul Shah, MD, FACS, Division of
Otolaryngology, Children's National Medical
Epiglottitis
Eelam A. Adil, MD, MBA*†1,
Ajman Adil, BA†1,
Rahul K. Shah, MD, FACS‡
E
piglottitis is an infection of the supraglottic larynx
(portion of the larynx superior to the vocal folds). It is
a potentially lethal condition if not recognized and
treated promptly. Prior to the introduction of the
conjugated Haemophilus influenzae type b (Hib) vaccine, epiglottitis
primarily affected children from 2 to 6 years of age. Since the
introduction of the vaccine, there has been a decline in pediatric
cases and an increase in adult supraglottitis, particularly those
between 45-64 years and older than 85 years. 1 Although there
has been a relative decrease in the incidence of disease,
epiglottitis should still be considered in the differential diagnosis
of any child who presents with acute upper airway obstruction.
This article will review the current microbiology, presentation,
evaluation, management, and prevention techniques of pediatric
epiglottitis.
MICROBIOLOGY
H influenzae type b was a significant source of pediatric
morbidity and mortality prior to the 1990s. This gram-negative
aerobic coccobacillus was the causative organism for most cases
of epiglottitis, meningitis, and other serious bacterial infections
in children. The Hib vaccine was introduced in the United States
in 1985 as a polysaccharide vaccine. Polysaccharides result in T
cell–independent B-cell activation, which results in poor or
absent immune response in infants who have an immature
immune system. 2 The polysaccharide component was later
attached to a protein carrier to improve the efficacy of the
vaccine by recruiting T cells to the immune response. The
conjugate vaccine is now recommended by the Centers for
Disease Control and Prevention for all US children younger
than 5 years. It is typically administered initially at 2 months
of age and is available in combination with other vaccines
such as diphtheria, tetanus, and pertussis to limit the number
of injections.
Despite widespread use of the Hib vaccine, vaccine failure is possible
and cases of Hib epiglottitis are still reported. 3–7Streptococcus
EPIGLOTTITIS / ADIL ET AL. • VOL. 16, NO. 3 149
150 VOL. 16, NO. 3 • EPIGLOTTITIS / ADIL ET AL.
Center, 111 Michigan Ave, NW, Washington,
DC 20010.
eelam.adil@childrens.harvard.edu (E.A. Adil),
ajmanadil@gmail.com (A. Adil),
rshah@cnmc.org (R.K. Shah)
1
Tel.: +1 617 355 2415.
1522-8401
© 2015 Elsevier Inc. All rights reserved.
EPIDEMIOLOGY
Since the introduction of the conjugate Hib
vaccine, there has been a dramatic decline in the
incidence of pediatric epiglottitis, particularly cases
where Hib was the causative organism. One study
noted an 84% decrease in incidence with 10.9 cases
per 10 000 admissions prior to 1990 and 1.8 cases
per 10 000 admissions from 1990 to 1992. 5 From a
national perspective, there continues to be a decline
in admission for epiglottitis, with more than 4500
cases in 1998 to approximately 3800 in 2006. 1
There has also been a shift in the age of patients,
with less patients younger than 18 years and more
middle-aged (45-64 years old) and elderly patients.
PRESENTATION
A child with epiglottitis typically has a toxic
appearance. Classically, caregivers will report rapid
onset of noisy breathing and inability to tolerate
secretions. On examination, the patient may have
inspiratory stridor and a muffled voice quality.
Drooling or spitting up secretions is common.
Suprasternal and/or subcostal retractions may also
be noted. Patients may assume the classic “tripod”
position in which they are leaning forward with their
arms extended to support them, or “sniffing”
position with their neck forward, head upward,
and their mouth open in order to maintain an
airway. Altered mental status, mottled skin, and
cyanosis are signs that airway obstruction and
circulatory collapse are imminent.
EVALUATION
Often the patient arrives via ambulance to the
emergency department. If possible, prior to arrival,
the attending emergency medicine, anesthesiology,
and otolaryngology staff should be made aware of
the patient. If airway obstruction is imminent,
arrangements should be made to transport the
patient directly to the operating room or for
pneumoniae and beta-hemolytic streptococcus, particularly
group A, have also been implicated in many recent cases.
Other less common infectious causes include Staphylococcus
aureus, nontypeable H influenzae, Moraxella catarrhalis, Pseu-
domonas, Haemophilus parainfluenzae, Candida albicans, and
Neisseria species. Infection of the epiglottis can occur in
isolation or as a result of bacterial superinfection of an upper
respiratory tract viral infection. Noninfectious causes such as
trauma, burns, caustic injury, and lymphoproliferative
disorder have also been described. 8
advanced airway equipment to be available in the
emergency department (Figure 1).
The evaluation of a pediatric patient with sus-
pected epiglottitis should proceed rapidly. The
patient should remain in a position of comfort,
typically sitting upright in the lap of a parent, and
should never be forced to assume a different
position. Caregivers should be questioned about
when the illness began, sick contacts, immunization
status, medical comorbidities, medications, and
their last meal (to be ready to secure the airway as
necessary). The extent of the physical examination
is determined on a case-by-case basis, but should
not agitate the patient, which could precipitate
airway obstruction. In addition, practitioners capa-
ble of resuscitation and securing the airway in the
event of acute obstruction should perform the
evaluation. Indeed our mentor, Dr Gerald B.
Healy, a father of pediatric otolaryngology, strongly
advocates that the patient should not be perturbed
and the diagnosis should be made based on the
above constellation of symptoms. This includes
minimal manipulation of the throat (avoiding use
of a tongue depressor, lowering the lights in the
room to keep the patient calm, etc).
Noninvasive hemodynamic monitors can usually
be applied without significant discomfort. Patients
will often exhibit tachycardia and tachypnea. The
presence of hypoxia is concerning for significant
airway obstruction. Auscultation will usually reveal
inspiratory stridor. Crackles may occur late in the
presentation as a result of negative pressure
pulmonary edema from inspiring against an
obstructed glottis. A basic oral cavity/oropharyngeal
examination without a tongue blade in a cooperative
child can help rule out peritonsillar or retrophar-
yngeal swelling. Neck swelling and decreased range
of motion of the neck are atypical and may be
indicative of a deep neck space infection (Table 1).
In a stable and tolerant patient, a portable lateral
neck radiograph can be considered to support the
diagnosis. The edematous epiglottis will have a
 EPIGLOTTITIS / ADIL ET AL. • VOL. 16, NO. 3 151

mask while an intravenous line is secured. Simul-

• Initial rapid assessment of potential for epiglottitis
Assessment
• Approach the child calmly and avoid aggravating the child, do
not use a tongue depressor to examine the oral cavity
Examination
• Ensure the multi-disciplinary team is available and alerted for
Personnel the potential patient
Resources
• Airway management if necessary should be performed in the
Airway
operating room with mask ventilation proceeding to airway
evaluation and intubation; a surgical airway is a last resort
Management
• Obtain cultures if possible, continue airway intubation in an
ICU setting until a leak develops, and begin appropriate
Ongoing
Care antibiotics as indicated
• Wean to extubate as airway parameters permit; consider an
Extubation
interval examination in the operating room prior to extubation
Figure 1. Approach the evaluation and management of a child
with epiglottitis.
“thumb print” appearance on lateral x-ray (Figure 2).
The aryepiglottic folds also may appear enlarged.
Hypopharyngeal distension can also be noted. Com-
puted tomography, ultrasound, and magnetic reso-
nance imaging are generally not necessary in the
evaluation of acute epiglottitis.
MANAGEMENT
Airway management should be performed in the
operating room if possible (Figure 1). Traditionally,
the patient's parent should accompany the patient
to the operating room to avoid unnecessary distress.
Blow-by oxygen is administered via a noninvasive
taneously, a plan for airway management is
rehearsed between the anesthesiology and otolar-
yngology physicians. Given the potential mortality
of this condition, the most experienced physicians
available should be the only providers allowed to
intervene. Other physicians and staff are available
for assistance if necessary. Ensure proper equip-
ment is available, including the necessary surgical
equipment, which should be opened and ready
to use.
Securing the airway is critical. Equipment for
cricothyroidotomy and tracheostomy should be
immediately available in the room. Airway adjuncts
such as nasopharyngeal airways and/or laryngeal
mask airways are generally not useful as they lie
above the area of airway obstruction. General
anesthesia is induced via face mask with inhala-
tional agents with the patient sitting upright on the
operating room table. Once anesthesia is induced,
the patient is left spontaneously ventilating and the
patient is brought into the supine position. The
intubating physician uses a rigid laryngoscope to
visualize the glottis. An endotracheal tube armed
over an infant telescope is used to intubate the
patient. External laryngeal manipulation can be
applied to improve the view if necessary. Common-
ly, all that can be seen is a central cleavage between
the very inflamed and edematous epiglottis and
arytenoids (Figure 3). If this cleavage is not seen,
compression on the chest may promote air escape
through the vocal cords and “air bubbles” that can
direct endotracheal tube placement.
If the airway cannot be secured via intubation and
the patient's condition begins to deteriorate, then
tracheostomy should be considered. Although this
was considered the standard of care decades ago, a
surgical airway is rarely used in the management
of epiglottitis in the modern era. This is because
there is much documentation that most patients

TABLE 1. Differential diagnosis of acute infectious pediatric upper airway obstruction.

Infection Clinical Hallmarks X-ray Imaging Findings

Epiglottitis Rapid onset, high fever, inspiratory stridor, “Thumb print,” thickened aryepiglottic folds,
toxic appearance, drooling, tripod position hypopharyngeal distension
Laryngotracheobronchitis (croup) Viral prodrome, hoarseness, stridor, barking cough “Steeple” sign
Peritonsillar abscess Trismus, drooling, muffled voice quality N/A
Retropharyngeal/parapharyngeal Fever, trismus, neck swelling, decreased Retropharyngeal thickening
abscess neck range of motion, drooling
Bacterial tracheitis Rapid onset, fever, cough, stridor, toxic appearance Tracheal haziness
152 VOL. 16, NO. 3 • EPIGLOTTITIS / ADIL ET AL.
Figure 2. Soft tissue lateral neck film showing diffuse thickening
of the epiglottis, with a thumbprint sign. The aryepiglottic folds are
also thickened. Courtesy of Joshua Nagler, MD, MHPEd.
with epiglottitis can be mask ventilated quite
successfully. 9 Cricothyroidotomy is generally not
feasible in younger children where the cricothyroid
membrane is just millimeters in height, but no lower
age limit has been defined. The patient is laid supine
and anterior neck landmarks are palpated. The
nondominant hand is used to hold the larynx steady.
A vertical skin incision is made through the skin and
subcutaneous tissue with the dominant hand be-
tween the inferior edge of the thyroid cartilage and
the upper tracheal cartilage. Blunt dissection is
Figure 3. Edematous, erythematous epiglottis as seen during
direct laryngoscopy in a patient previously intubated for epiglottitis.
Courtesy of Joshua Nagler, MD, MHPEd.
performed down to the tracheal cartilage. If avail-
able, a cricoid hook is applied by an assistant to
elevate the trachea anteriorly and superiorly. A
vertical incision is made in the tracheal cartilage
between the first and third tracheal rings. If there is
uncertainty regarding the location of the airway, an
18-gauge needle attached to a syringe filled with
saline can be used. The needle is advanced in the
suspected airway and negative pressure applied to
the syringe. The location of the airway can be
confirmed by withdrawal of air, manifested by
bubbles in the saline. An endotracheal tube or
tracheostomy tube can be inserted into the trache-
otomy and the anesthesia circuit applied. Cardio-
pulmonary resuscitation should begin if the patient
develops bradycardia according to the Pediatric
Advanced Life Support protocol.
Once the airway is established, aerobic and
anaerobic cultures of the epiglottis should be taken
(Figure 1). Blood cultures, white blood cell count,
electrolyte panel, and arterial blood gas should also be
performed. Intravenous antimicrobial therapy should
be administered once cultures have been obtained.
Third-generation cephalosporins such as ceftriaxone
or cefotaxime are the treatment of choice because they
eradicate Hib colonization. 10 With the airway secured,
the patient should be transported to the intensive care
unit for critical airway monitoring. Over the course
of the next 24 to 72 hours, the patient's toxicity
and fever are expected to gradually diminish. The
endotracheal tube can usually be removed within 72
hours. Depending on the patient condition and
facilities available, a decision should be made regard-
ing extubation in the intensive care setting or in the
operating room (Figure 1). Extubation in the operating
room allows for a direct laryngoscopy and bronchos-
copy to examine the entire airway prior to committing
to extubation. Antibiotic therapy is continued for 7 to
14 days. For patients younger than 2 years who
received an antibiotic other than ceftriaxone or
cefotaxime, rifampin should be administered prior to
hospital discharge as it eradicates nasopharyngeal
carriage in more than 95% of patients. 11–14
PREVENTION
The rate of secondary disease in the 60 days after
exposure to a patient infected with Hib is highest for
patients younger than 12 months (6%). 15 For
household contacts younger than 48 months, the
rate drops to 2.1%. The risk for household contacts
is highest; information regarding day care contacts
is conflicting. Regardless of immunization status,
chemoprophylaxis with rifampin is recommended
for household contacts that are young (b 4 years

of age) or immunocompromised (b 18 years of age). 10
Chemoprophylaxis is recommended for all children
and providers at a child care facility if there have been
more than 2 cases of invasive Hib infection in the prior
60-day period and if there are unimmunized or
underimmunized children who attend the facility.
SUMMARY
Acute pediatric epiglottitis is rare since the
introduction of the conjugated Hib vaccine. A recent
study using a national inpatient database found only
342 pediatric admissions for epiglottitis in the
United States in 2003. 16 Of these patients, 40
required an airway intervention such as intubation
or tracheostomy. Given the rarity of this condition
and its potential morbidity, clinicians must main-
tain a high index of suspicion when approaching any
child with acute upper airway obstruction. If there is
concern for acute epiglottitis based on rapid onset of
symptoms, inspiratory stridor, and toxic appear-
ance, then invasive assessments should be avoided
and immediate consultation with anesthesiology
and otolaryngology should be a priority.
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