Epiglottitis is inflammation and swelling of the epiglottis caused by infection, typically with haemophilus influenza type B. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing. Therefore, epiglottitis is a life threatening emergency.
Epiglottitis is now rare due to the routine vaccination program, which vaccinates all children against haemophilus. You need to be extra cautious and have high suspicion in children that have not had vaccines. It can present in a similar way to croup, but with a more rapid onset. In you exams keep a lookout for an unvaccinated child presenting with a fever, sore throat, difficulty swallowing that is sitting forward and drooling and suspect epiglottitis.
Presentation Suggesting Possible Epiglottitis
- Patient presenting with a sore throat and stridor
- Drooling
- Tripod position, sat forward with a hand on each knee
- High fever
- Difficulty or painful swallowing
- Muffled voice
- Scared and quiet child
- Septic and unwell appearance
Investigations
If the patient is acutely unwell and epiglottitis is suspected then investigations should not be performed. Performing a lateral xray of the neck shows a characteristic “thumb sign” or “thumbprint sign”. This is a soft tissue shadow that looks like a thumb pressed into the trachea. This is caused by the oedematous and swollen epiglottis. Neck xrays are also useful for excluding a foreign body.
Management
Epiglottitis is an emergency and there is an immediate risk of the airway closing. A key point that is often talked about with epiglottitis is the importance of not distressing the patient, as this could prompt closure of the airway. If you see a child with suspected epiglottitis, leave them well alone and in their comfort zone. Don’t examine them and don’t make them upset. The most important thing is to alert the most senior paediatrician and anaesthetist available.
Management of epiglottis centres around ensuring the airway is secure. Most patients do not require intubation, however there is an ongoing risk of sudden upper airway closure, so preparations need to be made to perform intubation at any time. Intubation is often difficult and needs to be performed in a controlled environment with facilities available to do a tracheostomy (intubating through the neck) if the airway completely closes. When patients are intubated they are transferred to an intensive care unit.
Additional treatment once the airway is secure:
- IV antibiotics (e.g. ceftriaxone)
- Steroids (i.e. dexamethasone)
Prognosis
Most children recover without requiring intubation. Most patients that are intubated can be extubated after a few days and also make a full recovery. Death can occur in severe cases or if it is not diagnosed and managed in time.
A common complication to be aware of is the development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.
Last updated August 2019