INTRODUCTION The pathogenesis, etiology, and clinical features of epiglottitis (also called

supraglottitis) will be reviewed here. The treatment and prevention of epiglottitis are discussed
separately. (See "Epiglottitis (supraglottitis): Treatment and prevention".)
DEFINITION Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures [1].
Without treatment, epiglottitis can progress to life-threatening airway obstruction. A rapid overview of
the recognition and management of epiglottitis in children is provided in the table (table 1).
ANATOMY The epiglottis forms the back wall of the vallecular space below the base of the tongue
(figure 1). It is connected to the thyroid cartilage and hyoid bone by ligaments. The epiglottis consists
of a thin cartilage that is covered anteriorly by a stratified squamous epithelial layer. This squamous
layer also covers the superior third of the posterior surface, where it merges with respiratory
epithelium that extends into the larynx. The epithelium and lamina propria beneath are tightly
adherent on the posterior (laryngeal) surface and loosely attached on the anterior (lingual) surface.
This creates a potential space on the lingual surface for edema fluid to collect.
PATHOGENESIS Infectious epiglottitis is a cellulitis of the epiglottis, aryepiglottic folds, and other
adjacent tissues. It results from bacteremia and/or direct invasion of the epithelial layer by the
pathogenic organism [2,3]. The posterior nasopharynx is the primary source of pathogens in
epiglottitis. Microscopic trauma to the epithelial surface (eg, mucosal damage during a viral infection
or from food during swallowing) may be a predisposing factor.
Swelling of the epiglottis results from edema and accumulation of inflammatory cells in the potential
space between the squamous epithelial layer and the epiglottal cartilage. The lingual surface of the
epiglottis and periepiglottic tissues have abundant networks of lymphatic and blood vessels that
facilitate spread of infection and the subsequent inflammatory response. Once infection begins,
swelling rapidly progresses to involve the entire supraglottic larynx (including the aryepiglottic folds
and arytenoids) [3,4]. The subglottic regions generally are not affected; swelling is halted by the tightly
bound epithelium at the level of the vocal cords.
Supraglottic swelling reduces the caliber of the upper airway, causing turbulent airflow during
inspiration (stridor) [3]. Additional mechanisms of airflow obstruction may include posterior and inferior
curling of the epiglottis (which acts as a ball-valve, obstructing airflow during inspiration but permitting
exhalation) and aspiration of oropharyngeal secretions [2,3].
Airway obstruction, which may result in cardiopulmonary arrest, can be rapidly progressive. The signs
of severe upper airway obstruction (eg, stridor/stertor, intercostal and suprasternal retraction,
tachypnea, and cyanosis) may be absent until late in the disease process, when airway obstruction is
nearly complete [5,6].
ETIOLOGY
Infectious causes Epiglottitis may be caused by a number of bacterial, viral, and fungal pathogens
(table 2). In previously healthy children, most cases are bacterial. The most frequent pathogens vary
depending upon patient age and immune status.
Children Haemophilus influenzae type b (Hib) is the most common infectious cause of
epiglottitis in children. Although the incidence of Hib epiglottitis declined after Hib was added to
the routine infant immunization schedule in the United States and other developed countries, Hib
epiglottitis still occurs, even in immunized children [7-11]. In a case series from a single
institution, Hib accounted for 6 of 19 cases between 1992 and 2002; five of the cases occurred
in children who had been fully immunized [7]. Additional causes of epiglottitis in children include
other H. influenzae (types A, F, and nontypeable), streptococci, and Staphylococcus

aureus (table 2), including methicillin-resistant strains [12]. Group A streptococcal epiglottitis
complicating primary varicella has also been reported [13].
Adults In adults, epiglottitis has been associated with a broad range of bacteria, viruses,
combined viral-bacterial infections fungi, and noninfectious causes (table 2) [5]. In most cases,
blood and throat cultures are negative [11,14,15]. However, among cases in which a pathogen is
identified, Hib is most common, accounting for 3 to 14 percent of all cases [11,14-17].
Immunocompromised hosts In immunocompromised hosts, epiglottitis may be caused
by Pseudomonas aeruginosa and Candida species [18-20]. A single case of epiglottitis caused
by Histoplasma capsulatum has also been described in an adult
receiving infliximab, prednisone, and azathioprine for Crohn disease [21].
Noninfectious causes Traumatic causes of epiglottitis include thermal injury, foreign body
ingestion, and caustic ingestion [22-26]. Epiglottitis also may rarely occur as a complication of bone
marrow or solid organ transplantation (eg, as a manifestation of post-transplant lymphoproliferative
disease or graft-versus-host disease) [27,28].
EPIDEMIOLOGY
Incidence and median age The epidemiology of epiglottitis changed after the addition of
the Haemophilus influenzae type b (Hib) conjugate vaccine to the routine infant immunization
schedule in the United States and other developed countries [29-36].
The two important changes are as follows:
Decreased incidence The average annual incidence of epiglottitis in children has
decreased. The annual incidence of epiglottitis among children declined dramatically after
introduction of vaccines against Hib. In the United States, the annual rate of epiglottitis prior to
the availability of Hib vaccines was approximately 5 per 100,000 children ages 5 years old [2].
Among immunized children in some populations, estimates of epiglottitis rates have ranged from
0.6 to 0.8 cases per 100,000 [5,8]. Additional studies suggest even greater overall declines in
epiglottitis in immunized children over time [32,37-39].
The incidence of epiglottitis in adults appears largely stable in the past few decades with 0.6 to
1.9 cases per 100,000 persons annually in Iceland and Denmark studies, respectively [32,38]. In
the United States, cases among adults also remained about the same from 1998 to 2006. There
were an estimated 3405 total cases in 2006 among persons 18 years old and 369 among
children <18 years old [40].
Based upon United States adult (20 years old) and pediatric (<20 years old) population
estimates of 217.4 million and 82 million for 2006 [41], there were about 1.6 cases of epiglottitis
per 100,000 adults and 0.5 cases per 100,000 children in the United States in 2006.
Increased age of children with epiglottitis The median age of children with epiglottitis has
increased from 3 years of age to approximately 6 to 12 years of age [7,37].
In the pre-Hib-vaccine era in the US, 72 percent of cases of epiglottis occurred in children
between the ages of one and five years, with peak occurrence in the third year of life [2]. The
median age of children with epiglottitis in one center increased from 36 months during 1979 to
1989 (134 children) to 80 months during 1990 to 1992 (8 children) [37]. In another center, the
mean ages of 9 children with epiglottis from 1992 to 1997, and 10 children from 1998 to 2002
were 5.8 years and 11.6 years, respectively (P = 008) [7]. Epiglottitis historically has been
somewhat more common in boys (58 percent) than girls [2].

Risk factors In children, risk factors for epiglottitis include incomplete or lack of immunization for
Hib and immune deficiency [42-44]. For example, a five year old with epiglottitis as the initial
presentation of systemic lupus erythematosus has been described [45]. In addition, some hosts may
be genetically more susceptible to invasive Hib infection [46-49]. (See "Epiglottitis (supraglottitis):
Treatment and prevention", section on 'Additional evaluation'.)
In adults, epiglottitis has been associated with a number of comorbid conditions, including
hypertension, diabetes mellitus, substance abuse, and immune deficiency [14,50-53].
CLINICAL FEATURES Suspected epiglottitis is a medical emergency. To minimize morbidity and
mortality, prompt recognition and treatment is critical (table 1).
Presentation The primary objective in the management of patients with epiglottitis is to make a
definitive diagnosis and initiate treatment before the onset of airway obstruction [3]. Maintenance of
the airway is the focus of treatment. In patients with signs of total or near-total airway obstruction,
airway control necessarily precedes diagnostic evaluation [3]. (See "Epiglottitis (supraglottitis):
Treatment and prevention" and "Emergency endotracheal intubation in children" and "Advanced
emergency airway management in adults".)
The clinical features of epiglottitis differ with age, severity, and etiology. Young children classically
present with respiratory distress, anxiety, and the characteristic "tripod" or "sniffing" posture (picture
1 and picture 2) in which they assume a sitting position with the trunk leaning forward, neck
hyperextended, and chin thrust forward in an effort to maximize the diameter of the obstructed airway
[6]. They may be reluctant to lie down [2]. However, the presentation may be subtle (picture 3).
Drooling is often present. Cough is typically absent. Older children, adolescents, and adults may
present with a severe sore throat but relatively normal oropharyngeal examination.
Children Abrupt onset and rapid progression (within hours) of dysphagia, drooling, and distress
("the three D's") are hallmarks of epiglottitis in children [6,54-58]. Although many patients have minor
antecedent upper respiratory tract symptoms, the usual duration of notable illness before
hospitalization is <24 hours and frequently <12 hours.
Sudden onset of high fever (between 38.8 and 40.0C), severe sore throat, odynophagia, and drooling
is common. Children with epiglottitis usually appear "toxic" (picture 2); however, there is a wide
spectrum of severity (picture 3). They experience a choking sensation, are distressed during
inspiration, and are anxious, restless, and irritable. Their speech is muffled, often described as a "hot
potato" voice [6]. Children with epiglottitis may also assume a sitting position with the trunk leaning
forward, neck hyperextended, and chin thrust forward in an effort to maximize the diameter of the
obstructed airway (the "tripod" posture, (picture 1)) [6]. Stridor is frequently present [59]. Furthermore,
children with epiglottitis generally lack hoarseness of the voice or cough, which are more
characteristic of croup. (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Clinical
presentation'.)
In a case series of 134 children with epiglottitis from a single state (1975 to 1992), the following
findings were documented in the history or physical examination [14]:
Symptoms:
Difficulty breathing (80 percent)
Stridor (80 percent)
Muffled or hoarse voice (79 percent)
Pharyngitis (73 percent)
Fever (57 percent)

Sore throat (50 percent)

Tenderness of anterior neck (38 percent)
Cough (30 percent)
Difficulty swallowing (26 percent)
Change in voice (20 percent)
In a series of 102 children with croup and 101 with epiglottitis, drooling, preferring to sit, refusal to
swallow and dysphagia were more common in children with epiglottitis while cough was more
common in those with croup [59]. Fever was present in >90 percent of children with epiglottitis,
drooling in 80 percent with epiglottitis but <10 percent with croup, and stridor and retractions in 80
percent of both conditions. Cough was noted in <10 percent of children with epiglottitis in this series.
Adults Presenting features of epiglottitis in adults include [5,14,15,32,60]:
Sore throat or odynophagia (90 to 100 percent)
Fever 37.5C (26 to 90 percent)
Muffled voice (50 to 80 percent)
Drooling (15 to 65 percent)
Stridor or respiratory compromise (approximately 33 percent)
Hoarseness (20 to 40 percent)
Sore throat is the most common major complaint in adults (91 to 94 percent) [11,50]. Airway
compromise also is far less common in adults than children.
Artificial airway support was required in only 7 of 106 (6.6 percent) of adults in one series [50] and 9 of
57 (16 percent) of patients in another series [11].
The progression of symptoms in adults is slower than that in children. In one series of 106 patients, 65
percent presented within two days of symptom onset, but 9 percent presented more than one week
later [50].
Examination The approach to diagnosing epiglottitis, including which patients should undergo
attempts at direct visualization, depend upon the patient's age, degree of illness, and the clinician's
suspicion for epiglottitis.
Visualization of the epiglottis is an accepted standard for clinical diagnosis in adults [11], although
radiographs are use to make the diagnosis in patients with mild disease, who may then be admitted to
an intensive care unit (ICU) for intravenous antibiotics without an artificial airway or direct
visualization.
Examining children Examination efforts should be individualized according to the severity of
illness of the child, immunization status, and the suspicion for epiglottitis (algorithm 1).
Epiglottitis likely There are rare reports of cardiorespiratory arrest in children during
attempts to visualize the epiglottis [61]. These arrests have been attributed to functional airway
obstruction (resulting from increased respiratory effort secondary to increased anxiety),
aggravation of airway obstruction caused by supine positioning, and/or laryngospasm.
Presumably the patients who have arrested after visualization have had pre-existing, nearly
complete obstruction from epiglottal swelling which would like manifest with the classical findings
of anxiety, severe respiratory distress, and assumption of the tripod and sniffing positions.
These patients would typically have fairly definitive signs of epiglottitis (eg, anxiety, "sniffing"
position (picture 2), and signs of upper airway involvement, particularly stridor, drooling, or

"tripod" posture (picture 1), and no cough). Prompt involvement of airway experts (eg,
otolaryngologists and anesthesiologists with pediatric expertise) to evaluate and manage such
patients is warranted prior to any attempts at visualization. (See 'Diagnostic criteria' below.)
Epiglottitis unlikely In children with mild symptoms in whom epiglottitis is a possibility but
for whom other diagnoses are also likely (table 3), cautious examination of the child's throat is
appropriate to determine best management. Mild symptoms are defined as (1) absence of
stridor, stridor that is not constant in resting state, or stridor that is associated with absent or mild
suprasternal retractions; (2) no or minimal increase in symptoms during agitation or exertion;
and (3) no cyanosis [62]. The risk of routine examination of the oropharynx is also lessened in a
child who is fully immunized against Haemophilus influenzae, type b.
The child should be permitted to take a position of comfort in the upright position and be
assessed gently, while being held by the parent to reduce anxiety that could provoke increased
respiratory distress. In children who are able to be cooperative (generally beyond toddler age
and only in moderate respiratory distress), direct pharyngoscopy with aid of a tongue blade has
been described as successful in some such children [62,63] and represents the usual approach
in most emergency departments. Alternatively, fiberoptic nasolaryngoscopy and/or indirect
laryngoscopy with a 70 degree endoscope can be attempted by a skilled practitioner [62-64].
The choice of setting where any endoscopic procedure is to be performed (ie, an operating
room, intensive care unit, or emergency department) should be determined on a case by case
basis, accounting for (1) the severity of illness of the child; (2) the skills and experience of
available health care personnel; and (3) the quality of the resuscitative resources available within
each option in a particular institution.
As an alternative for children in whom oral examination increases anxiety and epiglottitis
remains a distinct possibility, lateral neck radiographs may be obtained [3]. Such radiographs are
preferably obtained in the emergency department or intensive care unit rather than sending the
child to a radiology department where resuscitative capacity may be limited. (See 'Radiographic
features' below.)
Examining adults As in children, the approach to adults generally should be guided by the degree
of apparent respiratory compromise. Patients with impending or complete airway obstruction should
have the airway secured. (See "Advanced emergency airway management in adults".)
Direct (routine) examination of the oropharynx as an initial step generally is safer in adults than in
children given the lower frequency of airway compromise when epiglottitis is present. When such
examination fails to permit visualization of the epiglottis, or seems unsafe to attempt, clinicians may
proceed to either lateral neck films or laryngoscopy. Laryngoscopic visualization of the epiglottis (eg,
flexible nasolaryngoscopy, indirect or direct approaches) is likely the gold standard for clinical
diagnosis, but lateral neck films are abnormal (generally showing the classic "thumb sign") in 77 to 88
percent in two larger adult case series [11,50].
Diagnosis may be confirmed by radiography if direct examination appears unsafe or the epiglottis is
not seen [11] or laryngoscopy appears unsafe or unsuccessful. (See'Diagnostic criteria' below.)
Examination findings (children and adults) On examination of the oral cavity and oropharynx in
patients with epiglottitis, pooled secretions may be noted [3]. The laryngotracheal complex may be
tender to palpation, particularly in the region of the hyoid bone [65-67]. Examination findings
consistent with epiglottitis include inflammation and edema of the supraglottic structures (epiglottis,

aryepiglottic folds, and arytenoid cartilages) (picture 4) [5]. The false vocal cords also may be involved
[15].
However, the oropharyngeal examination is normal in the majority of patients and an enlarged
epiglottis is frequently not seen [5,15,68]. Nasolaryngoscopy, plain radiography, or visualization during
direct laryngoscopy under general anesthesia in the operating room is frequently necessary to confirm
the diagnosis. (See 'Diagnosis'below.)
Extra-epiglottic foci of infection Patients should also be examined for extra-epiglottic foci of
infection (eg, pneumonia, cervical adenitis, cellulitis, septic arthritis, or less commonly, meningitis),
particularly if a pathogen that frequently causes invasive disease at other sites is a possibility (eg, S.
pneumoniae, Haemophilus influenzae, type b) [69]. Additional evaluation for extra-epiglottic infection
is guided by clinical findings. (See appropriate topic reviews).
Laboratory features Laboratory studies should not be performed in patients in whom epiglottitis is
strongly suspected until the airway is secured because agitation caused by pain may worsen
respiratory distress. Laboratory evaluation should include complete blood count with differential, blood
culture, and epiglottal culture (in intubated patients).
Most patients with epiglottitis have an elevated white blood cell count [5], but this finding is
nonspecific.
The yield of blood and epiglottal cultures is discussed below. (See 'Microbiology' below.)
The laboratory evaluation for a child who develops Haemophilus influenzae, type b epiglottitis or
pneumococcal epiglottitis despite having been immunized is discussed separately. (See "Epiglottitis
(supraglottitis): Treatment and prevention", section on 'Additional evaluation'.)
Radiographic features Soft-tissue lateral neck radiographs can confirm the diagnosis of
epiglottitis but are not necessary in many cases in which the likelihood of epiglottitis is sufficiently low
(eg, immunized children with a hoarse voice and characteristic cough of croup), such that no imaging
is indicated, or high, in which case direct visualization in the operating suite, if possible, is preferred.
Radiographs are most helpful in the evaluation of patients in whom epiglottitis is a possibility, but other
conditions are more likely (table 3) [70].
Radiographs should be deferred if they increase the child's level of anxiety or will delay definitive
diagnosis and management [14,36]. If it is necessary for the patient with more than a low likelihood of
epiglottitis to be transported to the radiology department (ie, if portable radiographs cannot be
obtained), the patient must be accompanied by a personnel skilled with advanced airway
management and with proper equipment and medications.
Radiographic features of epiglottitis include [2,71]:
An enlarged epiglottis protruding from the anterior wall of the hypopharynx (the "thumb sign",
(image 1)). In adults with epiglottitis, the width of the epiglottis is usually >8 mm [72].
Loss of the vallecular air space, a finding that may be underappreciated.
Thickened aryepiglottic folds (image 2). In adults with epiglottitis, the width of the aryepiglottic
folds is usually >7 mm [72].
Distended hypopharynx (nonspecific).
Straightening or reversal of the normal cervical lordosis (nonspecific).
Bedside ultrasound evaluation of the epiglottis in adults has been described, but its role in diagnosing
epiglottitis is unclear [73,74]. The ultrasonographic appearance of epiglottitis in adults has been

described as an "alphabet P sign", formed by an acoustic shadow of the swollen epiglottis and hyoid
bone at the level of the thyrohyoid membrane when imaged in longitudinal orientation [73]. An
evaluation of ultrasound in 15 adults with epiglottitis and 15 healthy controls found that an increased
anteroposterior diameter of the epiglottis at either lateral edge may also discriminate between those
with and without epiglottitis. The lower limit of the diameter in adults with epiglottitis was 3.6 versus
3.2 mm upper limit in the controls [75]. No pediatric experience with ultrasound has as yet been
reported.
Causative organism Review of the clinical features, management, and outcome of 407 cases of
epiglottitis from a single state over an 18-year period suggests that the clinical features vary
depending upon whether or not Haemophilus influenzae (Hib) is the causative pathogen as follows
[14]:
Hib epiglottis is associated with the "classic" features; it is more common in young children, is
rapidly progressive, involves the epiglottis more than the surrounding structures, and has a high
risk of airway obstruction.
Non-Hib epiglottitis is more common in adults and generally has a slower onset, greater
involvement of the supraglottal structures than the epiglottis, and a lower risk of airway
obstruction.
DIAGNOSIS
Clinical suspicion Epiglottitis should be suspected in young children, especially those who are unor under-immunized against Haemophilus influenzae, type b (Hib) and who present with the
characteristic clinical features as follows:
Tripod" position (picture 1)
Anxiety (picture 2)
Sore throat
Stridor
Drooling
Dysphagia
Respiratory distress
Because of the potential for rapid progression to complete airway obstruction, the threshold for
suspicion of epiglottitis should be low.
Epiglottitis should be suspected in older children, adolescents, and adults in whom the severity of sore
throat is out of proportion to the findings on oropharyngeal examination [5].
Diagnostic criteria Maintenance of the airway is the mainstay of treatment. In patients with signs
of total or near-total airway obstruction, airway control necessarily precedes diagnostic evaluation [3].
(See "Epiglottitis (supraglottitis): Treatment and prevention" and "Emergency endotracheal intubation
in children" and "Advanced emergency airway management in adults".)
The diagnosis of epiglottitis is confirmed by visualization of an erythematous, edematous epiglottis
(picture 5) during direct laryngoscopy when securing the airway, nasolaryngoscopy using a fiberoptic
scope, or on oropharyngeal examination. Alternatively, demonstration of epiglottal swelling on lateral
neck radiographs in cases when direct visualization is not performed can provide the diagnosis
(algorithm 1). The diagnostic approach depends upon the patient's age and clinical status.
(See'Examination' above and 'Radiographic features' above.)

Visualization of the epiglottis in children or adults with suspected epiglottitis and signs of severe upper
airway obstruction should be attempted only in a setting where the airway can be secured
immediately if necessary (eg, the operating room, emergency department, or intensive care unit).
(See 'Examination' above.)
Radiographs are not necessary to make a diagnosis of epiglottitis, particularly if the patient shows
signs of impending or complete airway obstruction, the clinical diagnosis is apparent, or the epiglottis
is visualized during oropharyngeal examination using a tongue depressor (if safe and tolerated),
flexible nasolaryngoscopy, or other laryngoscopic approach. However, if radiographs can be obtained
without placing the patient at risk (eg, by increasing anxiety in a child or requiring the patient to leave
the emergency department), radiographic findings often can confirm a suspected diagnosis and be
used to mobilize the multidisciplinary airway management team. (See"Epiglottitis (supraglottitis):
Treatment and prevention".)
Findings on soft-tissue lateral neck radiographs that are consistent with epiglottitis include an
enlarged epiglottis, loss of the vallecular air space, thickened aryepiglottic folds, a distended
hypopharynx, and straightening of the cervical spine (image 1). (See 'Radiographic features' above.)
However, compared with visualization of the epiglottis, radiographs lack sensitivity (38 to 88 percent)
and specificity (78 percent), and may delay diagnosis in critically ill patients [11,65,76]. However, in
patients with a subacute presentation, radiographs may be indicated to evaluate conditions in the
differential diagnosis that are considered to be more likely than epiglottitis (table 3) [70].
(See 'Differential diagnosis' below.)
Microbiology The etiologic diagnosis is sometimes made by culture of a pathogenic organism
from the blood or the surface of the epiglottis.
Blood and epiglottic cultures should be obtained after the airway is secure [6,65]. Swabbing the
epiglottis is difficult, potentially dangerous, and contraindicated in patients who are not intubated
[36,77].
Epiglottal cultures are positive in 33 to 75 percent of patients with epiglottitis [15,60,77,78].
Blood cultures are positive in approximately 70 percent of children with epiglottitis caused by H.
influenza, type b (Hib) [79]. In children immunized against Hib, the yield of blood cultures is likely
lower. In adult case series, the yield of blood cultures ranges from 0 to 17 percent [5].
DIFFERENTIAL DIAGNOSIS The differential diagnosis of epiglottitis includes other causes of
acute upper airway obstruction, including (table 3):
Laryngotracheitis (croup) or spasmodic croup (angioedema-like response with less
inflammation visible by laryngoscopy)
Uvulitis
Bacterial tracheitis
Peritonsillar or retropharyngeal abscesses
Foreign body lodged in the larynx or vallecula
Angioedema (anaphylaxis or hereditary)
Congenital anomalies of the upper airway
Diphtheria
Upper airway trauma or thermal injury
The emergent evaluation of acute upper airway obstruction in children is discussed separately.
(See "Emergency evaluation of acute upper airway obstruction in children".)

Croup Epiglottitis is distinguished from croup by the absence of "barking" cough and the
presence of anxiety and drooling. Children with croup generally are comfortable in the supine
position and have a normal-appearing epiglottis, when visualized, on examination. If obtained,
lateral neck radiographs in patients with croup may demonstrate distention of the hypopharynx
during inspiration, subglottic haziness, and a normal epiglottis (image 3). (See "Croup: Clinical
features, evaluation, and diagnosis", section on 'Clinical presentation'.)
Uvulitis Infectious uvulitis may occur in conjunction with epiglottitis, pharyngitis, or as an
isolated infection. In patients with isolated uvulitis with a massively swollen uvula, the
presentation may mimic that of epiglottitis. Swelling and erythema of the uvula are the
characteristic findings on examination (picture 6). (See"Uvulitis: Clinical features and treatment",
section on 'Clinical features'.)
Bacterial tracheitis Bacterial tracheitis may be a complication of viral laryngotracheitis
(croup) or a primary bacterial infection. Primary bacterial tracheitis may present with acute onset
of upper airway obstruction, fever, and toxic appearance, similar to epiglottitis. However,
radiographs may demonstrate intraluminal membranes and irregularities of the tracheal wall, as
well as a normal epiglottis and supraglottic region (image 4). Direct tracheoscopy may be
necessary for diagnosis (picture 7). (See "Bacterial tracheitis in children: Clinical features and
diagnosis", section on 'Clinical features'.)
Peritonsillar or retropharyngeal infection Children with peritonsillar or
retropharyngeal cellulitis/abscess, or other painful infections of the oropharynx, may present with
drooling and neck extension [80]. Children with these infections usually are not as toxic
appearing or anxious as those with acute epiglottitis. However, a soft tissue lateral neck
radiograph may be helpful in confirming or excluding the presence of epiglottitis.
(See "Peritonsillar cellulitis and abscess" and"Retropharyngeal infections in children".)
Foreign bodies Foreign bodies in the larynx or trachea can cause complete or partial airway
obstruction that requires immediate treatment. Foreign bodies lodged in the esophagus in the
area of the cricoid cartilage or the tracheal bifurcation can compress the airway, causing partial
airway obstruction. Symptoms are likely to have an abrupt onset, and fever is absent.
(See "Emergency evaluation of acute upper airway obstruction in children", section on 'Foreign
bodies' and "Foreign bodies of the esophagus and gastrointestinal tract in children".)
Angioedema (anaphylaxis or hereditary) Allergic reaction or acute angioneurotic edema
has rapid onset without antecedent cold symptoms or fever. The primary manifestations are
swelling of the lips and tongue, urticarial rash, dysphagia without hoarseness, and sometimes
inspiratory stridor [81,82]. There may be a history of allergy or a previous attack.
(See "Anaphylaxis: Rapid recognition and treatment".)
Congenital anomalies and laryngeal papillomas Congenital anomalies of the upper airway
and laryngeal papillomas sometimes cause symptoms similar to those of epiglottitis. However,
these conditions have a chronic course and generally do not cause fever (unless symptoms are
due to exacerbation of airway narrowing due to a concomitant viral infection). (See "Congenital
anomalies of the larynx".)
Diphtheria The clinical presentation of diphtheria can be similar to that of epiglottitis. The
onset of symptoms is typically gradual. Sore throat, malaise, and low-grade fever are the most
common presenting symptoms. A diphtheritic membrane (gray and sharply demarcated, (picture
8)) may be present. Diphtheria is exceedingly rare in countries with high rates of immunization
for diphtheria, tetanus, and pertussis. (See "Epidemiology and pathophysiology of
diphtheria" and"Approach to diagnosis of acute infectious pharyngitis in children and
adolescents", section on 'Other bacteria'.)

Other causes of epiglottic enlargement Other causes of epiglottic enlargement, such as

neck radiation therapy, trauma, or thermal injury, generally can be elucidated by history
[22,83,84]. Laryngopyocele, an infectious complication of laryngoceles, which are uncommon
abnormal air sacs in the larynx, also may mimic epiglottitis both in clinical presentation and on
lateral neck radiographs [85].
SUMMARY AND RECOMMENDATIONS
Epiglottitis (supraglottitis) is inflammation of the epiglottis and adjacent supraglottic structures.
A rapid overview of the recognition and management of epiglottitis in children is provided in the
table (table 1). (See 'Definition' above.)
In adults, epiglottitis may be caused by a number of bacterial, viral, and fungal pathogens
(table 2). In the otherwise healthy child, most cases are bacterial. Epiglottitis also may be
caused by trauma (eg, foreign body ingestion, thermal injury, or caustic ingestion).
(See 'Etiology' above.)
Young children with epiglottitis classically present with fever, stridor, drooling, respiratory
distress, anxiety, and the characteristic "sniffing" posture (picture 2), but the presentation may be
more subtle (picture 3). Older children, adolescents, and adults may present with a severe sore
throat, relatively mild respiratory symptoms, and anterior neck pain, but relatively normal
oropharyngeal examination. (See 'Clinical features' above.)
In the patient with impending or complete obstruction, or with a convincing picture of epiglottitis,
the clinician should focus on interventions that may be needed for airway management without
attempting any other diagnostic procedures. (See "Epiglottitis (supraglottitis): Treatment and
prevention", section on 'Airway management'.)
For patients without impending or complete upper airway obstruction or in whom the diagnosis
of epiglottitis is unclear, the diagnostic approach depends upon the patient's age and clinical
status (see 'Diagnosis' above):
The approach for a child with suspected epiglottitis is provided in the algorithm (algorithm
1).
In the adult with suspected epiglottitis, attempted visualization of the epiglottis using a
tongue depressor may be accomplished safely more often than in children. The clinician
may proceed to laryngoscopy (eg, indirect, flexible fiberoptic, or direct approaches) if direct
examination appears unsafe or the epiglottis is not seen.
Diagnosis of epiglottitis is confirmed by visualization of inflammation and edema of the
supraglottic structures (epiglottis, aryepiglottic folds, and arytenoid cartilages) (picture 5) or in
cases when direct visualization is not performed, epiglottic swelling on lateral neck radiographs
(image 1). If performed, visualization of the epiglottis should occur in a setting where the airway
can be secured immediately if necessary. (See 'Diagnosis' above and 'Examination' above.)
Soft-tissue radiographs of the lateral neck are not necessary to make a diagnosis of epiglottitis
but represent a reasonable choice in stable patients for whom there is a low suspicion of
epiglottitis and may be indicated when other diagnostic considerations remain in the differential
diagnosis (table 3). (See 'Radiographic features'above and 'Differential diagnosis' above.)
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Topic 6080 Version