Epiglottitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Epiglottitis is a life-threatening bacterial infection causing acute inflammation and swelling of the epiglottis, leading to airway obstruction. It is a medical emergency requiring immediate recognition and management.

Aetiology

The most common causes include:

  • Infectious causes:
    • Haemophilus influenzae type B (Hib): most common cause, particularly in unvaccinated children.
    • Streptococcus pneumoniae: more common in adults.
    • Staphylococcus aureus: can be associated with severe cases.
    • Neisseria meningitidis: rare but possible cause.
  • Non-infectious causes:
    • Thermal injury (e.g., inhalation of hot steam or smoke).
    • Direct trauma to the throat.
    • Caustic ingestion (e.g., chemical burns).

Pathophysiology

Epiglottitis develops due to bacterial invasion and inflammation of the epiglottis, leading to:

  • Rapid swelling of the epiglottis and surrounding structures.
  • Obstruction of the upper airway, causing stridor and respiratory distress.
  • Potential progression to complete airway obstruction if untreated.

Risk factors

  • Unvaccinated children (Hib vaccine reduces risk).
  • Immunosuppression (e.g., HIV, chemotherapy, steroid use).
  • Smoking or second-hand smoke exposure.
  • Recent upper respiratory tract infections.

Signs and symptoms

Epiglottitis presents acutely, often with the "classic triad" of:

  • Dysphagia: difficulty swallowing.
  • Drooling: due to inability to swallow saliva.
  • Distress: agitation, anxious appearance.

Other features:

  • High fever.
  • Stridor (late sign indicating airway obstruction).
  • Severe sore throat with minimal visible findings on examination.
  • Tripod positioning (leaning forward to improve airflow).
  • Soft voice or inability to speak.

Investigations

Do not delay treatment for investigations if airway obstruction is suspected.

  • Lateral neck X-ray:
    • May show the "thumb sign" (swollen epiglottis).
    • Should only be done if the airway is stable.
  • Fibreoptic nasoendoscopy:
    • Diagnostic but should only be performed in a controlled setting (e.g., anaesthetic room with airway backup).
  • Blood tests:
    • Full blood count (FBC) may show leukocytosis.
    • Blood cultures if sepsis is suspected.

Management

Epiglottitis is a medical emergency. do not attempt to examine the throat with a tongue depressor as this may precipitate airway obstruction.

1. Immediate Management:

  • Call for urgent airway support: involve anaesthetics and ENT specialists immediately.
  • Keep the patient calm: avoid unnecessary distress as this can worsen obstruction.
  • Administer high-flow oxygen: via a non-rebreather mask.

2. Airway Management:

  • Perform controlled intubation in a specialist setting (operating theatre or ICU).
  • If intubation is not possible, emergency cricothyroidotomy may be required.

3. Antibiotic Therapy:

  • First-line: IV ceftriaxone or cefotaxime.
  • Alternative: IV co-amoxiclav in penicillin-allergic patients.
  • Continue for 7–10 days.

4. Adjunctive Therapy:

  • Dexamethasone: reduces inflammation and swelling.
  • Fluids if the patient is unable to maintain oral intake.

Referral

All cases of suspected epiglottitis require immediate referral to secondary care:

  • Emergency Department: Immediate transfer for airway assessment and stabilisation.
  • ENT Specialist: for airway management and possible intubation.
  • Intensive Care Unit (ICU): If advanced airway support is required.
 
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