{
 "topic": "Epiglottitis",
 "slug": "epiglottitis",
 "category_id": 15806,
 "summary": "Epiglottitis/supraglottitis: the abrupt drooling-dysphagia-distress triad, why it must not be confused with croup, and controlled airway management plus antibiotics.",
 "written_by": "claude-sonnet",
 "references": [
  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
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   ]
  },
  {
   "title": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online",
   "author": null,
   "pages": [
    974
   ]
  },
  {
   "title": "Illustrated Textbook of Paediatrics (Tom Lissauer, Will Carroll)",
   "author": "Lissauer, Tom,Carroll, Will",
   "pages": [
    312,
    313
   ]
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    1764,
    3857,
    7640
   ]
  },
  {
   "title": "Pediatric Board Study Guide",
   "author": null,
   "pages": [
    300,
    688
   ]
  },
  {
   "title": "The Harriet Lane Handbook (The Johns Hopkins Hospital)",
   "author": null,
   "pages": [
    31
   ]
  },
  {
   "title": "The Harriet Lane Handbook 22nd Edition (2020) (The Johns Hopkins Hospital)",
   "author": null,
   "pages": [
    31
   ]
  }
 ],
 "short": [
  {
   "title": "In short",
   "content": "- Epiglottitis (supraglottitis) is a life-threatening, rapidly progressive inflammation of the epiglottis and surrounding supraglottic structures, classically caused by Haemophilus influenzae type B (Hib).\n- Peak age is 1-8 years (most sources say 2-7 years), though it can occur at any age; onset is abrupt, typically presenting within 6-24 hours of first symptoms.\n- Since Hib vaccination, incidence has fallen dramatically - as low as 0.02 per 100,000 in Western countries - and today's cases are more often Streptococcus pneumoniae, group A streptococcus, or Staphylococcus aureus, with sporadic Hib cases in unimmunized children or vaccine failures.\n- Classic triad: drooling, dysphagia, and (respiratory) distress, with high fever and a toxic, anxious appearance; the child often sits upright leaning forward or in a tripod position (upright, neck extended, mouth open).\n- Unlike croup, there is no preceding viral prodrome or barky cough, and the voice may be muffled (\"hot potato\" voice); stridor, when present, is typically quiet and not always prominent.\n- Lateral neck radiograph may show the \"thumbprint sign\" (enlarged, thickened epiglottis and aryepiglottic folds) with occasional mild subglottic narrowing, but direct instrumentation/visualization should only be attempted in a controlled operative setting given the risk of precipitating airway obstruction.\n- Do not agitate the child or manipulate the oropharynx outside a controlled setting - this can precipitate sudden, complete airway obstruction.\n- Management: secure the airway (endotracheal or nasotracheal intubation, rarely tracheostomy), typically for 2-3 days until inflammation subsides, plus broad-spectrum antibiotics such as vancomycin and cefotaxime (or ceftriaxone/cefotaxime).\n- Occult H. influenzae bacteremia can lead to meningitis or other focal infection in 30-50% of cases, underscoring the need for prompt antibiotic treatment of the underlying infection.\n"
  }
 ],
 "long": [
  {
   "title": "Definition",
   "content": "Epiglottitis, more accurately termed supraglottitis, is an infectious process causing rapidly progressive inflammation and edema of the epiglottis and its associated supraglottic structures - the aryepiglottic folds, arytenoids, ventricular bands, and (per some sources) the uvula - that can quickly obstruct the airway and constitutes a true medical emergency. The subglottic space and trachea are typically spared.\n"
  },
  {
   "title": "Epidemiology",
   "content": "Epiglottitis primarily affects children between 1 and 8 years of age, with most sources citing a peak between 2 and 7 years, though it may occur at any age including infants, older children, and adults. Since the introduction of the Hib conjugate vaccine, incidence has fallen dramatically, to as low as 0.02 per 100,000 in Western countries, and it is now uncommon enough that many younger clinicians have never encountered a case - raising the risk of delayed diagnosis. Sporadic cases still occur in unimmunized children, in children with vaccine failure, and it remains an important cause of epiglottitis in adults. Disease is also more common in elderly and immunocompromised patients relative to the general population.\n"
  },
  {
   "title": "Etiology",
   "content": "Historically, Haemophilus influenzae type B accounted for the great majority (over 90%) of pediatric epiglottitis. Following widespread Hib vaccination, the predominant pathogens shifted to Streptococcus pneumoniae, Staphylococcus aureus, group A beta-hemolytic streptococci, and Moraxella catarrhalis. Less common infectious causes include Pseudomonas species, herpesviruses, fungi, and viral agents such as parainfluenza, HSV-1, and varicella. Noninfectious causes include direct trauma, thermal injury, caustic ingestion, and foreign body.\n"
  },
  {
   "title": "Clinical Features",
   "content": "Onset is abrupt: a previously well child spikes a high fever and rapidly develops sore throat, dysphagia, and drooling, progressing within 6-24 hours (most within 12 hours) to respiratory distress. The classic clinical triad is drooling, dysphagia, and distress. The child appears toxic, anxious, and febrile, often sitting upright and leaning forward, or adopting a tripod stance (upright, neck extended, mouth open) to maximize airflow. Stridor, when present, is typically quiet rather than harsh, and is not always a prominent feature. Voice may be muffled (\"hot potato\" voice). Critically, unlike croup, there is no preceding viral prodrome and no barky cough, and the child is not hoarse. Sudden, complete airway compromise can be precipitated by agitation or manipulation of the oropharynx.\n"
  },
  {
   "title": "Diagnostics",
   "content": "Diagnosis is primarily clinical, and distinguishing epiglottitis from croup is essential since their management differs substantially. A lateral soft-tissue neck radiograph may show the classic \"thumbprint sign\" - an enlarged, thickened epiglottis and aryepiglottic folds - sometimes with mild subglottic narrowing, but obtaining radiographs should never delay airway management, and in severe cases unnecessary studies should be avoided until the airway is secured. Direct visualization confirms a swollen, erythematous (classically cherry-red) epiglottis, but instrumentation or direct laryngoscopy is best performed in a controlled operative setting with anesthesia and surgical airway back-up available, because attempted visualization outside this setting risks precipitating complete obstruction. A skilled provider should remain with the patient continuously until the airway is visualized and secured.\n"
  },
  {
   "title": "Differential Diagnosis",
   "content": "The key distinction is from croup (viral laryngotracheobronchitis), which has a preceding viral prodrome, barky cough, and hoarseness, in contrast to the abrupt, toxic presentation of epiglottitis without cough or hoarseness. Other considerations include retropharyngeal abscess, bacterial tracheitis, foreign body aspiration, caustic or thermal injury, and (rarely) diphtheria.\n"
  },
  {
   "title": "Treatment",
   "content": "Management centers on securing the airway and eradicating the infection. Immediate involvement of otolaryngology (and ideally a pediatric anesthesiologist and pediatric surgeon or otolaryngologist) is a mainstay, with intubation (nasotracheal, or occasionally tracheostomy) performed under controlled conditions to establish a definitive airway; children are generally intubated for about 2-3 days, since response to antibiotics is usually rapid. The child should be kept as calm as possible and undisturbed until the airway is secured, using standard precautions. Broad-spectrum antibiotics are started promptly - for example vancomycin plus cefotaxime, or ceftriaxone/cefotaxime - to cover the range of causative organisms.\n"
  },
  {
   "title": "Complications",
   "content": "Occult H. influenzae bacteremia accompanying epiglottitis leads to meningitis or another deep/focal infection in 30-50% of cases, which is a major reason for prompt, adequate antibiotic therapy in addition to airway management.\n"
  }
 ],
 "clinical": [
  {
   "title": "Recognizing and Stabilizing the Child with Epiglottitis",
   "content": "Suspect epiglottitis in a toxic-appearing, febrile child aged roughly 1-8 years with the triad of drooling, dysphagia, and respiratory distress, especially when sitting upright, leaning forward, or tripoding, with no preceding viral prodrome, no barky cough, and no hoarseness - features that separate it from croup. Do not agitate the child, attempt to examine the oropharynx with a tongue depressor, place the child supine, or send the child alone for imaging: any of these can precipitate sudden, complete airway obstruction. Keep the child calm, ideally in a caregiver's lap, and move directly toward definitive airway management. If a lateral neck radiograph is obtained, it should not delay this process; a thumbprint sign supports the diagnosis but a normal or unobtainable film does not exclude it in a clinically classic presentation. A skilled provider should stay with the patient at all times until the airway is visualized and secured.\n"
  },
  {
   "title": "Airway Management and Antibiotics",
   "content": "Involve otolaryngology (and, where available, a pediatric anesthesiologist and pediatric surgeon or otolaryngologist) immediately for controlled evaluation and, typically, nasotracheal intubation in the operating room; tracheostomy is used less often. Direct visualization/instrumentation should be performed only in this controlled setting because of the risk of triggering complete obstruction. Expect intubation to be needed for about 2-3 days given the usually rapid response to antibiotics. Start broad-spectrum antibiotics promptly - vancomycin plus cefotaxime, or ceftriaxone/cefotaxime - to cover H. influenzae, S. pneumoniae, group A streptococcus, and S. aureus. Because occult H. influenzae bacteremia leads to meningitis or another deep/focal infection in 30-50% of cases, adequate systemic antibiotic treatment of the underlying infection is essential alongside airway management.\n"
  }
 ]
}