Epiglottitis

Etiology

• Pathogens:
  • Historically: Haemophilus influenzae type b (Hib) (most common in unvaccinated/undervaccinated).
  • Current vaccinated era: Streptococcus pneumoniae, Streptococcus pyogenes (GAS), Staphylococcus aureus (including MRSA), non-typeable H. influenzae.
• Risk Groups:
  • Unvaccinated/undervaccinated children (peak historically 2–7 years).
  • Adults (mean age ~45 years, especially with DM, obesity, or immunosuppression).

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Pathophysiology

Mnemonic

The hallmarks of epiglottitis are the three Ds: Dysphagia, Drooling, and Distress.

• Drooling is due to pain in swallowing.

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Clinical features

• Acute, rapidly progressive course (<24 hours).
• The Classic “3 Ds”:
  • Drooling (due to severe odynophagia).
  • Dysphagia.
  • Dysphonia (muffled, “hot potato” voice).
• Other Key Signs:
  • High fever, severe sore throat out of proportion to pharyngeal exam (pharyngeal findings are typically normal) c
  • Tripod/Sniffing position (sitting up, leaning forward, hyperextended neck, open mouth).
    • Eases respiration as the airway diameter is increased by leaning forward and extending the neck in a seated position
  • Inspiratory stridor, tachypnea, suprasternal/intercostal retractions.
  • Absence of a barking cough (distinguishes from croup).

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Diagnostics

• Initial/Screening:
  • Clinical suspicion: Do NOT agitate the patient (avoid IV lines, supine positioning, or pharyngeal exam with tongue depressor prior to securing the airway $\to$ risk of fatal laryngospasm).
• Imaging (Only if stable and diagnosis in doubt): c
  • Lateral neck X-ray: Demonstrates “thumbprint sign” (swollen, enlarged epiglottis) and loss of the vallecular space.
• Confirmatory/Gold Standard:
  • Direct visualization/Nasopharyngolaryngoscopy: Performed strictly in a controlled setting (OR/ICU) with surgical airway backup.
  • Shows swollen, cherry-red epiglottis and arytenoids.
• Key Labs (Obtained after airway is secured):
  • Blood cultures (frequently positive in Hib).
  • Epiglottic surface swab/culture.
  • CBC: Marked leukocytosis with left shift.

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Differential Diagnostics

• Croup (Laryngotracheobronchitis):
  • Diff by viral prodrome, subacute onset, low-grade fever, “barking” seal-like cough, and “steeple sign” (subglottic narrowing) on AP neck X-ray. c
• Peritonsillar Abscess (Quinsy):
  • Diff by unilateral tonsillar bulge, uvula deviation to contralateral side, and prominent trismus; common in older adolescents/young adults.
• Retropharyngeal Abscess:
  • Diff by fever, limited neck extension/torticollis, and widened prevertebral soft tissue shadow on lateral neck X-ray; confirmed via contrast-enhanced CT neck.
• Foreign Body Aspiration:
  • Diff by sudden-onset choking/stridor without fever or infectious prodrome; unilateral focal wheezing or air trapping on chest X-ray.
• Bacterial Tracheitis:
  • Diff by “croup-like” illness that rapidly worsens with high fever, toxic appearance, and thick, purulent tracheal secretions resistant to nebulized epinephrine.

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Treatment

• 1. Airway Stabilization (First-Line / Absolute Priority):
  • Keep child calm (allow to remain in parent’s lap, provide blow-by ${\text{O}}_2$).
  • Immediate controlled Endotracheal Intubation (ETT) in the operating room (OR) by skilled personnel (ENT and Anesthesia).
  • Prepare for immediate surgical airway (cricothyrotomy/tracheostomy) if ETT fails.
• 2. Medical Therapy (Empiric IV Antibiotics):
  • Initiate immediately after airway control:
    • IV 3rd-generation cephalosporin (Ceftriaxone or Cefotaxime)
    • PLUS an anti-staphylococcal agent covering MRSA (Vancomycin or Clindamycin).
  • Duration: 7–10 days total (transition to PO based on sensitivities once extubated and afebrile).
• 3. Chemoprophylaxis:
  • Rifampin prophylaxis for all household contacts if H. influenzae type b is isolated AND there is an unvaccinated/undervaccinated child $<4$ yo or an immunocompromised contact in the home.