Epiglottitis
Otolaryngology
Illness script · Otolaryngology
Epiglottitis
Acute, life-threatening supraglottic inflammation causing rapid airway obstruction; classically Haemophilus influenzae type b in children, now more common in adults.
This illness script for Epiglottitis covers predisposing factors, classic presentation, mechanism, workup, management, and the clinical pivots that separate it from look-alikes—written for USMLE Step 1 and clerkship reasoning.
01
Predisposing factors
- Children 2–7 y (pre-Hib vaccine era); now adults predominate in vaccinated populations
- Unvaccinated or immunocompromised patients at highest risk
- Pathogens: H. influenzae type b, Streptococcus pyogenes, S. pneumoniae, S. aureus
- Thermal/chemical injury can mimic infectious epiglottitis in adults
02
Presentation
- Classic triad: high fever, drooling, dysphagia (the '3 Ds') + muffled 'hot-potato' voice
- Tripod/sniffing position — child leans forward on hands to maximize airway
- Rapid progression over hours (distinguishes from croup's gradual onset)
- Inspiratory stridor; no barky cough (key negative vs. croup)
- Toxic-appearing, anxious child; throat exam contraindicated — may precipitate arrest
- Adults present more indolently: sore throat, odynophagia, anterior neck tenderness
03
Pathophysiology
- Bacterial invasion → cellulitis and edema of epiglottis and supraglottic structures
- Edematous epiglottis curls posteriorly, progressively occludes glottic inlet
- Airway obstruction worsens with agitation or supine positioning
04
Diagnostics
- Do NOT attempt throat exam or lay patient supine before airway is secured
- Lateral neck X-ray: 'thumbprint sign' (swollen epiglottis) — if patient is stable
- Gold standard: direct laryngoscopy in controlled OR/setting showing cherry-red edematous epiglottis
- Blood cultures positive in ~25% of H. influenzae cases
- CT neck useful in adults when diagnosis is uncertain and airway is stable
05
Management
- Airway first: immediate ENT + anesthesia to OR for intubation or surgical airway
- Keep patient calm, upright, with parent; avoid agitating procedures before airway secured
- IV antibiotics: ceftriaxone (covers H. influenzae + streptococci) ± vancomycin if MRSA concern
- Corticosteroids (dexamethasone) commonly used to reduce edema — evidence limited but standard practice
- ICU admission after airway secured; extubate in 24–48 h once edema resolves
06
Clinical pivots
How to separate this script from the look-alikes that show up on exams and on the wards.
Croup (Laryngotracheobronchitis)
Croup has barky/seal cough, steeple sign on X-ray, gradual onset, and non-toxic appearance
Bacterial Tracheitis
Bacterial tracheitis shows subglottic narrowing + tracheal pseudomembranes; epiglottis is normal
Peritonsillar Abscess
Peritonsillar abscess causes uvular deviation and trismus, not supraglottic edema or thumbprint sign
Foreign Body Aspiration
No fever or toxic appearance; sudden onset during eating/play; radiopaque object may be visible
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Educational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.