What are the causes of a high riding epiglottis?

Causes of High Riding Epiglottis

The most common causes of high riding epiglottis include congenital anomalies, laryngomalacia, and anatomical variations that may be normal in many individuals, particularly children. 1

Congenital and Anatomical Causes

• Congenital laryngeal anomalies:

  • Laryngomalacia - most common congenital laryngeal anomaly causing stridor in infants 2
  • Shortened aryepiglottic folds 2
  • Retroflexed epiglottis 2
  • Normal anatomical variation - especially in children, an elongated high-rising epiglottis can be a normal variant 1

• Structural abnormalities:

  • Bifid epiglottis 2
  • Ventral cleft of the larynx 2
  • Laryngeal webs and atresia 2

Pathological Causes

• Inflammatory conditions:

  • Acute epiglottitis - causes swelling that can alter epiglottic position 3
  • Chronic laryngitis 4
  • Gastroesophageal reflux disease (GERD) - can cause laryngopharyngeal reflux changes 2, 4

• Traumatic causes:

  • Foreign body ingestion or aspiration 5
  • Direct trauma from surgical or anesthetic interventions 2
  • Iatrogenic injury from laryngoscopy or intubation 2

• Neuromuscular disorders:

  • Vocal cord paralysis - third most common congenital laryngeal anomaly 2
  • Diminished laryngeal tone 2

• Floppy epiglottis:

  • Idiopathic cases 6
  • Secondary cases (often associated with neck masses or other pathology) 7

Clinical Significance and Diagnosis

• High riding epiglottis may present with:

  • Stridor (particularly inspiratory) 2
  • Foreign body sensation in the throat 1
  • In severe cases: dyspnea, oxygen desaturation, or apnea 2

• Diagnostic approach:

  • Flexible laryngoscopy is the gold standard for diagnosis 2
  • Examination during symptomatic periods is crucial, as findings may be normal at rest 2
  • Continuous laryngoscopy during exercise may be needed for exercise-induced symptoms 2

Clinical Pearls and Pitfalls

• A high-riding epiglottis in children is often a normal variant and may not require treatment if asymptomatic 1

• Misdiagnosis is common:

  • May be mistaken for asthma or paradoxical vocal cord movement 6
  • Can be confused with exercise-induced bronchoconstriction 2

• When evaluating stridor, it's essential to examine both upper and lower airways, as abnormalities below the epiglottis were found in up to 68% of cases 2

• Delayed diagnosis can lead to increased healthcare costs and potentially life-threatening complications 4

• In adults, a floppy or high-riding epiglottis is more likely to be pathological and requires thorough investigation 7