Management of Suspected Epiglottitis
In suspected epiglottitis, immediately secure the airway in a controlled setting with emergency equipment ready, avoid any throat examination or manipulation that could precipitate complete airway obstruction, obtain blood cultures for diagnosis, and initiate broad-spectrum antibiotics while monitoring in an intensive care unit. 1, 2
Immediate Priorities: Airway First
Do NOT Examine the Throat
- Never attempt throat examination with tongue depressors or swabs, as this may precipitate complete airway obstruction and death. 3, 1, 2
- The epiglottis may swell dramatically, and any disturbance can cause sudden tracheal occlusion 3
- Direct visualization should only occur in a controlled setting with emergency airway equipment immediately available 1
Airway Management Strategy
- Position the patient upright if conscious to optimize airway patency 1
- Immediately discuss with an intensivist and prepare for rapid transfer to ICU 1
- Have difficult airway equipment at bedside including videolaryngoscope, supraglottic airway devices, and surgical airway equipment for emergency cricothyroidotomy 1
- Follow a structured difficult airway algorithm with clear plans for failed intubation 1
The decision to intubate prophylactically remains somewhat controversial in adults. While pediatric mortality dropped from 7% to 1% with aggressive airway management, adult mortality remains at 7% 4. Adults often present with milder symptoms than children, and selective intubation based on clinical severity is reasonable 5, 6. However, any signs of respiratory distress, stridor, oxygen desaturation, dyspnea, or inability to handle secretions warrant immediate preparation for emergency airway management 7, 6.
Clinical Indicators for Immediate Intubation
- Severe respiratory distress or signs of upper airway obstruction 7, 5
- Stridor (present in only 42% of cases, so absence does not exclude severe disease) 6
- Inability to swallow secretions (83% of cases) 6
- Oxygen desaturation 7
- Laryngeal edema on visualization 7
Diagnostic Approach
Preferred Diagnostic Method
- Blood cultures are the preferred diagnostic sample because they avoid the risk of precipitating airway obstruction during direct examination 3, 2
- Blood cultures often identify Haemophilus influenzae as the causative organism 2, 8
Visualization When Safe
- Fiberoptic laryngoscopy is the gold standard for diagnosis when it can be performed safely 4, 6
- Lateral neck X-rays have utility but less sensitivity than direct visualization 4
- A normal oropharyngeal examination does NOT exclude epiglottitis—44% of patients have normal oropharynx on routine examination 6
Medical Management
Antibiotic Therapy
- Initiate broad-spectrum intravenous antibiotics immediately 8, 6
- Ampicillin/sulbactam is appropriate empiric coverage 8
Adjunctive Therapy
- Intravenous corticosteroids (dexamethasone) 8, 6
- NSAIDs for symptom management 6
- Consider adrenaline inhalation 6
Monitoring and Disposition
ICU Admission Mandatory
- All patients with suspected or confirmed epiglottitis require ICU admission for continuous monitoring, even if initially stable 1, 5, 6
- Patients can deteriorate despite treatment, even if initial findings are mild 7
- Most patients require 24 hours of ICU monitoring before transfer to wards 5
Critical Pitfall to Avoid
The most dangerous error is failing to recognize that patients can rapidly deteriorate after initial presentation. 7 Even patients without initial respiratory symptoms can progress to complete airway obstruction. The clinical threshold for airway intervention must remain low, as this is the only way to prevent death 6. One case report describes a patient initially treated for asthma exacerbation who died when emergency intubation failed without a tracheostomy set at bedside 6.
Key Clinical Presentation Features
The classic presentation includes sudden onset of severe sore throat, odynophagia (100% of cases), inability to swallow secretions (83%), fever (75%), and potential rapid progression to airway obstruction 2, 6. However, stridor is present in less than half of cases, so its absence should not provide false reassurance 6.