Acute Epiglottitis: Clinical Management and Treatment
Immediate Airway Management is the Priority
Acute epiglottitis is a life-threatening emergency requiring immediate airway assessment and preparation for emergency intervention, as airway obstruction can occur suddenly and unpredictably. 1
Critical Initial Actions
- Do NOT examine the throat with a tongue depressor - this can precipitate complete airway obstruction and is absolutely contraindicated 1
- Immediately contact an intensivist and prepare for emergency airway management with appropriate equipment and personnel 1
- Position the patient upright if conscious to optimize airway patency 1
- Maintain continuous monitoring for signs of deterioration 1
Clinical Presentation
The classic presentation includes:
- Odynophagia (100% of cases) - severe throat pain with swallowing 2
- Inability to swallow secretions (83%) - often with drooling 2
- Dyspnea (58%) and respiratory distress 2
- Fever (75%) and tachycardia (50%) 2
- Stridor occurs in only 42% of cases - its absence does not exclude the diagnosis 2
- Hoarseness (50%) 2
Critical pitfall: 44% of patients have a normal oropharyngeal examination, making visualization of the epiglottis via fiberoptic laryngoscopy essential for diagnosis 2
Diagnostic Approach
- Fiberoptic laryngoscopy is the gold standard for visualizing the inflamed epiglottis 2
- Lateral neck radiograph can rapidly confirm the diagnosis (97% sensitivity) showing the classic "thumb sign" 3
- Obtain blood cultures to identify the causative organism (typically Haemophilus influenzae type b in 97% of cases) 3
Airway Management Decision Algorithm
Indications for immediate airway intervention:
- Laryngeal edema on examination 4
- Oxygen desaturation 4
- Dyspnea with respiratory distress 4
- Inability to manage secretions 2
- Any signs of impending airway compromise 1
Even patients with mild initial findings can deteriorate rapidly - two cases in one series worsened despite treatment, emphasizing the need for continuous vigilance 4
Airway Intervention Methods
Nasotracheal intubation is the preferred method for short-term airway management in acute epiglottitis 3, 5
- Perform intubation in a controlled setting (operating room or ICU) with difficult airway equipment immediately available 1
- Have videolaryngoscope, supraglottic airway devices, and surgical airway equipment ready for emergency cricothyroidotomy 1
- Average intubation duration is 2.3-2.9 days 6
- Tracheotomy is equally safe but typically reserved for failed intubation or when prolonged airway support is anticipated 6
Critical preparation: Never attempt intubation without a complete difficult airway setup and backup plan for failed intubation 1
Medical Management
Antibiotic therapy (start immediately after blood cultures):
- Target Haemophilus influenzae type b as the primary pathogen 3, 2
- Third-generation cephalosporin (e.g., ceftriaxone) is standard empiric therapy 2
- Continue antibiotics for 7-10 days 2
Adjunctive therapy:
- NSAIDs for pain and inflammation 2
- Nebulized epinephrine may provide temporary relief in mild cases 2
- Corticosteroids are NOT recommended - they provide no benefit in reducing intubation duration and are associated with gastrointestinal bleeding 5
Hospital Course and Monitoring
- All patients must be admitted to an ICU or facility with immediate airway intervention capability 2
- Average hospital stay is 6-7 days 6
- Continuous monitoring for deterioration is essential, even in initially stable patients 4
- The clinical threshold for airway intervention should remain low, as this is the only way to prevent mortality 2
Mortality Considerations
One case report illustrates the fatal consequences of delayed diagnosis: a 40-year-old initially misdiagnosed with asthma exacerbation died when emergency intubation was attempted without proper preparation and failed 2. This underscores the absolute necessity of early recognition, appropriate preparation, and low threshold for definitive airway management.