Clinical Presentation of Epiglottitis in Pediatric Patients
Classic Presentation
Pediatric epiglottitis presents as a rapidly progressive airway emergency characterized by the "4 D's": dysphagia, drooling, distress, and dysphonia (muffled voice), often accompanied by high fever and the classic "tripod" or "sniffing" positioning to maintain airway patency. 1, 2
Cardinal Signs and Symptoms
- Severe sore throat and dysphagia are the most common presenting symptoms, often preventing the child from swallowing secretions 3, 2
- Drooling occurs due to inability to swallow saliva and is a hallmark sign 1, 4
- Respiratory distress manifests as stridor (typically inspiratory), tachypnea, and use of accessory muscles; approximately half of patients present with some degree of respiratory compromise 3, 2
- Muffled or "hot potato" voice results from supraglottic edema 4, 2
- High fever is typically present, distinguishing epiglottitis from other causes of stridor 4, 2
- Anxious appearance and refusal to lie flat, with the child preferring to sit upright and lean forward in the "tripod position" 1, 2
Critical Distinguishing Features from Other Causes of Stridor
Unlike croup (laryngotracheobronchitis), epiglottitis presents with sudden onset, toxic appearance, high fever, drooling, and absence of the characteristic barking cough. 2 The stridor in epiglottitis is typically softer and more muffled compared to the harsh, barking cough of croup 2. Laryngomalacia causes inspiratory stridor but without fever, toxic appearance, or acute onset 1.
Age and Epidemiology
- Post-Haemophilus influenzae type b (Hib) vaccine era: Epiglottitis has become rare in vaccinated children, with only 1 case per 200,000 children reported in the United States 5
- Can still occur in vaccinated children from non-Hib pathogens or non-infectious causes 5, 4
- Peak age historically was 2-7 years, though this has shifted with widespread vaccination 2
Non-Infectious Etiologies to Consider
Thermal epiglottitis from substance use (particularly cannabis inhalation) should be considered in adolescents presenting with classic epiglottitis symptoms, especially when cultures are negative and substance use history is positive. 4 Other non-infectious causes include trauma, caustic ingestion, and angioedema 4, 2.
Diagnostic Approach
Clinical Diagnosis
Direct visualization by flexible laryngoscopy is the gold standard for diagnosis, revealing a swollen, cherry-red epiglottis with edema of surrounding supraglottic structures. 6, 4 However, this should only be performed in a controlled setting with airway management capabilities immediately available 6, 2.
Imaging
- Lateral neck radiograph shows the classic "thumb sign" (swollen epiglottis) and has high reliability, though less sensitive than direct visualization 3, 6
- Imaging should never delay airway management in a child with impending respiratory failure 1, 2
Critical Pitfall to Avoid
Never examine the oropharynx with a tongue depressor or agitate the child in any way, as this can precipitate complete airway obstruction. 1, 5, 2 The diagnosis of acute epiglottitis is generally contraindicated for flexible bronchoscopy in the emergency setting 1.
Management Priorities
Airway Management
Immediate airway protection in a controlled operating room environment with experienced personnel (anesthesiologist, otolaryngologist, and pediatric intensivist) is the priority. 1, 6, 5
- Avoid agitating the patient during transport or examination 5, 2
- Keep the child in position of comfort (typically sitting upright) with parent present 1, 5
- Supplemental oxygen should be provided gently without forcing mask application 2
- Intubation should be performed in the operating room under controlled conditions with surgical airway backup available 6, 5, 2
Medical Management
- Broad-spectrum intravenous antibiotics should be initiated promptly, typically third-generation cephalosporins to cover common pathogens 2
- Corticosteroids are commonly used to reduce airway edema, though evidence is limited 3, 2
- Intensive care monitoring for at least 48 hours is essential even if intubation is not required 3, 6
Prognosis
Aggressive treatment has decreased pediatric mortality from 7% to approximately 1%, but this requires early recognition and appropriate airway management. 6 The key to good outcomes is maintaining a high index of suspicion, avoiding patient agitation, and securing the airway in a controlled environment with experienced personnel 5, 2.