What are the guidelines for diagnosis and management of adult epiglottitis?

Adult Epiglottitis: Diagnosis and Management

Critical Differences from Pediatric Presentation

Adult epiglottitis presents with a more subacute, variable clinical course compared to the acute respiratory distress typical in children, but carries a persistently higher mortality rate of approximately 7% versus 1% in pediatric cases. 1

Key Clinical Features in Adults

Presenting symptoms differ significantly from pediatric cases:

• Severe odynophagia (dysphagia) is the most common presenting symptom in adults (100% of cases), not acute respiratory distress 2
• Inability to swallow secretions occurs in 83% of adult cases 2
• Sore throat is present in 67% of cases 2
• Dyspnea occurs in only 58% of adult presentations 2
• Stridor, the supposedly "classic" sign, is present in only 42% of adult cases—making it an unreliable diagnostic marker 2
• Drooling, muffled voice, and hoarseness are additional features but less consistent 3, 2
• Fever (>37.2°C) occurs in 75% of cases 2

Critical pitfall: 44% of adult patients have a completely normal oropharyngeal examination, meaning routine throat inspection can miss the diagnosis entirely 2

Diagnostic Approach

Gold Standard Diagnosis

Direct visualization by flexible fiberoptic laryngoscopy is the gold standard for diagnosis and should be performed in any patient with clinical suspicion 1, 2

• Laryngoscopy allows direct visualization of the inflamed, edematous epiglottis 2
• This procedure should be performed in a controlled setting with personnel skilled in emergency airway management immediately available 2, 4

Radiographic Studies

Lateral neck radiographs have utility but lower sensitivity than direct visualization 1

• Can show the classic "thumb sign" (swollen epiglottis) 3
• May be falsely negative, so normal radiographs do not exclude epiglottitis 3
• Should not delay definitive diagnosis if clinical suspicion is high 3

Microbiological Diagnosis

Blood cultures are the preferred diagnostic specimen for epiglottitis 5

• Swabbing of the epiglottis should be avoided or resisted due to risk of precipitating sudden airway obstruction from mechanical stimulation 5
• If swabbing is attempted, it must only be done in a setting with emergency airway equipment and personnel immediately available 5
• Common pathogens include Streptococcus and Staphylococcus species 3

Airway Management: The Critical Decision

Risk Stratification

The severity of clinical presentation should guide airway management decisions—prophylactic intubation is not mandatory in all adult cases, unlike pediatric protocols 1, 6

Immediate airway intervention is indicated for:

• Severe respiratory distress 6
• Signs of upper airway obstruction 6
• Stridor with respiratory compromise 6
• Inability to handle secretions with impending obstruction 6

Close monitoring without immediate intubation is appropriate for:

• Adults presenting without respiratory symptoms 6
• Stable patients with mild to moderate symptoms 1
• However, all patients must be monitored in an intensive care setting with immediate access to emergency airway equipment 6

Intubation Technique When Required

When airway intervention is necessary, the approach has evolved from traditional direct laryngoscopy:

• Flexible intubating endoscopy and video laryngoscopy are now preferred techniques 3
• Assistance from anesthesia and/or otolaryngology should be obtained if available 3
• Intubation should always be performed by the most skilled personnel available, as repeated attempts increase periepiglottal swelling and obstruction risk 4
• A tracheostomy set must be at the bedside during any intubation attempt 2

Critical pitfall: One reported fatality occurred when conventional oral intubation was attempted without a tracheotomy set at bedside and failed 2

Medical Management

Antibiotic Therapy

Antibiotics should be administered immediately upon diagnosis 3, 2

• Empiric coverage for Streptococcus and Staphylococcus species 3
• Continue until culture results guide targeted therapy 2

Adjunctive Therapies

NSAIDs should be administered for symptom relief and anti-inflammatory effect 2

Corticosteroids are controversial but should be considered 3

Nebulized epinephrine:

• Should be considered in acute management 3
• However, racemic epinephrine should be avoided due to rebound effect that may worsen obstruction 4

Monitoring and Disposition

All patients must be admitted to intensive care settings for close airway observation, regardless of initial severity 3, 2, 6

• Majority of patients require 24-hour ICU monitoring before transfer to wards 6
• The clinical threshold for airway insertion should remain low, as this is the only way to prevent death 2

Common Pitfalls to Avoid

Misdiagnosis as common viral pharyngitis or bronchial asthma exacerbation due to the subacute presentation in adults 2

Relying on absence of stridor to rule out epiglottitis—present in less than half of adult cases 2

Assuming a normal oropharyngeal examination excludes epiglottitis—nearly half of cases have normal throat exams 2

Attempting to swab the epiglottis for culture, which can precipitate sudden airway obstruction 5

Performing intubation without the most skilled personnel or without tracheostomy equipment immediately available 2, 4

Discharging patients from the emergency department without ICU-level monitoring 3, 6