CASE REPORT

Medical Management of Epiglottitis

Regçna A. E. Dowdy, DDS,* and Bryant W. Cornelçus, DDS, MBA, MPH†
*Resident, Division of Oral and Maxillofacial Surgery and Dental Anesthesiology, The Ohio State University, Columbus, Ohio, †Program Director
of Dental Anesthesiology, Division of Oral and Maxillofacial Surgery and Dental Anesthesiology, The Ohio State University, Columbus, Ohio

Epiglottitis is most commonly caused by bacterial infection resulting in inflammation and edema of the epiglottis and
neighboring supraglottic structures. Acute infection was once found predominantly in children ages 2 to 6 years old,
but with the introduction of the Haemophilus influenzae B (HiB) vaccine the incidence of cases in adults is increasing.
Typical clinical presentation of epiglottitis includes fever and sore throat. Evidence of impending airway obstruction
may be demonstrated by muffled voice, drooling, tripod position, and stridor. Radiographs can be helpful in diagnosing
epiglottitis; however, they should not supersede or postpone securing the airway. An airway specialist such as an
otolaryngologist, anesthesiologist, or intensivist should ideally evaluate the patient immediately to give ample time for
preparing to secure the airway if necessary. All patients with epiglottitis should be admitted to the intensive care unit
for close monitoring.

Key Words: Epiglottitis; Emergent tracheostomy; Total airway obstruction; Stridor.

piglottitis is defined as inflammation of the

E epiglottis and/or
structures including
neighboring supraglottic
the hypopharynx. Epiglottitis is typically caused by a
bacterial infection. Historically, epiglottitis has been an
infection mostly prevalent in children ages 2 to 6 years
old. However, since the introduction of the
Haemophilus influenzae B (HiB) vaccine, there has been
a shift with increasing incidence within the adult
population. Com- mon signs and symptoms upon
clinical presentation include odynophagia, dysphagia,
use of the tripod position, and stridor. Consultation of
airway specialists including otolaryngologists,
anesthesiologists, or inten- sivists is imperative so that
early interventions can be pursued if necessary.
Generally, it is recommended that patients be observed
in a high acuity, closely monitored environment, such as
an intensive care unit (ICU), until signs and symptoms
resolve. The following is a case report involving a 63-
year-old female who presented with epiglottitis, which
required medical management and emergent
procurement of a surgical airway.
CASE PRESENTATION
The patient was a 63-year-old African-American female
with a past medical history of hepatitis C with liver
Received July 28, 2018; accepted for publication September 18, 2019.
Address correspondence to Regina A. E. Dowdy, 2154 Postle
Hall, 305 W 12th, Columbus, OH 43021; dowdy.55@osu.edu.
Anesth Prog 67:90–97 2020 j DOI 10.2344/anpr-66-04-08
© 2020 by the American Dental Society of Anesthesiology
cirrhosis, hypertension, gastroesophageal reflux, osteo-
arthritis of the lumbar spine, alcohol addiction, and
obesity. Her reported medications included rifaximin
550 mg twice daily, acetaminophen 650 mg twice daily,
losartan 25 mg daily, hydrochlorothiazide 25 mg daily,
and ranitidine 150 mg twice daily. The patient reported
allergies to sulfamethoxazole/trimethoprim and lisino-
pril. The patient had a height of 165 cm (5 0500), a weight
of 89.8 kg (198 lb), and a body mass index of 32.95 kg/
m2. Her social history included alcohol abuse and 27-
pack per year smoking history. She presented to the
emergency department (ED) at approximately 3:00 PM
with complaints of a sore throat that had reportedly
started the previous evening. Her detailed complaint
consisted of a bilateral sore throat, which was more
severe on the left size and radiated to her left ear. The
patient had attempted to take acetaminophen the night
before but was unable to actually swallow the pills
secondary to persisting dysphagia. Upon initial intake,
the patient was noted to be afebrile, despite reporting
the presence of a fever while at home. Physical
examination in the ED revealed the notable presence
of mild erythema involving the patient’s left temporo-
mandibular joint without swelling or drainage. There
was no evidence of vocal changes or trismus, her tonsils
were not appreciable, and the posterior oropharynx was
normal in appearance. The patient was also noted to be
in mild emotional distress with noted anxiety regarding
the severity of her sore throat. There were no
appreciable signs of swelling upon examination of the
patient’s head or neck, nor any tenderness to palpation.
The patient did not display any signs or symptoms
90
Anesth Prog 67:90–97 2020
suggestive of labored breathing, stridor, or respiratory
distress at the time of initial presentation.
The ED course included a computed tomography
(CT) scan of her head and neck to evaluate for a deep
space infection as the patient was adamant that she was
unable to tolerate swallowing anything, including her
own saliva. The official read of the CT included the
following statement, ‘‘a lesion protruding out into the
hypopharynx and piriform sinus region on the left side.
There are small air bubbles nearby. Theoretically this
could be related to infection. Might be related to an
infected diverticulum. It is not a classic tumor but is
certainly possible’’ (Figure 1). A rapid streptococcus
test was run to assess for streptococcal pharyngitis but
was negative. A complete blood count was drawn
producing results all within normal ranges.
The decision was made to admit the patient at
roughly 9:00 PM for observation and to obtain an ear,
nose, and throat (ENT) consult as she was symptom-
atic and unwilling to be discharged at that time.
Overnight, she continued to deteriorate with continued
complaints of difficulty swallowing and increasing
pain. At 4:50 AM it was noted that the patient’s
peripheral oxygen saturation (SpO2) had dropped to
88% on room air; supplemental oxygen was adminis-
tered via nasal cannula at a rate of 2 l/min producing a
modest improvement of the patient’s SpO2 to 94%.
At 7:50 AM a resident from the admitting medicine
team examined the patient at bedside during pre-rounds.
Of note, the patient was able to walk around with mild
work of breathing. However, upper airway stridor was
noted when in close proximity to the patient, which had
not been noted in any previous examinations.
At 9:45 AM the entirety of the medicine team rounded
on the patient, and it became apparent that the patient
was now experiencing significant respiratory distress.
She was no longer able to speak above a whisper and
unable to open her mouth more than 1 cm due to severe
pain. However, there was still no appreciable edema
noted at this time. Stridor was audible when entering the
room, and the patient was seated in the tripod position
with increased work of breathing and shortness of
breath. The decision was made to administer intrave-
nous (IV) methylprednisolone 125 mg and nebulized
racemic epinephrine. An ICU attending was called to
the patient’s room where he immediately advocated the
patient be transferred to the ICU. The ICU attending
noted that the airway was unsafe to attempt intubation
and that an emergent tracheostomy was needed. The
ENT attending was notified immediately.
When the ENT team arrived in the ICU, an
examination of the airway was performed via awake
flexible fiberoptic laryngoscopy using topical/local
anesthesia only. Severe edema and erythema of the
Dowdy and 91
Cornelius
epiglottis was noted upon visualization of the airway
anatomy. A ‘‘minimal airway’’ was noted, and the
larynx was unable to be visualized due to the substantial
edema. The mass or lesion, which was previously noted
on the CT scan, clinically measured 1.6 3 1.4 cm. The
diagnosis of epiglottitis was subsequently made by the
ENT attending; however, epiglottic surface cultures
were not taken due to the urgency of the situation.
Immediately following the clinical assessment and
diagnosis, the patient was taken to the operating room
where an emergent awake tracheostomy was performed
under local anesthesia without complications. She
returned to the ICU for close postoperative monitoring
where she remained on supplemental O 2 overnight. IV
dexamethasone 4 mg every 8 hours and IV ceftriaxone 2
g daily were started.
The patient was monitored in the ICU for 48 hours
after the tracheostomy during which time she remained
afebrile. A repeat CT scan was obtained, which
confirmed correct placement of the tracheostomy and
found extensive upper lung opacification, indicative of
new-onset pneumonia (Figure 2). Thickening of the
hypopharyngeal soft tissues was present bilaterally but
noted to be more prominent on the left, measuring 11
mm, which was less prominent than noted on the prior
CT scan. The epiglottis at 4 mm was noted to be thicker
than on the initial scan, which was 2 mm, both measured
in the antero-posterior view. The patient’s symptoms,
such as difficulty and pain with swallowing, started to
resolve, and the patient was evaluated by the speech and
language pathologist for swallowing and placement of a
Passy-Muir speaking valve to facilitate speech. Repeat
flexible nasolaryngoscopy was performed on postoper-
ative day 5 and revealed resolving edema and erythema
of the epiglottis, which was anatomically within normal
limits, as well as a resolving exudate present overlying
the arytenoids. It was also noted that there was paralysis
of the left true vocal cord in the paramedian position
with a good airway, meaning cord paralysis did not
occur in the adductor position, and partial approxima-
tion of the cords. No signs of soft tissue obstruction
were noted. Three days later, the tracheostomy was
subsequently capped and planned for decannulation.
The patient was discharged 2 days later with a
prescription of ceftriaxone to complete her 10-day
course as well as a dexamethasone taper and a plan to
decannulate after the completion of her antibiotic
treatment.
EPIDEMIOLOGY
Epiglottitis is defined as inflammation of the epiglottic
or adjacent supraglottic structures including the hypo-
Figure 1. Computed tomography (CT) scan of the neck with contrast at time of admission. (A) Sagittal cut reveals a mass in the
hypopharynx and piriform sinuses; note the limited airway space. (B) Axial cut at the level of the hyoid bone reveals a mass that is
1.4 3 0.5 cm in size. (C) Coronal cut revealing the mass intruding upon the midline of the larynx.
Figure 2. Computed tomography (CT) scan of the neck with contrast 2 days after placement of the tracheostomy. (A) Sagittal cut
reveals a mass in the hypopharynx and piriform sinuses; note the limited airway space. (B) Axial cut at the level of the hyoid bone
reveals a mass that is 1.4 3 0.5 cm in size.
pharynx. If left untreated, the progression of epiglottitis
and the resulting edema can be devastating leading to
complete or partial airway obstruction. While there are
several causes of epiglottitis, the most common is
bacterial infection. In the pediatric population, this
bacterial infection is typically seen in children ages 2 to
6 years old; incidence of epiglottitis in children due to
bacterial infection has decreased by as much as 90%
since the introduction of the HiB vaccine.1–4 By
comparison, the annual incidence epiglottitis due to
bacterial infection in adults is approximately 1 to 4 in
100,000, which is 2.5 times the incidence in children. 5–7
The male to female ratio of infection ranges from 1.2 to
4.9 : 1. Thirty-five to fifty percent of cases of adult
epiglottitis cases initially go misdiagnosed. 5 In the case
presented here, for example, the initial thought was that
the patient had strep throat, and rapid step test was
negative. In adults, concomitant chronic diseases such as
hypertension and chronic obstructive respiratory dis-
eases increase the risk for epiglottitis, and cigarette
smokers are more commonly afflicted.5,7 Mortality is
estimated at 4 to 7% in adults and 2 to 3% in children
for all cases of epiglottitis.8 The higher degree of
mortality for adults is likely primarily related to initial
misdiagnosis as commonly noted with adult cases.
Failure to intervene prior to loss of the airway carries
a six-fold increase in mortality.1 Increased risk of
mortality from epiglottitis include advanced age and
male sex.9 Other bacterial causes of epiglottitis include
Streptococcus pneumonia, Streptococcus pyogenes,
Staphylococcus aureus, Streptococcus viridans, and
Neisseria meningitides.6 Surface cultures of the
epiglottis and supra glottic structures are typically
negative, and blood cultures are not completely sensitive
for identify- ing pathogens, especially when antibiotics
have already been administered.6
CLINICAL PRESENTATION
When a patient presents with anxiety, sore throat,
dysphagia, muffled voice, respiratory distress, stridor, or
posturing in the tripod position, there should be high
suspicion for an upper airway infection and attempts
should be made to secure the airway prior to obtaining
any sort of invasive clinical (ie, laryngoscopy) or
radiographic diagnostic evaluation.1,9 The tripod posi-
tion is demonstrated when the patient is sitting upright
with their neck extended, using the arms to support their
trunk, and maximal jaw thrust effort in an attempt to
open the airway. Epiglottitis is typically seen more
acutely in young children with symptoms occurring less
than 24 hours before admission when compared with
adolescents and adults who tend to present 1 to 2 days
after the onset of symptoms.10,11 Adults are more likely
to present with sore throat, dysphagia, and odynophagia
(painful swallowing that occurs in nearly 100% of
cases).5–8 The difference in obstructive incidence is
likely due to the anatomical structures of the adult,
which are more rigid and less likely to gravitationally
and mechanically obstruct the glottic opening. 5
Dispropor- tional severity of the sore throat symptoms
combined with the physical findings of the
oropharyngeal exam- ination are an additional indicators
suggestive of epiglottitis. Stridor is generally a late sign
and indicates that the airway is partially obstructed.2,12
Complications can occur other than impending
airway obstruction. In such a scenario it is possible to
have complications caused by treatment such as allergic
reaction to medications. An additional complication of
epiglottitis is the formation of an epiglottic abscess,
which increases mortality to 30%.5
DIAGNOSIS
Deterioration can occur rapidly and quite unexpectedly;
therefore, early involvement of airway specialists is
imperative. Specialists that warrant consideration for
consultation can include: otolaryngologists (ENT),
anesthesiologists, or intensivists. Although their
involve- ment may ultimately prove to be unnecessary,
early consultation may provide sufficient time for
securing the airway under more ideal clinical
conditions.13 Definitive diagnosis can be made during
nasolaryngoscopy, typically utilizing a flexible
fiberoptic scope, performed in the emergency room for a
compliant patient, but should be delayed for a child until
general anesthesia has been attained as the added stress
of the procedure could increase the risk of airway loss.14
If a cherry red edematous epiglottis is visualized during
the nasolar- yngoscopy, a diagnosis of epiglottitis can be
made. Immediate steps should be taken to secure the
patient’s airway either by intubation or placement of a
tracheos- tomy.12 If intubation is deemed necessary,
pressing down on the patient’s chest may allow for an
air bubble to form in the glottic opening, which may aid
in the placement of the endotracheal tube. Prophylactic
intubation should be strongly considered in all pediatric
patients found to have epiglottitis for airway protection
as the clinical progression can be unpredictable and has
the potential to evolve quickly.7,12 In adult patients,
some authors advocate for early prophylactic intubation
in all cases, whereas others believe that a more
conservative approach can be taken in adults due to
the larger diameter of the adult larynx.10
Although obtaining radiographic studies upon ad-
mission is not always advisable due to the rapid
progression of epiglottitis, such studies can be helpful
in diagnosing for patients who are otherwise clinically
stable. A single, lateral, upright view of the neck in
extension can help diagnose epiglottitis when the
diagnosis is not established upon physical examinations.
Lateral neck radiographs are most useful in facilities
where CT imaging and flexible bronchoscopy are not
readily available.7,15 CT scans or magnetic resonance
imaging are helpful in evaluating for complications such
as the spread of infection or abscess formation, although
a magnetic resonance imaging can take a considerable
amount of time and may take away from time that could
be used to secure the airway.7 Care should be taken in
patient positioning as manipulation of the neck or
inflicting discomfort can lead to further airway obstruc-
tion. In a healthy patient, the lateral plain radiograph of
the neck will reveal the epiglottis as a thin, curved soft
tissue opacity separated from the tongue by the
vallecula, which is represented as radiolucency. 15 In a
patient with epiglottitis, the epiglottis is often noted to
be quite edematous similar in appearance to a thumb-
print (Figure 3A).1,15 Other radiographic findings may
include thickening of the aryepiglottic folds, preverte-
bral soft tissue swelling, and expansion of the hypo-
pharynx. Sensitivity and specificity of radiography of
epiglottitis in adults varies from 38 to 98%.7,8 In
approximately 25% of adult cases, a chest radiograph
will reveal a concurrent pneumonia.16
TREATMENT
Antimicrobial therapy is preferably based upon results
from blood and epiglottic cultures when possible. The
most commonly encountered bacterial organisms are
HiB, Streptococcus pneumonia, Group A Streptococcus,
and Staphylococcus aureus including methicillin-resis-
tant S aureus strains.11,13,17 Empiric combination
antibiotic therapy with a third-generation cephalosporin
and an antistaphylococcal agent is usually recommend-
ed.11,14 Vancomycin is the antistaphylococcal agent of
choice in patients with epiglottitis complicated by
sepsis, those with concomitant meningitis, or those from
areas with an increased prevalence of clindamycin-
resistant methicillin-resistant S aureus.13 Patients with a
penicillin allergy should be treated with vancomycin and
a quinolone antibiotic agent. Antibiotics should be
altered as culture sensitivities are identified by lab and
adjusted
Figure 3. Classic radiographic findings. (A) Lateral radiograph of the neck revealing ‘‘thumb sign’’ appearance of epiglottitis. (B)
Anteroposterior radiograph of the neck revealing ‘‘steeple sign’’ seen in croup.
to ensure completion of a 10-day course. Routine
vaccination for HiB is not recommended in adults.
However, older children or adults at an elevated risk of
contracting an HiB infection includes those with a
history of functional or anatomic asplenia, immunode-
ficiency, immunosuppression from cancer chemothera-
py, infection with HIV, and receipt of a hematopoietic
stem cell transplant.5 For high-risk patients who are also
previously unvaccinated, the administration of at least 1
pediatric dose of an HiB conjugate vaccine should be
considered.
There are a variety of adjuvant therapies available
that can be utilized on a case-by-case basis. Adminis-
tration of supplemental humidified oxygen along with
IV hydration can help to limit the risk of sudden airway
obstruction.9 Glucocorticoids are not universally rec-
ommended for initial treatment because evidence of a
clear benefit, such as reduced length of stay or shorter
duration of intubation in the ICU, is lacking. Some
studies have indicated when steroids are given that
hospital stays are typically longer; however, that
correlation may be complicated by the fact that steroids
are more likely to be given in more extreme or severe
cases.18 If corticosteroids are to be used, the recom-
mended course of treatment in adults is IV dexameth-
asone 4 to 10 mg as an initial bolus with a repeated IV
dose of 4 mg every 6 hours along with close observation
of the airway.3 Other steroids, such as IV methylpred-
nisolone 125 mg, can also be considered for adminis-
tration in adults.9 Steroids should be tapered as the signs
and symptoms resolve. Administration of epinephrine,
racemic, or subcutaneous may help to improve upper
airway edema.1
Patients should be monitored in the ICU regardless of
the placement of an airway, such as their natural airway,
intubation, or tracheostomy, so they can be monitored
more closely for airway deterioration.19 Ideally, daily
examination of the supraglottic structures should be
performed with fiberoptic nasolaryngoscopy to assess
the patient’s response to therapy and evaluate for any
complications such as epiglottic abscesses. For patients
in whom the airway has been secured, care must be
taken to avoid dislodgement of the endotracheal tube or
tracheostomy, as reintubation may not be feasible
leading to significant morbidity or mortality depending
upon the severity of the clinical situation. The patient
may require additional respiratory care and periodic
suctioning to maintain airway patency. Extubation
criteria include resolution of the patient’s fever, odyno-
phagia/dysphagia symptoms, and airway edema as
assessed by nasolaryngoscopy or a positive cuff leak
test. Edema typically improves within 2 to 3 days of
initiating antimicrobial treatment.2
DIFFERENTIAL DIAGNOSES
Stridor is a high-pitched wheezing sound that results
from disrupted airflow, a key sign of partial airway
obstruction that can be associated with several different
disease states. Stridor itself is caused by restrictions to
airflow most commonly resulting from inflammation in
the tissues surrounding the airway. In a healthy patient,
airflow in the upper respiratory tract approximates
laminar flow. In said patient, the moving column of air
will create a slightly negative pressure on the wall of the
airway.20 But narrowing of the airway, often due to
inflammation from infection or trauma, can cause an
increase in airway resistance and turbulent air flow
along the narrowed segment, as described by the Venturi
effect. According to the Bernoulli principle, as the flow
velocity increases, there is an increase in intraluminal
negative pressure at the already narrowed lumen site,
which promotes further collapse of the airway. 20 The
increase in turbulent flow is demonstrated clinically as
stridor. Stridor can be evident during the different stages
of respiration. Stridor during inspiration can be
attributed to supraglottic swelling due to collapse of
unsupported soft tissues when negative pressure is
generated during inspiration.20 Biphasic stridor is
characteristic of a fixed obstruction at the level of the
cricoid. If a narrowing occurs at the intrathoracic
trachea or bronchiole level, an expiratory stridor will
likely develop due to the increased intrathoracic
pressure generated during exhalation, which contributes
to narrowing of the distal airways.20
Croup (Laryngotracheobronchitis)
Croup, or laryngotracheobronchitis, is an upper airway
infection that results in narrowing of the glottis and
subglottis and is usually viral in nature. 20 Clinical signs
and symptoms typically become evident following
several days of an upper respiratory infection that
develop into a barking cough, hoarseness, and stridor.
Stridor is typically inspiratory but can become biphasic
indicating severe airway compromise.20 The most
commonly affected are children ages 6 months to 3
years and account for as many as 90% of infectious
airway obstructions. Anteroposterior radiographs can
be helpful with diagnosis as they will typically reveal a
radiopaque narrowing in the subglottic area that is also
known as the steeple sign (Figure 3B). Administration
of
humidified air is the most commonly used treatment.
Racemic epinephrine, a 1 : 1 mixture of levo- and
dextro-isomers of epinephrine, can be administered via
nebulizer with 0.5 mL of the 2.25% solution further
diluted in 3 mL of normal saline, and clinical
improvement can be expected in 10 to 30 minutes.20
The administration of steroids for croup is controver-
sial; however, recent studies have demonstrated that a
single dose of 0.6 mg/kg dexamethasone orally, intra-
muscularly, or intravenously helps to decrease length of
hospital stay.20
Tracheitis
Tracheitis is a bacterial infection that typically occurs as
a complication of viral croup. The causative organisms
are Staphylococcus aureus, Haemophilus influenzae,
alpha hemolytic Streptococcus, and group A Strepto-
coccus.20 Clinical presentation stereotypically includes a
history of an upper respiratory illness, typically viral,
present for several days with symptoms similar to croup,
followed by a rapid development of a high fever,
respiratory distress, and overall ill appearance.20
Odynophagia and drooling are absent, in contrast to
epiglottitis. Lateral radiographs may show the tracheal
air column as hazy, not radiolucent, with plaque-like
irregularities projecting into the lumen or a poorly
defined tracheal wall. Peak incidence of tracheitis occurs
in the fall and winter and primarily afflicts children age
6 months to 8 years old.
Epiglottitis Due to Other Causes
Although epiglottitis is most commonly infectious in
nature, there are also noninfectious causes. The most
commonly reported causes of noninfectious epiglottitis
include thermal injury and ingestion of caustic agents or
foreign bodies. Consuming overly hot foods or bever-
ages can cause thermal injury-induced epiglottitis.
Epiglottitis due to ingestion of a foreign body is
generally caused when retrieval of the objected is
attempted with a blind finger sweep, typically due to a
scratch by the fingernail.21,22 There is a reported case
where epiglottitis occurred in a patient who underwent
anesthesia with the use of a laryngeal mask airway; the
cause of epiglottitis was proposed to be traumatic
placement of the laryngeal mask airway. 23 Symptoms
and radiographic imaging are essentially identical for
infectious versus noninfectious epiglottitis. With regards
to foreign body obstruction, there have been cases
reported when symptoms of epiglottitis did not occur
until 18 hours after the causal event. Therefore, it is
recommended that a period of inpatient observation or
monitoring be considered for these patients.21
SUMMARY
Epiglottitis is defined as inflammation of the epiglottis
and/or neighboring supraglottic structures and is
generally caused by a bacterial infection. Although this
type of infection was historically more prevalent in
children ages 2 to 6 years, a decreasing incidence in
pediatric patients has been observed following the
introduction of the HiB vaccine. In contrast, there has
recently been an increasing shift in incidence within the
adult population. Clinical presentation of epiglottitis
can include odynophagia, dysphagia, use of the tripod
position, and stridor once the resulting edema begins to
cause substantial airway obstruction. Early involvement
of airway specialists such as otolaryngologists, anesthe-
siologists, or intensivists is warranted if epiglottitis is
suspected. It is generally recommended that patients be
managed and monitored in a high acuity environment,
such as an ICU, until signs and symptoms resolve.
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