Acute epiglottitis

Overview

•Rapid onset (hours) - high fever (>38.5°C), severe sore throat, odynophagia

•3 Ds - drooling, dysphagia, distress (classic paediatric triad)

•Tripod position - sits upright, leans forward with hands on knees to maximise airway diameter

•Stridor - inspiratory; late and ominous sign of significant obstruction

•Muffled 'hot potato' voice, anxiety/agitation, absent or mild cough

🚨

Do NOT examine the throat with a tongue depressor or lay the patient flat - stimulating the pharynx can trigger laryngospasm and complete airway obstruction. Keep the patient calm and upright.

Investigations

•Investigations must NEVER delay airway management - secure airway first

🥇 First-line

•Lateral soft tissue neck X-ray - 'thumb sign' (rounded, swollen epiglottis); normal X-ray does NOT exclude diagnosis

•Blood cultures, FBC, CRP - taken after airway secured

🏆 Gold standard

•Direct laryngoscopy under controlled general anaesthesia in theatre with surgical backup - visualises cherry-red swollen epiglottis and allows intubation

Differential diagnosis

Epiglottitis vs Croup vs Diphtheria

Feature	Epiglottitis	Croup	Diphtheria
Age	Any (now more common in adults)	6 months - 3 years	Any (unvaccinated/travel history)
Onset	Hours	Days	Gradual
Cough	Absent/mild	Barking (prominent)	Absent
Drooling	Yes	No	No
Pharynx	Cherry-red swollen epiglottis	Normal	Grey pseudomembrane
Cardiac involvement	No	No	Complete heart block (AV node damage)

🎯

Diphtheria key identifiers: travel to Eastern Europe/endemic area, grey pseudomembrane on pharynx, negative strep antigen test, complete heart block on ECG - the toxin damages the AV node.

Management

⚠️

Dexamethasone and nebulised budesonide are the mainstay of croup treatment - NOT epiglottitis. A child with epiglottitis who fails corticosteroids and develops worsening stridor needs intubation, not more steroids. CPAP and NIV are contraindicated when airway loss is a risk.