Epiglottitis

Overview

•Rapid onset (hours) of high fever, severe sore throat, dysphagia, and deteriorating upper airway obstruction - toxic-appearing child

•Tripod position - sits forward, leaning on outstretched arms, neck extended; maximises airway calibre and prevents epiglottis prolapsing over laryngeal inlet

•Drooling - cannot swallow own saliva (key discriminator from croup)

•Inspiratory stridor - partial upper airway obstruction at supraglottic level

•Muffled 'hot potato' voice - swollen supraglottic structures distort phonation

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Do NOT examine the throat with a tongue depressor, lie the child down, insert a cannula before securing the airway, or send for lateral neck X-ray if deteriorating - any of these can precipitate complete airway obstruction.

Aetiology

•Haemophilus influenzae type b (Hib) - classic and most important causative organism; dramatically reduced since Hib vaccine introduced in UK in 1992

•Other organisms: Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus (including MRSA), Klebsiella

•Now more common in adults than children in the UK; when it occurs in children, remains a life-threatening emergency

Investigations

•Diagnosis is clinical - do not delay airway management for investigations

•Pulse oximetry - continuous monitoring; hypoxia is a pre-terminal sign

•Lateral soft tissue neck X-ray ('thumb sign') - only if child is stable and diagnosis in doubt; shows swollen epiglottis resembling a thumb; contrast with 'steeple sign' of croup on AP view

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

🏆 Gold standard

•direct visualisation via laryngoscopy in theatre under controlled conditions - reveals cherry-red, swollen epiglottis

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'Thumb sign' (epiglottitis, lateral X-ray) vs 'steeple sign' (croup, AP X-ray) - classic exam discriminator. Never delay airway management for an X-ray in an unwell child.

Management

•Immediate: call senior anaesthetist, ENT surgeon, and paediatrician - coordinate transfer to theatre

•Keep child calm - allow position of comfort; do not agitate (agitation can precipitate complete obstruction)

•Airway first: controlled endotracheal intubation in theatre by most experienced anaesthetist available - first-line intervention when airway is compromised or child is deteriorating

•Cricothyroidotomy - only if intubation is impossible and child cannot maintain airway; not indicated while intubation remains feasible in hospital

•After airway secured: blood cultures, then IV ceftriaxone (third-generation cephalosporin) - targets Haemophilus influenzae type b (Hib) and other causative organisms

•Steroids (e.g. IV dexamethasone, inhaled budesonide) - reduce oedema; if no improvement, escalate to intubation

•CPAP, NIV, humidified oxygen - not appropriate if airway loss is imminent or child is deteriorating; NIV contraindicated when secure airway is needed

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Endotracheal intubation is the correct escalation in a deteriorating child with epiglottitis who fails medical therapy and develops marked stridor - not CPAP, NIV, or humidified oxygen. Cricothyroidotomy is a last resort only when intubation is impossible.