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Pediatrics, Epiglottitis

Robert Allan Felter, MD, FAAP, CPE, FACPE, Professor of Clinical Pediatrics, Department of Pediatrics, Georgetown University College of Medicine; Medical Director, Pediatric Emergency Medicine and Inpatient Services, Inova Loudoun Hospital, Leesburg, Virginia
Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE, Emergency Physician, Commonwealth Emergency Physicians; Director of Pediatric Quality Care Management, INOVA Loudon Hospital; Adjunct Clinical Professor, Georgetown University School of Medicine

Updated: Jan 29, 2009

Introduction

Background

Epiglottitis, also termed supraglottitis, is an inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula. 

As with many other aspects of the pediatric airway, the epiglottis is significantly different in the child than in the adult. In the infant, the epiglottis is located more anteriorly and superiorly than in the adult, and it is at a greater angle with the trachea. It is also more omega shaped and floppy than the more rigid, U-shaped epiglottis in the adult. Numerous causes of the inflammation exist, but the common problem is airway occlusion caused by the tissue swelling, and, when untreated, can lead to respiratory failure and death. In the young child, this can take place in hours.

Comparison of a normal pediatric airway and airway from a child who died from epiglottitis.

Pathophysiology

Epiglottitis was historically caused by infection of the supraglottic structures by Haemophilus influenza B (see Haemophilus Influenzae Infection). Since the widespread use of the HiB vaccine, the incidence and causative agents of epiglottitis have changed. Both H influenza type B (HiB) and Streptococcus pneumonia (see Causes) can colonize the pharynges of healthy children through respiratory transmission from intimate contact. These bacteria may penetrate the mucosa invading the bloodstream, causing bacteremia and seeding of the epiglottis and surrounding tissues. Bacteremia can also lead to infection of the meninges, skin, lungs, tears, and joints.

Bacterial infection of the epiglottis leads to acute onset of inflammatory edema, beginning on the lingual surface of the epiglottis where the submucosa is loosely attached. Swelling significantly reduces the airway aperture. Edema rapidly progresses to involve the aryepiglottic folds, the arytenoids, and the entire supraglottic larynx. The tightly bound epithelium on the vocal cords halts edema spread at this level. Aspiration of oropharyngeal secretions or mucus plugging can cause respiratory arrest.

Inflammation of any of the structures around the epiglottis may also become inflamed from trauma, mechanical, thermal, or chemical. Reports have been made of epiglottitis caused by blunt injury to the neck.¹

Frequency

United States

The use of the HiB vaccine has reduced the incidence of epiglottitis. Introduction of the polysaccharide vaccine in 1985, followed by the highly effective conjugate vaccine, has dramatically reduced the incidence of epiglottitis, with consequent decline in hospital admissions. Studies show an annual incidence rate of 0.3 cases per 100,000 persons. Studies in children of all ages with epiglottitis report no seasonal variation in incidence.

International

International incidence varies widely and is significantly more prevalent in countries without universal immunization. In countries with mandatory immunization, the reported incidences are 0.9 cases per 100,000 persons in Sweden and 0.6 cases per 100,000 in the United Kingdom. Recent discussion exists that epiglottitis is increasing in frequency in the United Kingdom.² The reason for this is unclear and may be due to giving 3 vaccines rather than 4. Recent studies suggest that bacterial tracheitis is now the most common serious airway infection in children.^3,4

Mortality/Morbidity

Mortality rates as high as 10% can occur in children whose airways are not protected by endotracheal incubation. With endotracheal intubation, mortality is less than 1%.

Race

Most studies showed no racial predominance, although a recent study showed higher incidence among African Americans and Hispanics.

Sex

Most studies show a 60% male predominance. This has remained true even with the changing epidemiology of epiglottitis.

Age

Historically, epiglottitis occurred most commonly in children aged 2-7 years. However, it may occur at any age. Once believed to occur exclusively in children, adult cases have been reported for years and some evidence suggests the incidence in adults is increasing.

Clinical

History

Epiglottitis usually presents abruptly and rapidly with fever, sore throat, dysphagia, respiratory distress, drooling, and anxiety. The classic presentation is a young child who develops a fever and may complain of a sore throat. The child may refuse to eat. As the disease progresses, the patient may not be able to maintain his or her airway and this may lead to airway obstruction.

• The clinical triad of drooling, dysphagia, and distress is the classic presentation. Fever with associated respiratory distress or air hunger occurs in most patients. Drooling occurs in up to 80% of cases.
• Age of patient, prodrome, type of cough, and degree of toxicity can all contribute to differentiation of epiglottitis from severe croup. Usually, croup occurs in younger children and has a viral prodrome. Most importantly, the child with croup has a barking cough and rarely appears toxic. Bacterial tracheitis can mimic severe croup or epiglottitis.
• If the cause of epiglottitis is not infectious, the presentation may vary. A child presenting with upper airway respiratory distress without an obvious source or fever should be questioned regarding the possibility of ingestion of a toxic or hot liquid, or a traumatic event such as falling on an object with an open mouth or swallowing or having a foreign body removed.⁵

Physical

• In classic epiglottitis, the patient appears acutely ill, anxious, and usually assumes a characteristic tripod position if old enough to do so. 
• Because of the pain in the supraglottic area, even secretions are not tolerated and the child is often drooling.
• Early on, the child may have stridorous respirations, but as the disease progresses, airway sounds may diminish. Additional signs of upper airway obstruction are also evident including suprasternal, subcostal, and intercostal retractions. 
• In the older child, pain may be noted on movement of the hyoid bone.⁶  
• Although not recommended in the child suspected to have epiglottitis, visualization of the epiglottis may show the classic swollen, cherry red epiglottis. 
• In more advanced cases, the child is in respiratory failure and shock.

Causes

No one organism is predominant in causing epiglottitis.

• Historically, Hib was the predominant organism.
  • The Hib vaccine has decreased the number of cases due to infection with this organism.
  • Recent reports have shown that even vaccinated children can develop epiglottitis from H influenzae.
• S aureus
• S pneumoniae
• Varicella can cause a primary or secondary infection often with group A beta-hemolytic streptococci.
• C albicans, especially in immunocompromised patients⁷
• Several viruses, including herpes species and parainfluenza
• Lymphoproliferative diseases may causes epiglottic swelling.
• Traumatic epiglottitis can occur from direct trauma and thermal injury.

Differential Diagnoses

Other Problems to Be Considered

Pediatrics, bacterial tracheitis
Tracheitis

Workup

Laboratory Studies

• Securing an airway is the overriding priority. All further evaluations should follow.
• Blood cultures and culture of the epiglottis should be performed only after the airway is secured.
• The white blood cell count may be elevated from 15,000-45,000 cells/uL with the predominance of bands.
• In cases of HiB epiglottitis, blood cultures have a low yield (estimates about 15%).
• Cultures of the surface of the epiglottis obtained during endotracheal intubation are positive in up to 75% of cases.⁸

Imaging Studies

• If epiglottitis is seriously considered, no imaging studies are required.
• In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or ruling out epiglottitis.
• If epiglottitis is in the differential diagnosis, the child should never be left alone even if imaging studies are being obtained. The child should always be accompanied by personnel who are able to achieve rapid airway access if needed.
  • Lateral neck radiographs may show an enlarged epiglottis protruding from the anterior wall of the hypopharynx called the thumb sign.
  • Recommendations for CT scan of the neck in early or unusual cases have been suggested,⁹ although great care should be used because of the positioning of the patient.
  • Negative findings on lateral radiographs do not rule out the diagnosis, especially in the early stages of presentation.
  • Post intubation chest radiographs occasionally show pulmonary edema.
  • Chest radiography may also reveal a pneumonia in as many as 15% of patients.

Other Tests

• Blood cultures and cultures of the epiglottis should be obtained after the airway is secured.
  • Blood cultures are positive in less than 15% of cases caused by H influenzae.
  • Epiglottic cultures are positive in 50% of cases caused by H influenzae.

Procedures

• Fiberoptic laryngoscopy
  • Laryngoscopy can exclude other diagnoses in an older child who is cooperative. However, do not perform a laryngoscopy if the procedure might increase anxiety, which can exacerbate the airway obstruction.
  • The nares can be anesthetized with lidocaine jelly before inserting the fiberoptic laryngoscope. Insert the laryngoscope through the nares, advancing slowly into the supraglottic region. The epiglottis should be easily visualized to determine the presence of swelling.
• Percutaneous transtracheal ventilation
  • Also termed needle cricothyroidotomy or translaryngeal ventilation, percutaneous transtracheal ventilation is a temporizing method used to treat cases of severe epiglottitis when the patient cannot be intubated proceeding to a formal tracheostomy.
  • Percutaneous transtracheal ventilation involves inserting a needle through the cricothyroid membrane, which lies inferior to the thyroid cartilage and superior to the cricoid cartilage. The cricothyroid artery typically courses through the superior portion of the membrane.
  • The procedure is performed as follows:
    • Begin by localizing the cricothyroid membrane. This can be accomplished by finding the thyroid cartilage prominence (ie, the Adam's apple) and running a finger down until the depression of the cricothyroid membrane is felt. Another method is to find the trachea and run the fingers up the tracheal rings until a more prominent fold representing the cricoid ring is felt; the cricothyroid membrane is above this bulge. The latter technique has been shown to be more useful in some infants.
    • Prepare the membrane area with anesthetic solution. If the patient is awake, use lidocaine to anesthetize the skin overlying the membrane.
    • Use the thumb and middle finger of the nondominant hand to hold the trachea in place. In the dominant hand, hold a 3- or 5-mL syringe containing 2 mL of saline or lidocaine, which is attached to the needle and a 16- or 18-gauge catheter.
    • Place the needle through the inferior portion of the cricothyroid membrane in the mid-line, carefully directing the needle at a 45° angle, and puncture the skin and subcutaneous tissue. A small incision with a number 11 scalpel facilitates needle and catheter insertion.
    • Apply continuous negative pressure while advancing the needle; the needle should be inside the trachea when bubbles become visible in the syringe.
    • Advance the catheter of the needle until its hub rest against the skin surface. Remove the needle and syringe.
    • Connect high pressure tubing to the catheter and administer 100% oxygen at 25- to 35-lb per square inch for small children.
• Perform ventilation to a rate of 1 second of inhalation to 40 seconds of exhalation. Exhalation is easily accommodated by cutting a small hole in the distal end of the high pressure tubing to create a side hole. Inhalation occurs when the hole is covered with a finger, exhalation when the hole is left open.

Treatment

Prehospital Care

• Immediate transport to the nearest appropriate facility is necessary (emergency department approved for pediatrics [EDAP] or pediatric critical care center [PCCC]).
• Obtaining vital signs or any other diagnostic procedures are secondary to securing the airway.
• The child should be allowed to assume a position of comfort. The parent should be allowed to hold the child.
• Oxygen may be administered if it does not disturb the child.
• If the child has a respiratory arrest, first attempt ventilation with a bag-valve mask. Long, slow ventilations are best.
• Orotracheal intubation should be attempted if unable to ventilate the child. Needle cricothyroidotomy is used only if unable to secure an airway.
• If the child is to be transported to another facility, the airway should be secured. Only then should an intravenous line be placed. The child should be sedated and given antibiotics prior to transfer.

Emergency Department Care

The first priority for a patient with epiglottitis is securing and providing respiratory support before a definitive airway is obtained. Initially humidified oxygen can be given by a nasal cannula or a nonrebreather mask as required. The patient should have respiratory and cardiac monitoring placed, and the patient should be kept in plain view of medical staff at all times.

• If respiratory arrest occurs, the patient should be ventilated using a bag-valve mask device and intubation should be performed. Nonblind, fiberoptic-assisted nasotracheal intubation under controlled conditions is preferred. In a patient with respiratory distress, "rescue" airway equipment should be prepared prior to rapid sequence intubation. Anesthesia and ear, nose, and throat (ENT) specialists should be notified of the airway risk, and a collective decision should be made regarding intervention.
• Orotracheal intubation or needle cricothyroidotomy may be necessary in emergent situations.
• Pediatric epiglottitis is one of the few instances in which the emergency physician may need to rapidly perform needle cricothyrotomy.
• Most physicians are not aware that normal, volume-controlled, oxygen wall ports are incapable of delivering the pressure needed to adequately oxygenate an adult through a 14-g catheter (50 psi). In some trauma centers, needle jet setups specifically are preinstalled to address this concern, with a pressure-controlled port (instead of the volume-controlled port). For children, a setting of 1 psi/kg is recommended, although literature is lacking.
• Transtracheal jet insufflation does little for ventilation; however, it may salvage enough time in cases of complete inspiratory airway occlusion to perform tracheostomy or begin extracorporeal bypass maneuvers.
• The child's condition must be periodically evaluated in order to determine need for intubation. Minor procedures, such as intravenous access, may cause respiratory distress and can be performed more safely after intubation.
• Direct visualization of the epiglottis should not be performed unless staff members capable of securing an airway are present.
• Tracheostomy should be reserved for patients in which endotracheal intubation is unsuccessful due to severe laryngeal edema.
• Currently, no controlled studies exist on the use of intravenous steroids for reduction of airway structure edema due to pediatric epiglottitis. Nonetheless, some clinicians routinely use them in cases with adults.
• Despite evidence of increased morbidity and mortality in patients treated without intubation, reports of children managed on an observation basis have been reported. Patients managed successfully with observation were generally older and able to tolerate their secretions. This approach should be used with caution.
• Currently, the cause of infection more likely will be S aureus or group A streptococci as opposed to Hib because of vaccine use, and therapy should be directed as such.
• Empiric therapy should be directed to cover the above mentioned organisms.

Consultations

• An ENT or general surgeon should be consulted immediately. In addition, anesthesia should be immediately present. Ideally, the child should be taken to the operating room to secure the airway.
• Because the child should be admitted to an intensive care unit, the intensivist must be consulted.

Medication

Antibiotic therapy is necessary but should be initiated after securing the airway. Prior to culture results, use antibiotics covering the most likely organisms. Following trauma to the epiglottis, S aureus should be suspected. With the presence of white patches, C albicans should be suspected. Sedation for comfort is also required.

Antibiotics

Empiric antimicrobial therapy must cover all likely pathogens in the context of the clinical setting. Treatment should continue for 7-10 d in general.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Dosing

Adult

1-2 g IV q12-24h

Pediatric

75-100 mg/kg/d IV q12-24h

Interactions

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Ceftriaxone displaces bilirubin from binding sites on albumin; adjust dose in renal impairment; caution in breastfeeding women and in allergy to penicillin

Cefuroxime (Ceftin)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have. Adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determines proper dose and route of administration.

Dosing

Adult

750 mg to 1.5 g IV q8h

Pediatric

100-150 mg/kg/d IV divided tid

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Ampicillin (Omnipen, Principen)

When combined with chloramphenicol, this is an alternative if unable to use cephalosporins. Beta-lactam antibiotic, which has activity against some gram-positive and gram-negative organisms. Inhibits bacterial cell wall synthesis during active multiplication.

Dosing

Adult

1-2 g IV q6-8h

Pediatric

100-200 mg/kg/d IV divided q6h

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; commonly causes rash (evaluate rash and differentiate from hypersensitivity reaction)

Chloramphenicol (Chloromycetin)

When combined with ampicillin, this is an alternative if unable to use cephalosporins. Elicits activity against some gram-positive, gram-negative, and anaerobic organisms. Inhibits protein synthesis by reversibly binding to the 50S ribosomal subunit.

Dosing

Adult

50 mg/kg/d IV divided q6h

Pediatric

50-100 mg/kg/d IV divided q6h

Interactions

Coadministration with barbiturate may decrease chloramphenicol serum levels, while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; hydantoins may either increase or decrease chloramphenicol levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)

Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.

Dosing

Adult

600-1200 mg/d IV divided bid/qid

Pediatric

25-40 mg/kg/d IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Dosing

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Follow-up

Further Inpatient Care

• The patient should be admitted to the pediatric intensive care unit and, if intubated, should be sedated and/or paralyzed.
• Laryngoscopy should be repeated 24-48 hours after treatment to evaluate the degree of inflammation, and a decision should be made when to consider extubation. Criteria for extubation include air leaks around the endotracheal tube or decreased edema and erythema of the epiglottis.
• After observation of 24-48 hours postextubation, the patient can be discharged on oral antibiotics.

Transfer

• If the hospital is unable to care for critically ill children, transfer should be arranged to the nearest appropriate facility, which, ideally, would be a hospital with a pediatric intensive care unit.
• Transport of patients with epiglottitis may be a concern, especially for patients who are maintaining an airway in the emergency department but could lose airway protection during transport. A survey done at the 1990 Pediatric Critical Care Transport Leadership Conference showed that 49% of physicians recommend intubation prior to interhospital transfer. The other 49% made decisions on a patient-to-patient basis. Therefore, the physician should use clinical judgment in making this decision.

Deterrence/Prevention

• The Hib vaccine has dramatically reduced the incidence of epiglottitis. This vaccine is recommended for all children. Epiglottitis can still occur in children who are completely vaccinated.
• According to the Red Book 2006 of the American Academy of Pediatrics, rifampin prophylaxis (20 mg/kg per dose over 1 mo of age; maximum of 600 mg) for 4 days should be given to all household contacts if any of the following exist:
• One or more child in the household younger than 4 years who has not received his or her age-appropriate number of doses of Hib vaccine
• One or more child younger than 12 months who has not received the primary series of Hib vaccine
• An immunocompromised child, regardless of the vaccination history
• Children older than 2 years with epiglottitis do not need vaccination because the disease provides immune protection.

Complications

• During the bacteremic phase of the disease, other foci of infection are possible. Pneumonia is the most commonly cited associated illness, with otitis media being the second. Meningitis has been reported in association with epiglottitis.
• As with other causes of upper airway obstruction, pulmonary edema can be observed after the airway has been secured. Accidental extubation and respiratory arrest are the 2 most common complications.
• Accidental extubation can cause additional complications.
• Cervical adenitis, tonsillitis, and otitis media have also been documented.
• Specifically with Hib, meningitis, septic shock, cellulitis, and septic arthritis can be seen.

Prognosis

• Once the airway has been secured, prognosis is excellent, with the mortality rate falling below 1%.

Miscellaneous

Medicolegal Pitfalls

• If epiglottitis is suspected, immediate assembly of a team capable of securing a protected airway is the utmost priority.
• Never leave the child unaccompanied.
• No diagnostic tests are required before taking the child to the operating room.
• Direct visualization of the epiglottis in the ED is unwise, although, in reality, no cases of laryngospasm due to such visualization have ever been reported in the literature.
• As the disease becomes more rare, its existence and its quick progression may be forgotten.
• A written protocol should be available for a child presenting with possible epiglottitis.
• A patient complaining of a severe sore throat but with minimal findings on examination should be considered to have epiglottitis.

Special Concerns

• Laryngoscopy is the best way to confirm the diagnosis, but it is not advised to attempt any procedures without securing the airway. Simply depressing the child's tongue with a tongue blade may visualize the epiglottitis in some situations. Some concern exists regarding the safety of such procedures, which can provoke anxiety and increased respiratory effort during examination leading to airway obstruction.
• A study performed in Germany recommended laryngoscopy to aid in the diagnosis in patients with atypical presentations or with crouplike coughs. It also showed that fiberoptic endoscopy is especially useful in cooperative older children with moderate respiratory distress.

Multimedia

Media file 1: Comparison of a normal pediatric airway and airway from a child who died from epiglottitis.

Media file 2: Child assuming the sniffing position with upper airway obstruction.

Media file 3: Radiograph of a child with acute epiglottitis; note hypopharyngeal dilatation, obliteration of vallecula, and aryepiglottic folds—a positive thumb sign.

Media file 4: Correct positioning for a cricothyroid needle insertion.

Media file 5: Child with acute epiglottitis after intubation. Note cherry red epiglottis. This image was taken in 2008 and the child was completely immunized and grew HiB from surface culture.

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Keywords

epiglottitis, epiglottis, Hib, supraglottitis, epiglottitis in children, Haemophilus influenzae type b, Hib vaccine, H influenzae, Streptococcus, Streptococcus pneumoniae, S pneumoniae, Klebsiella pneumoniae, K pneumoniae, Candida albicans, C albicans, Staphylococcus aureus, S aureus, Neisseria meningitidis, N meningitidis, Haemophilus parainfluenzae, H parainfluenzae, varicella zoster, herpes simplex type 1, parainfluenza

Contributor Information and Disclosures

Author

Robert Allan Felter, MD, FAAP, CPE, FACPE, Professor of Clinical Pediatrics, Department of Pediatrics, Georgetown University College of Medicine; Medical Director, Pediatric Emergency Medicine and Inpatient Services, Inova Loudoun Hospital, Leesburg, Virginia
Robert Allan Felter, MD, FAAP, CPE, FACPE is a member of the following medical societies: American Academy of Pediatrics and American College of Physician Executives
Disclosure: Nothing to disclose.

Coauthor(s)

Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE, Emergency Physician, Commonwealth Emergency Physicians; Director of Pediatric Quality Care Management, INOVA Loudon Hospital; Adjunct Clinical Professor, Georgetown University School of Medicine
Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

James Li, MD, Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, 
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

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