Pediatric Epiglottitis Clinical Presentation

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jun 6, 2011
 

History

Epiglottitis is characterized by the abrupt onset of severe symptoms. Without airway control and medical management, symptoms may rapidly progress to respiratory obstruction and death in a matter of hours.

Usually, no prodromal symptoms occur in children. Fever is usually the first symptom, and temperatures often reach 40°C. This is rapidly followed by stridor and labored breathing. Dysphagia, refusal to eat, muffled (ie, guttural) or hoarse voice, sore throat, and anxiety are common. Cough and ear pain are less frequent.

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.

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.[10]

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Physical Examination

The child appears toxic; shock may occur early in the course of the disease. Marked restlessness, irritability, and extreme anxiety are common.

The child may sit with his or her chin hyperextended and body leaning forward (ie, tripod or sniffing position) to maximize air entry and improve diaphragmatic excursion (see the following image).

Child assuming the sniffing position with upper aiChild assuming the sniffing position with upper airway obstruction.

The mouth may be open wide and the tongue may protrude; an affected child often drools, because swallowing is difficult or painful.

An erythematous and classic swollen, cherry red epiglottis can often be seen during careful examination of the oropharynx, although this examination should not be attempted if it may compromise respiratory effort.

Early on, the child may have stridulous respirations, but as the disease progresses, airway sounds may diminish. Stridor can occur with marked suprasternal, subcostal, and intercostal retractions.

Anterior neck examination may reveal tender adenopathy. In the older child, pain may be noted on movement of the hyoid bone.[11]

Cyanosis, which occurs late in the course of the condition, indicates a poor prognosis.

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Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Coauthor(s)

Antonio Muñiz, MD  Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital

Antonio Muñiz, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Medical Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Ashir Kumar, MD, MB  Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MB is a member of the following medical societies: American Association of Physicians of Indian Origin and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

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Swollen epiglottis with characteristic thumbprint sign.
Comparison of a normal pediatric airway (bottom) and airway from a child who died from epiglottitis (top).
Child assuming the sniffing position with upper airway obstruction.
Swollen epiglottis with characteristic thumbprint sign.
Radiograph of a child with acute epiglottitis; note the hypopharyngeal dilatation, obliteration of the vallecula, and thickened aryepiglottic folds—a positive thumb sign.
Correct positioning for a cricothyroid needle insertion
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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