eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Epiglottitis

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
Coauthor(s): Antonio Muñiz, MD, Associate 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
Contributor Information and Disclosures

Updated: Jan 22, 2009

Introduction

Background

Epiglottitis, also termed supraglottitis or epiglottiditis, is an inflammation of structures above the insertion of the glottis. The condition is almost always caused by bacterial infection. Affected structures include the epiglottis, aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula. The epiglottis is the most common site of swelling. Acute epiglottitis and associated upper airway obstruction has significant morbidity and mortality and may cause respiratory arrest and death.

Pathophysiology

Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae (see Causes) can colonize the pharynges of otherwise healthy children through respiratory transmission from intimate contact. These bacteria may penetrate the mucosal barrier, invading the bloodstream and causing bacteremia and seeding of the epiglottis and surrounding tissues. Bacteremia may also lead to infection of the meninges, skin, lungs, ears, and joints.

Hib 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 mucous plugging can cause respiratory arrest.

Frequency

United States

The use of the Hib vaccine has reduced incidence of epiglottitis.1 Introduction of the polysaccharide vaccine in 1985, followed by the highly effective conjugate vaccine, has dramatically reduced the incidence of epiglottitis, with concomitant declines in hospital admissions. Studies show an annual incidence rate of 0.63 cases per 100,000 persons.2 Studies of children of all ages with epiglottitis report a seasonal variation in incidence.

International

Incidence widely varies. Epiglottitis is more prevalent in countries without universal immunization. The incidence rate in Stockholm, Sweden is 14.7 cases per 100,000 persons3 compared with 34 cases per 100,000 persons in Geneva, Switzerland.4

Mortality/Morbidity

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

Race

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

Sex

Males represent 60% of cases.

Age

In the past, epiglottitis occurred most commonly in children aged 2-7 years; however, it may occur at any age. Epiglottitis was once believed to occur exclusively in children. However, adult cases have been reported in recent years and some evidence suggests incidence in adults is increasing.

Clinical

History

  • Epiglottitis is characterized by 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.
  • 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, and sore throat are common.
  • Cough and ear pain are less frequent.

Physical

  • 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 chin hyperextended and body leaning forward (ie, tripod or sniffing position) to maximize air entry and improve diaphragmatic excursion. The mouth may be open wide and the tongue may protrude.
  • An affected child often drools because swallowing is difficult or painful.
  • Stridor can occur with marked suprasternal, subcostal, and intercostal retractions.
  • Anterior neck examination may reveal tender adenopathy.
  • An erythematous and swollen epiglottis can often be seen during careful examination of the oropharynx, although this should not be attempted if the examination may compromise respiratory effort.
  • Cyanosis, which occurs late in the course of the condition, indicates a poor prognosis.

Causes

  • Hib is the etiologic agent in more than 90% of pediatric epiglottitis cases.
  • Other known bacterial causes include the following:
    • S pneumoniae
    • Group A and group C (ie, beta-hemolytic) streptococci
    • Staphylococcus aureus
    • Moraxella catarrhalis
    • Haemophilus parainfluenzae
    • Neisseria meningitidis
    • Pseudomonas species
    • Candida albicans
    • Klebsiella pneumoniae
    • Pasteurella multocida
  • Although viruses normally do not cause epiglottitis, a prior viral infection may allow bacterial superinfection to occur. Viral agents may include herpes simplex, parainfluenzae, varicella-zoster, and Epstein-Barr.
  • Noninfectious etiologies include thermal injuries, trauma-causing blind finger sweeps to remove a foreign body from the pharynx, angioneurotic edema, and acute leukemia.

More on Epiglottitis

Overview: Epiglottitis
Differential Diagnoses & Workup: Epiglottitis
Treatment & Medication: Epiglottitis
Follow-up: Epiglottitis
Multimedia: Epiglottitis
References
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Further Reading

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Keywords

epiglottitis, acute leukemia, airway obstruction, angioneurotic edema, aryepiglottic folds, arytenoid soft tissue, bacteremia, cervical cellulitis, cyanosis, epiglottiditis, epiglottis, Epstein-Barr virus, glottis, Haemophilus influenzae type B, Hib, herpes simplex, inflammatory edema, meningitis, otitis media, parainfluenzae, pericarditis, pneumomediastinum, pneumonia, pneumothorax, pulmonary edema, respiratory arrest, septic arthritis, septicemia, Streptococcus pneumoniae, supraglottitis, tracheal stenosis, upper airway obstruction, uvula, varicella-zoster

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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 Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Antonio Muñiz, MD, Associate 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.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
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

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.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

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: None None None

 
 
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