Last updated: July 31, 2023

Summarytoggle arrow icon

Epiglottitis is the rapid progressive inflammation of the epiglottis and surrounding supraglottis that was historically primarily caused by Haemophilus influenzae type b (Hib). Since the introduction of the Hib vaccine in 1985, the incidence of Hib epiglottitis has significantly decreased. Epiglottitis is now more common in adults than in children and is usually caused by other bacteria (e.g., streptococci and staphylococci). Children with epiglottitis typically appear acutely ill and position themselves in a tripod stance (sitting and leaning forward) in an attempt to improve their airway diameter. The disease is characterized by the acute onset of fever, drooling, sore throat, dysphagia, and, in severe cases, respiratory distress accompanied by inspiratory retractions and cyanosis. Impending airway obstruction is also accompanied by a muffled voice and restlessness. Epiglottitis is diagnosed based on clinical presentation. If the diagnosis is unclear and the patient is stable, a lateral cervical x-ray may be considered on which a thumb sign may be seen. If the patient is unstable, their airway should first be secured, after which direct laryngeal examination may be performed. Patients should be closely monitored in a hospital and receive IV antibiotics. Most patients make a full recovery after prompt and adequate treatment.

Epidemiologytoggle arrow icon

  • More common in adults than children [1]
  • Peak incidence in children: 6–12 years [2]
  • Peak incidence in adults: 40–50 years [1]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon


Pathophysiologytoggle arrow icon

Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and vallecula) → supraglottic inflammation and edema narrowing of the airway airway obstruction (partial or complete) [3]

Clinical featurestoggle arrow icon

The hallmarks of epiglottitis are the three Ds: Dysphagia, Drooling, and Distress.


Airway managementtoggle arrow icon

In young children, airway management is a higher priority than diagnostic evaluation . Advanced airway placement is rarely required in adults. [4]

Approach [4][6][7]

Acute epiglottitis is an airway emergency. Urgently consult a physician experienced in difficult airway management (e.g., an emergency physician, anesthesiologist, or otolaryngologist).

Endotracheal intubation [5][7][9]

Intubation should be performed under direct visualization; avoid blind nasotracheal intubation as it risks airway obstruction. [4]

Emergency surgical airway [9][10]

Indicated if intubation is unsuccessful

Diagnosticstoggle arrow icon

Approach [6][11][12][13][14]

Secure the airway before initiating diagnostic studies or procedures in patients with impending airway compromise, especially in children.

Visualization of the epiglottis [6][11][12][13][14]

  • Indication: There is suspicion for epiglottitis but no clinical features of airway obstruction.
  • Procedure
  • Additional considerations
    • Avoid increasing anxiety (especially in children).
      • Keep the patient comfortable and in a calm setting.
      • Keep the patient in a sitting position at all times (do not force the patient to lie supine).
      • If the patient is a child, let the parent/guardian hold the mask, and use distractions and humor to help keep the child relaxed.
    • In children, this procedure should only be performed by a skilled otolaryngologist.
  • Characteristic findings

Imaging [6][11][12][13][14]

Soft-tissue lateral neck x-ray [15]

  • Indication: mainly performed in children if the clinical presentation in early cases is inconclusive
  • Procedure: should be carried out under the supervision of an experienced physician
  • Characteristic findings
    • Thumb sign (also referred to as thumbprint sign): enlarged epiglottis and supraglottic narrowing
    • Narrowing or complete loss of the normal pre-epiglottic air shadow (vallecula sign)
    • Thick aryepiglottic folds

CT of the neck with IV contrast [16]

Additional diagnostic studies [11]

Treatmenttoggle arrow icon

Empiric IV antibiotics [7][11]

There are no guidelines on specific empiric antibiotic recommendations. All patients should receive IV antibiotics that are active against Hib, S. aureus, S. pyogenes, and S. pneumonia. Following cultures, antibiotics can be narrowed according to identified organisms.

Adjunctive therapy [11][14][20][21]

Acute management checklisttoggle arrow icon

Differential diagnosestoggle arrow icon

Prognosistoggle arrow icon

Preventiontoggle arrow icon

Referencestoggle arrow icon

  1. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  2. Lindquist B et al.. Adult Epiglottitis: A Case Series. The Permanente Journal. 2016.doi: 10.7812/tpp/16-089 . | Open in Read by QxMD
  3. J. Lance Lichtor, Maricarmen Roche Rodriguez, Nicole L. Aaronson, Todd Spock, T. Rob Goodman, Eric D. Baum. Epiglottitis. Anesthesiology. 2016; 124 (6): p.1404-1407.doi: 10.1097/aln.0000000000001125 . | Open in Read by QxMD
  4. Sobol SE, Zapata S. Epiglottitis and Croup. Otolaryngol Clin North Am. 2008; 41 (3): p.551-566.doi: 10.1016/j.otc.2008.01.012 . | Open in Read by QxMD
  5. Felton P, Lutfy-Clayton L, Gonen Smith L, Visintainer P, Rathlev N. A Retrospective Cohort Study of Acute Epiglottitis in Adults. West J Emerg Med. 2021; 22 (6): p.1326-1334.doi: 10.5811/westjem.2021.8.52657 . | Open in Read by QxMD
  6. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013; 118 (2): p.251-270.doi: 10.1097/aln.0b013e31827773b2 . | Open in Read by QxMD
  7. COTÉ CJ, HARTNICK CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?. Pediatric Anesthesia. 2009; 19: p.66-76.doi: 10.1111/j.1460-9592.2009.02996.x . | Open in Read by QxMD
  8. Alcaide ML, Bisno AL. Pharyngitis and Epiglottitis. Infect Dis Clin North Am. 2007; 21 (2): p.449-469.doi: 10.1016/j.idc.2007.03.001 . | Open in Read by QxMD
  9. Shapira Galitz Y, Shoffel-Havakuk H, Cohen O, Halperin D, Lahav Y. Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention.. Laryngoscope. 2017; 127 (9): p.2106-2112.doi: 10.1002/lary.26609 . | Open in Read by QxMD
  10. Frantz TD. Acute Epiglottitis in Adults. JAMA. 1994; 272 (17): p.1358.doi: 10.1001/jama.1994.03520170068038 . | Open in Read by QxMD
  11. Guardiani E, Bliss M, Harley E. Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: Evolving principles in diagnosis and management. Laryngoscope. 2010; 120 (11): p.2183-2188.doi: 10.1002/lary.21083 . | Open in Read by QxMD
  12. Darras KE, Roston AT, Yewchuk LK. Imaging Acute Airway Obstruction in Infants and Children. Radiographics. 2015; 35 (7): p.2064-2079.doi: 10.1148/rg.2015150096 . | Open in Read by QxMD
  13. Smith MM, Mukherji SK, Thompson JE, Castillo M. CT in adult supraglottitis. AJNR Am J Neuroradiol. 1996; 17 (7): p.1355-8.
  14. Willert C. Management of Acute Epiglottitis. JAMA: The Journal of the American Medical Association. 1982; 247 (1): p.26.doi: 10.1001/jama.1982.03320260014009 . | Open in Read by QxMD
  15. Zoorob R, Sidani MA, Fremont RD, Kihlberg C. Antibiotic use in acute upper respiratory tract infections.. Am Fam Physician. 2012; 86 (9): p.817-22.
  16. Saag MS et al. The Sanford Guide to Antimicrobial Therapy 2016. Antimicrobial Therapy, Inc ; 2016
  17. Glynn F, Fenton JE. Diagnosis and management of supraglottitis (Epiglottitis). Curr Infect Dis Rep. 2008; 10 (3): p.200-204.doi: 10.1007/s11908-008-0033-8 . | Open in Read by QxMD
  18. Kent S, Hennedige A, McDonald C, et al. Systematic review of the role of corticosteroids in cervicofacial infections. British Journal of Oral and Maxillofacial Surgery. 2019; 57 (3): p.196-206.doi: 10.1016/j.bjoms.2019.01.010 . | Open in Read by QxMD
  19. Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Adult epiglottitis. Am J Emerg Med. 2022; 57: p.14-20.doi: 10.1016/j.ajem.2022.04.018 . | Open in Read by QxMD
  20. Kivekäs I, Rautiainen M. Epiglottitis, Acute Laryngitis, and Croup. Infections of the Ears, Nose, Throat, and Sinuses. 2018: p.247-255.doi: 10.1007/978-3-319-74835-1_20 . | Open in Read by QxMD
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  22. Woods CR. Epiglottitis (Supraglottitis): Treatment and Prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: June 23, 2015. Accessed: February 18, 2017.
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