Have you ever wondered what prevents food and drink from going down your windpipe and into your lungs when you eat or drink? It is your epiglottis, a flap of tissue located at the back of the throat which lifts up to allow you to breathe, but covers your larynx during swallowing so that food and drink travel down your oesophagus into your stomach and not into your lungs.
When this becomes inflamed due to infection or injury it swells. This is known as epiglottitis. The swelling can be dangerous as the epiglottis may then cover your larynx completely and prevent air from getting into your airways.
Epiglottitis is usually due to a bacterial infection, but it can also be caused by an injury or burn. In the past, epiglottitis mainly occurred in children between the ages of 2 and 6 years of age due to an infection with Haemophilus influenzae type B (Hib) bacteria. However, since the introduction of the vaccine against Hib in young children, it is now more common in adults.1
The condition tends to be more serious and progress quicker in a child due to the epiglottis of a child having a slightly different positioning and pliancy and the child’s airways being narrower than that of adults, and it is therefore, more likely to affect a child’s breathing.2 This is why babies need to receive the Hib vaccine as part of their vaccination schedule.
Epiglottitis requires urgent medical attention as severe cases can lead to respiratory arrest. Symptoms can include a severe sore throat, pain when swallowing and respiratory distress. However, with proper diagnosis and treatment, the condition usually improves, rapidly.
Causes of epiglottitis
- Inflammation of the epiglottis is mainly caused by bacterial infections, usually with Hib bacteria.3 Hib can cause life-threatening infections, especially in babies and young children or people with a weakened immune system. They are also a cause of conditions like meningitis and pneumonia. As with most other respiratory diseases, Hib is spread via droplets in the air when an infected person coughs or sneezes. Hib can also be spread by an asymptomatic carrier as they are found in the nose and throat. The best way to prevent a Hib infection is through vaccination and by practising good hand hygiene
- Epiglottitis has also been linked to other types of bacteria, such as Streptococcus pneumoniae
- Previous cases have shown inflammation of the epiglottis may also be due to fungal infections in people with weakened immune systems as throat cultures have shown the presence of Candida spp,4 although it is sometimes not clear if these are just present as part of the normal flora of the mouth and throat
- A virus such as the varicella-zoster virus (causes chickenpox) or the herpes simplex virus (causes cold sores) can also lead to epiglottitis
- Epiglottitis can also have non-infectious causes such as an injury to the throat.3 This can be caused by a blow to the throat or also by consuming too hot food or beverages or ingesting a foreign object or toxic substance as this can cause injury to the epiglottis and therefore lead to swelling
- Smoking, especially illegal substances such as cannabis, crack or cocaine can also lead to inflammation of the epiglottis.5,6 Vaping, which is becoming increasingly popular among young adults, has also been reported to cause acute epiglottitis and in vitro studies have shown that e-cigarette vapour can lead to vocal fold mucous membrane remodelling
Signs and symptoms of epiglottitis
Symptoms of epiglottitis can come on quite suddenly and get worse quickly (within hours), especially in a young child.7 A child with epiglottitis will typically exhibit the following:
- a high fever
- stridor (a high-pitched whistling sound made during breathing and caused by airway obstruction)
- drooling or difficulty swallowing.
They may also have a sore throat or pain when swallowing and have difficulty breathing.7
Epiglottitis can sometimes be confused with croup in a young child. This is a common paediatric disease which may have similar symptoms as it affects a child's airways but it is usually far milder. A child suffering from croup will have a distinctive barking cough, they are also less likely to have drooling or exhibit the “tripod” position and usually appear less distressed than those suffering from epiglottitis.7
In adults, acute epiglottitis usually develops more slowly. The most common symptom is usually a severe sore throat. An adult may also display some of the following:
- difficulty swallowing
- difficulty breathing
- hoarseness or muffled voice
In adults, other types of infectious diseases such as viral infections need to be considered.
Management and treatment for epiglottitis
The first thing that is done is to ensure that the patient’s airways are open and that they can breathe properly. The person’s breathing and blood oxygen levels should be monitored.
If the patient is struggling to breathe and their blood oxygen levels drop too low they may need to be given oxygen through an oxygen mask.
If this does not work the patient may need endotracheal intubation. This is where a tube is placed through the person’s nose or mouth and into their windpipe to help keep their upper airway open and deliver oxygen into the lungs.
If the swelling of the epiglottis is too severe and oxygen is needed urgently a tracheostomy may need to be performed. This is when a small cut is made in the windpipe and at the front of the neck and the breathing tube is then inserted through this cut, thus allowing oxygen to be delivered to the person’s lungs quickly.
If the inflammation and swelling of the epiglottis is thought to be due to an infection the patient may be treated with broad-spectrum antibiotics. This may need to be changed to different more specific antibiotics later on in treatment once throat cultures have been done.
If the patient is struggling to swallow, they will also be given fluids intravenously.
Once the patient's airway is secured and they are receiving enough oxygen, diagnostic tests may be carried out. These can include the following: flexible laryngoscopy, throat swab, blood tests, X-rays and CT Scans.
- Flexible or fibreoptic laryngoscopy is a procedure which is used to be able to view the back and inside of your throat. A doctor inserts a thin, flexible tube with a lens, light and a video camera attached through the patient’s nose or mouth and into their throat. They will then be able to view the back of the patient’s throat and be able to record the images. The patient will usually receive some numbing medication and possibly a nasal decongestant to make the procedure more comfortable.
- A throat swab and culture are usually carried out to check if the inflammation is due to a bacterial infection, and if so by which type of bacteria. A swab will usually be taken from the back of the throat by using a cotton bud and then sent to the laboratory for testing.
- Blood tests and blood cultures may also be carried out to count the number of white blood cells and check for viruses or bacteria or any issues with the immune system. White blood cells fight infection in the body, so a high white blood cell count usually indicates the person is fighting an infection.
- An X-ray or CT scan may also be performed to confirm the diagnosis and check the level of swelling. If the “thumb sign” is seen on an X-ray it may indicate epiglottitis.8,9
How can I prevent epiglottitis?
One of the best ways to prevent epiglottitis is to ensure all your vaccinations are up to date, as one of the main causes of epiglottitis is infection with Hib, and the Hib vaccine is part of a child’s routine vaccination schedule.2 It is also a good idea to practise good hygiene such as regular hand washing.
How common is epiglottitis?
Due to the Hib vaccine being part of a child’s routine vaccination schedule, epiglottitis is now seen far less in young children than it was in the past.2 It is a relatively rare condition in adults, but when it does occur it needs emergency care.
Who is at risk of epiglottitis?
A child younger than 12 months who hasn’t been fully vaccinated against Hib is at higher risk of epiglottitis. Also, an older person or someone with a weakened immune system or underlying health conditions may be at a greater risk of epiglottitis.4
When should I see a doctor?
Epiglottitis is considered to be a medical emergency as a swollen epiglottis can prevent oxygen from getting into your lungs. On account of the hindered airflow to the lungs, epiglottitis is known to be a medical emergency. It is especially serious in a baby or young child. If you or your child is struggling to breathe or swallow you should call an ambulance and try to remain calm as this will make it easier to breathe.
Epiglottitis is considered to be a serious condition which requires prompt airway management. This is especially the case in young children as it tends to be more severe due to the slightly different physiology of a child’s throat and epiglottis. In the past, epiglottitis was usually due to an infection with the Hib bacterium, but with the introduction of the Hib vaccine as part of the childhood vaccination schedule, it is now rare in children. If epiglottitis is suspected the person should be kept calm and an emergency care provider should be contacted. With quick and proper medical care the medical condition resolves quickly.
- Dowdy RAE, Cornelius BW. Medical management of epiglottitis. Anesth Prog [Internet]. 2020 [cited 2023 Jun 20];67(2):90–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342809/
- Guerra AM, Waseem M. Epiglottitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK430960/
- Orhan İ, Aydın S, Karlıdağ T. Infectious and noninfectious causes of epiglottitis in adults, review of 24 patients. Turk Arch Otorhinolaryngol [Internet]. 2015 Mar [cited 2023 Jun 20];53(1):10–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791800/
- Chen C, Natarajan M, Bianchi D, Aue G, Powers JH. Acute epiglottitis in the immunocompromised host: case report and review of the literature. Open Forum Infect Dis [Internet]. 2018 Feb 17 [cited 2023 Jun 23];5(3):ofy038. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846294/
- Bozzella MJ, Magyar M, DeBiasi RL, Ferrer K. Epiglottitis associated with intermittent e-cigarette use: the vagaries of vaping toxicity. Pediatrics [Internet]. 2020 Mar 1 [cited 2023 Jun 23];145(3):e20192399. Available from: https://publications.aap.org/pediatrics/article/145/3/e20192399/36887/Epiglottitis-Associated-With-Intermittent-E
- Lungova V, Wendt K, Thibeault SL. Exposure to e-cigarette vapor extract induces vocal fold epithelial injury and triggers intense mucosal remodeling. Disease Models & Mechanisms [Internet]. 2022 Aug 1 [cited 2024 Jan 9];15(8):dmm049476. Available from: https://journals.biologists.com/dmm/article/15/8/dmm049476/276414/Exposure-to-e-cigarette-vapor-extract-induces
- Kivekäs I, Rautiainen M. Epiglottitis, acute laryngitis, and croup. Infections of the Ears, Nose, Throat, and Sinuses [Internet]. 2018 May 4 [cited 2023 Jun 23];247–55. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120939/
- Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi J Anaesth [Internet]. 2012 [cited 2023 Jun 22];6(3):279–81. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/
- Lee J, Loh J, Lee TS. Double thumb sign in a case of epiglottitis. Radiology Case Reports [Internet]. 2021 Jul [cited 2024 Jan 10];16(7):1810–4. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1930043321002156