Overview
Definition:
Epiglottitis is a life-threatening bacterial infection causing rapid inflammation and edema of the epiglottis and surrounding structures, leading to severe upper airway obstruction
Severe croup (acute laryngotracheobronchitis) is a viral illness characterized by inflammation of the larynx and trachea, causing a barking cough, stridor, and hoarseness, with airway compromise typically less severe than epiglottitis.
Epidemiology:
Epiglottitis incidence has dramatically decreased in developed countries following widespread Haemophilus influenzae type b (Hib) vaccination, but remains a concern where vaccination rates are low
it typically affects children aged 2-7 years
Severe croup is more common, predominantly affecting infants and young children (6 months to 3 years), with a peak incidence between 6 months and 2 years
it is most common in autumn and winter.
Clinical Significance:
Accurate and timely differentiation between epiglottitis and severe croup is critical due to the vastly different management strategies and potential for rapid deterioration
Epiglottitis is a surgical emergency requiring immediate airway protection, often with intubation, while severe croup can usually be managed non-invasively with supportive care and medical therapies
Misdiagnosis can lead to fatal airway compromise.
Clinical Presentation
Symptoms:
Epiglottitis: Sudden onset of severe sore throat
Difficulty swallowing (odynophagia)
High fever
Muffled or "hot potato" voice
Drooling saliva
Restlessness, anxiety
Rapid progression of respiratory distress
Croup: Gradual onset of a barking cough
Hoarseness
Inspiratory stridor
Mild to moderate fever
Symptoms often worse at night
Absence of significant drooling or severe dysphagia in most cases.
Signs:
Epiglottitis: Tripod position
Muffled voice
Marked drooling
Appears acutely ill, toxic
Cervical lymphadenopathy
Tachypnea, tachycardia
Retractions
Possible cyanosis
Croup: Barking cough
Stridor (inspiratory, can be biphasic in severe cases)
Retractions (subcostal, intercostal, suprasternal)
Nasal flaring
Mild to moderate distress
Lethargy may be present in severe cases but typically less toxic appearance than epiglottitis.
Diagnostic Criteria:
No strict diagnostic criteria for either condition
diagnosis is primarily clinical and supported by investigations
Epiglottitis is suspected in a child with acute onset of fever, sore throat, dysphagia, and airway distress, especially if associated with drooling and tripod positioning
Severe croup is suspected in a child with characteristic barking cough, hoarseness, and stridor, especially if accompanied by signs of respiratory distress and an appropriate age group.
Diagnostic Approach
History Taking:
Focus on the speed of symptom onset
Severity of sore throat and dysphagia
Presence or absence of drooling
Immunization status (Hib)
Recent upper respiratory tract infection symptoms
History of allergies
Fever height and duration
Cough character (barking vs
other).
Physical Examination:
Assess overall appearance: toxic vs
mildly ill
Measure vital signs: heart rate, respiratory rate, temperature, oxygen saturation
Inspect the oropharynx CAREFULLY and minimally, without causing distress
avoid using a tongue depressor in a potentially epiglottitic child if it can be avoided
Look for tripod position, drooling, stridor, retractions, accessory muscle use
Palpate the neck for lymphadenopathy or neck stiffness.
Investigations:
Epiglottitis: Lateral neck X-ray may show a swollen epiglottis ("thumb sign"), but this is not always present and the X-ray should not delay airway management
Direct visualization of the epiglottis via laryngoscopy is definitive but risky in the ER and should only be performed in a controlled setting with airway equipment ready
expect a swollen, erythematous epiglottis
White blood cell count may show leukocytosis
Blood cultures for bacterial pathogens
Croup: Lateral neck X-ray may show subglottic narrowing ("steeple sign"), but this is not always present and diagnosis is often clinical
Arterial blood gas if severe hypoxia or hypercapnia suspected
Viral respiratory panel via nasal swab if diagnosis is unclear and hospitalization is needed.
Differential Diagnosis:
Other causes of stridor: Retropharyngeal abscess (similar presentation to epiglottitis but may have neck stiffness)
Bacterial tracheitis (often follows viral croup, can be severe with purulent secretions)
Foreign body aspiration (sudden onset of choking, unilateral wheezing)
Laryngeal edema from trauma or allergic reaction
Vocal cord paralysis
Congenital airway anomalies.
Management
Initial Management:
Epiglottitis: IMMEDIATELY secure the airway
This is a surgical emergency
Prepare for intubation by an experienced provider (anesthesiologist or ENT surgeon)
Keep the child calm and in a position of comfort
Do NOT agitate the child or attempt to visualize the epiglottis unless immediate intubation is possible
Administer oxygen
IV access
Croup: Assess severity using a validated scoring system (e.g., Westley Croup Score)
If mild to moderate: humidified oxygen, racemic epinephrine (nebulized), corticosteroids (dexamethasone orally or IM)
Monitor closely for improvement or deterioration
If severe: Continuous nebulized racemic epinephrine, IV dexamethasone, consider hospitalization and close observation for potential intubation.
Medical Management:
Epiglottitis: Intravenous antibiotics are crucial
Ceftriaxone (50-100 mg/kg/day IV divided every 12-24 hours) is the drug of choice
Other options include cefotaxime or ceftizoxime
Duration of therapy is typically 7-10 days
May add clindamycin or vancomycin if suspected resistant organisms
Croup: Corticosteroids: Dexamethasone (0.6 mg/kg PO or IM, max 10 mg) is effective in reducing inflammation and need for hospitalization
Racemic epinephrine: 0.05 mL/kg of 1:1000 solution diluted in 3 mL normal saline, nebulized over 15-20 minutes
effects are temporary (2-4 hours), monitor for rebound stridor after administration.
Surgical Management:
Epiglottitis: Definitive airway management
Endotracheal intubation is usually required, often performed blindly or under direct visualization
Tracheostomy may be considered in cases where intubation is impossible or prolonged ventilation is anticipated
Croup: Rarely requires surgical intervention
intubation may be necessary for severe, refractory cases unresponsive to medical management.
Supportive Care:
Epiglottitis: IV fluids for hydration
Analgesia
Close monitoring in an intensive care unit (ICU) setting
Humidified air may be beneficial
Croup: Humidified air or oxygen
Hydration (oral or IV if needed)
Rest
Observation for signs of impending airway obstruction
Removal from stressful stimuli.
Complications
Early Complications:
Epiglottitis: Complete airway obstruction leading to hypoxia and cardiac arrest
Pneumonia
Sepsis
Lung abscess
Mediastinal abscess
Croup: Hypoxia
Hypercapnia
Secondary bacterial infection (e.g., bacterial tracheitis, pneumonia)
Respiratory failure requiring intubation.
Late Complications:
Epiglottitis: Generally rare with prompt and appropriate treatment
potential for vocal cord damage or subglottic stenosis from prolonged intubation
Croup: Very rare with typical management
subglottic stenosis if prolonged or traumatic intubation.
Prevention Strategies:
Epiglottitis: Widespread vaccination against Haemophilus influenzae type b (Hib) is the most effective preventative measure
Croup: No specific preventative measures beyond general hygiene to reduce viral transmission
Prompt recognition and treatment of viral infections.
Prognosis
Factors Affecting Prognosis:
Epiglottitis: Promptness of diagnosis and airway management
Severity of initial illness
Presence of complications
Croup: Severity of initial stridor and respiratory distress
Age of the child
Presence of underlying comorbidities
Response to racemic epinephrine and corticosteroids.
Outcomes:
Epiglottitis: With rapid diagnosis and intervention, the prognosis is generally good, with most children recovering fully
However, delayed treatment can lead to irreversible hypoxic brain injury or death
Croup: Most cases resolve within 3-7 days with supportive care
Children requiring intubation have a slightly higher risk of complications but usually recover well.
Follow Up:
Epiglottitis: Typically requires ICU monitoring post-intubation
Once extubated, follow-up with ENT and pediatrician to ensure complete recovery and monitor for any airway sequelae
Croup: For children treated as outpatients, follow-up with pediatrician if symptoms do not improve or worsen
For hospitalized children, follow-up to ensure no residual respiratory issues.
Key Points
Exam Focus:
Remember: Epiglottitis is a rapid, life-threatening bacterial emergency
Croup is a more common, usually viral illness with gradual progression
The "thumb sign" on lateral neck X-ray suggests epiglottitis, while the "steeple sign" suggests croup (though neither is definitive)
Immediate airway management is paramount in epiglottitis.
Clinical Pearls:
In a child with stridor and sore throat, assume epiglottitis until proven otherwise, especially if drooling and dysphagia are present
Avoid agitating a child suspected of epiglottitis
do not use a tongue depressor unless intubation is imminent and necessary for visualization
Racemic epinephrine for croup is a temporizing measure
response should be monitored for rebound stridor
Dexamethasone is crucial for treating the inflammation in croup.
Common Mistakes:
Mistaking epiglottitis for a severe case of croup and delaying definitive airway management
Attempting to visualize the epiglottis in a distressed child without airway equipment ready
Underestimating the severity of croup and failing to monitor for signs of impending airway compromise
Relying solely on X-ray findings for diagnosis without clinical correlation.