Epiglottitis is acute inflammation and rapid swelling of the epiglottis and adjacent supraglottic structures that can occlude the airway within hours. Before routine Haemophilus influenzae type b (Hib) vaccination in 1985, the disease struck roughly 5 per 100,000 children aged 2-7 each year in the United States; pediatric incidence has since fallen by more than 95% and adults now account for over 70% of cases, with an incidence of 1-4 per 100,000 adults per year.
Epiglottitis (ICD-10: J05.10 without obstruction; J05.11 with obstruction), also called acute supraglottitis, is rapidly progressive inflammation of the epiglottis, aryepiglottic folds, arytenoids, and false vocal cords. The condition typically begins with bacterial seeding of the rich loose connective tissue of the supraglottis, producing edema that can narrow the airway lumen from a normal 6-8 mm to under 2 mm within hours. Haemophilus influenzae type b (Hib) was the dominant causative organism in the pre-vaccine era, accounting for over 90% of pediatric cases. After universal Hib immunization, the microbiology has shifted: Streptococcus pneumoniae, group A and group B streptococci, Staphylococcus aureus (including methicillin-resistant strains), and non-typeable H.
The key symptoms of Epiglottitis are: Rapidly progressive severe sore throat that is disproportionate to oropharyngeal examination findings, developing over 6-24 hours., Odynophagia (painful swallowing) and dysphagia severe enough that patients refuse oral intake including their own saliva., Drooling because swallowing saliva is too painful and the inflamed epiglottis obstructs the entrance to the esophagus., Muffled, thick, hot-potato voice (dysphonia without true hoarseness), reflecting supraglottic edema rather than vocal-fold pathology., Inspiratory stridor, neck retraction, and accessory-muscle use signaling impending airway obstruction; absence of stridor does not exclude critical narrowing., Fever (often 38.5-40 °C in pediatric cases; more variable in adults), tachycardia, and prostration., Tripod posture — sitting upright, leaning forward, neck extended, jaw thrust, mouth open — adopted instinctively to maximize airway caliber..
Diagnosis is clinical and the patient's airway is protected before any investigation that requires lying flat. The classic triad — severe sore throat, drooling, and muffled voice in a patient who looks toxic — should prompt immediate transfer to a setting with airway expertise. Direct fibreoptic laryngoscopy by an experienced ENT surgeon or anesthesiologist is the reference standard and visualizes a swollen, cherry-red, or pale-edematous epiglottis and aryegligottic folds. Lateral soft-tissue neck radiograph (the historical thumb sign) is still useful in stable patients and shows an enlarged epiglottic shadow, but should be deferred in any child or unstable adult because positioning for the film can precipitate obstruction. Contrast-enhanced CT or MRI of the neck is reserved for suspected abscess or non-infectious supraglottitis once the airway is secured. Blood cultures are drawn before antibiotics; epiglottic swabs are usually deferred because of airway risk. White blood count typically shows neutrophilic leukocytosis with left shift. In children, the differential includes croup (viral laryngotracheobronchitis), retropharyngeal abscess, foreign body aspiration, and bacterial tracheitis; in adults, peritonsillar abscess, angioedema, anaphylaxis, and lingual tonsillitis must be excluded. Point-of-care ultrasound of the anterior neck is an emerging adjunct that demonstrates a thickened epiglottis (≥6 mm in adults).
Outcome depends almost entirely on the speed of airway protection and antibiotic delivery. Adults reaching a hospital with full airway capability before complete obstruction have mortality rates below 1% and full recovery in over 90% of cases. Pediatric mortality has fallen from approximately 7% in the pre-vaccine era to under 1% with prompt management. Failure to recognize the diagnosis is the strongest predictor of death: case-fatality rises to 7-20% when initial evaluation does not include direct visualization or when intubation is delayed beyond 6 hours of stridor onset. Most survivors require 24-72 hours of intubation; tracheostomy is necessary in 5-15% of adults and under 5% of children. Recurrence occurs in 4-8% of adults, particularly those with diabetes, immunosuppression, or prior radiotherapy. Long-term laryngeal dysfunction, including chronic dysphonia or aspiration, develops in fewer than 5% of survivors.
Any patient with suspected epiglottitis requires immediate evaluation in an emergency department capable of summoning ENT and anesthesia together. Outpatient evaluation by a primary care clinician is inappropriate once severe sore throat with drooling, voice change, or stridor is reported; the patient should be transported directly to a hospital with operating-room airway capability.
Find specialists →Intubation is required for a median of 36-48 hours. Most patients are extubated in the operating room once cuff-leak testing is positive and re-laryngoscopy shows decongestion. Hospital stay averages 4-7 days. Symptomatic recovery (normal voice, comfortable swallowing) is complete within 2-3 weeks in over 90% of cases. Outpatient laryngoscopy at 2-4 weeks confirms anatomical resolution.
Light activity (walking) can resume 48 hours after discharge in uncomplicated cases. Strenuous exercise, swimming, and contact sports should wait until the supraglottis has fully decongested on outpatient laryngoscopy at 2-4 weeks. Patients with tracheostomy follow specific airway-care protocols.
After acute admission, choose an ENT surgeon affiliated with a center that performs at least 50 awake fibreoptic intubations per year and has 24-hour anesthesia and intensive-care backup. Adult patients with recurrent episodes should also be seen by infectious disease and, in selected cases, immunology services.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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