The n e w e ng l a n d j o u r na l of m e dic i n e

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“Thumb Sign” of Epiglottitis

A
58-year-old man presented to the emergency department after Casey Grover, M.D.
having had severe throat pain, hoarseness, and fever for 2 days. A physical Stanford University Medical Center
examination revealed no stridor, respiratory distress, or drooling. The re- and Kaiser Permanente
sults of an oropharyngeal examination were unremarkable. A lateral soft-tissue ra- Stanford, CA
diograph of the neck showed a “thumb sign” (arrow) (a normal lateral soft-tissue cgrover@stanford.edu
radiograph of the neck is shown in the Supplementary Appendix, available with the
full text of this article at NEJM.org). This radiographic sign is a manifestation of an
enlarged and edematous epiglottis, and it suggests a diagnosis of acute infectious
epiglottitis. Intravenous antibiotics were administered, and subsequent fiberoptic
laryngoscopy confirmed that the epiglottis was swollen and inflamed. An apical
epiglottic abscess was also present; it was not drained and was managed medically.
Countries with routine pediatric immunization for Haemophilus influenzae serotype b
have witnessed a dramatic reduction in the incidence of epiglottitis in children, with
the result that the majority of cases of infectious epiglottitis now occur in adults.
Given the substantial risk of airway compromise, this patient was admitted to the
intensive care unit for observation. No causative organism was identified in blood
cultures. When his symptoms diminished, the patient was discharged to his home
and instructed to complete a course of oral antibiotics.
Copyright © 2011 Massachusetts Medical Society.

n engl j med 365;5 nejm.org august 4, 2011 447

The New England Journal of Medicine
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.