Case #137: Sore throat and difficulty breathing -

Epiglottitis
Author: J. Kimo Takayesu MD MS
Co Author: -
Reviewer #1: Kriti Bhatia MD
Reviewer #2: Joshua Feblowitz MD MS

PRO

Correct Disposition:
Send to Operating Room for Intubation
Differential Diagnosis
Name: Allison Meyers
Retropharyngeal Abscess, Strep Pharyngitis, Viral Pharyngitis, Peritonsilar
Abscess, Tracheitis, Croup, Angioedema Age: 5 years
Height: 101 cm
Description
5yo female presents with acutely worsening difficulty breathing and fever. Weight: 17 kg
Triage Nurse
5yo F with sore throat for one day now increasing work of breathing, refusing
to eat or drink. Looks distressed - to resuscitation bay.
EMS Text
Patient was brought in by parents.

History

HPI: 5yo female brought in by parents for rapidly worsening difficulty breathing. She
complained of a sore throat last night and had a fever to 102.5F. Given
acetaminophen by parents and went to bed but awoke 4 hours later sitting upright
and refused to drink or eat. Parents noted "raspy breathing" similar to a previous
episode of croup.
Past Medical: None
Medications: None
Allergies: NKDA
Family History: Non-contributory.
Social History: Lives with parents. Only child, no sick contacts, attends pre-kindergarden. Parents
report child has had no immunizations.

Abnormal Review of Systems

Cardiovascular: No chest pain or syncope.

Constitutional: +fever, no unexplained
weight loss.
Ear/Nose/Throat: +sore throat and runny
nose, no epistaxis, pulling
at ears.
Eyes: No visual complaints
noted by parents.
Gastrointestinal: +difficulty swallowing, no
distention, vomiting,
diarrhea, hematochezia,
or melena.
Genitourinary: No urinary frequency or
hematuria noted by
parents.
Integumentary: No rashes, pruritus,
eczema or hair loss.
Musculoskeletal: No extremity pain, joint
swelling, or limitation in
range of motion.
Neurological: +raspy voice with intact
speech, no focal
weakness, seizures, or
gait/coordination
difficulty.
Respiratory: +shortness of breath and
dry cough; no hemoptysis
or wheezing noted by
parents.

Abnormal Examinations

Airway Exam Result: +inspiratory stridor and

Breathing Exam Result:
Cardiovascular Exam
Result:
Developmental/Psych:
Disability Exam Result:
HEENT Exam Result:
Neck Exam Result:
Neurological Exam
Result:
Pulmonary Exam Result:
drooling.
Bilateral, symmetric
breath sounds with
transmitted upper airway
sounds throughout.
Tachycardic rate and
regular rhythm, no
murmurs, rubs, or gallops.
Anxious and lethargic
appearing.
Pupils are equal and
reactive. Patient moves all
extremities.
+drooling and stridor
present; child refuses to
open mouth.
Normocephalic,
atraumatic, PERRL, EOMI.
+anterior adenopathy,
trachea midline, refusing
to flex or extend neck.
Lethargic, CN 2-12 grossly
intact, moving all
extremities.
+transmitted upper
airway sounds; no
wheezes, rhonchi or rales.

Abnormal Vitals

Heart Rate: 135 beats per minute

Oxygen Level: 94
Respiratory Rate: 33 per minute
Temperature: 38.7 C

Abnormal Tests & Labs

Peak Expiratory Flow Patient is unable to

Meter: cooperate with this exam
due to respiratory
distress.
White Blood Cells: 17.2 x 10^9/L

Abnormal Consultation Results

Consult Anesthesia: "I am concerned about the

Consult General
Surgery:
Consult Infectious
Disease:
Consult
Otolaryngology:
Consult Pediatrician:
patient's stridor. Call me
back if you find anything I
can help with."
"If you need a rigid
bronchoscopy for
aspirated foreign body I
can come in."
"The airway symptoms are
concerning with that high
fever. Strep throat or a
PTA is possible, but the
stridor is unusual for
those conditions. Is the
child fully immunized?"
"I am concerned about the
patient's stridor. Call me
back if you find anything I
can help with."
"We tried to convince the
parents on immunizations,
but they were against it
unfortunately. This makes
for a broad differential,
including some conditions
rarely seen in immunized
individuals. If you don't
find anything else, you can
admit the patient to my
service if they need
hydration."

Abnormal Images

XR - Lateral Soft Tissue Neck:

Abnormal Bedside Tests

Peak Expiratory Flow Meter: Patient is unable to cooperate with this exam due to respiratory distress.

Actions With Abnormal Effects

Non-Rebreather Consult Anesthesia -> "I haven't seen this in a long time. I will take the patient directly to the
Mask: OR for airway assessment and intubation. Nice work!"

XR - Lateral Soft Consult Anesthesia -> "I haven't seen this in a long time. I will take the patient directly to the
Tissue Neck: OR for airway assessment and intubation. Nice work!"
Consult Otolaryngology -> "I haven't seen this in a long time. I will take the patient directly to
the OR for airway assessment and intubation. Nice work!"

Racemic Respiratory Rate -> -%15per minute

Epinephrine
Oxygen Level -> +%5
Neb:
Nurse Text: Her breathing seems to be slightly better after the racemic epi neb! after 7
seconds
Airway Exam Result -> Inspiratory stridor diminished, now intermittent; drooling decreased,
HEENT Exam Result -> Intermittent stridor, able to open mouth 1-2cm, unable to visualize
posterior pharynx.
General -> Anxious-appearing with less respiratory distress.
Consult Anesthesia -> "I haven't seen this in a long time. I will take the patient directly to the
OR for airway assessment and intubation. Nice work!"

Review of Systems Scoring

Critical Scores
Constitutional, Ear/Nose/Throat, Respiratory
Recommended Scores
Allergic/Immune
Unnecessary Scores
None
Harmful Scores
None

Multi-Action Scores
None

Score Explanations
Constitutional
Assessing for a history of infectious symptoms is essential in this patient with acute airway compromise.
Ear/Nose/Throat
Assessing for associated ENT symptoms is critical in this patient with acute airway compromise.
Respiratory
Assessing for a history of associated respiratory symptoms is valuable in this patient with acute shortness of
breath.
Gastrointestinal
Associated gastrointestinal symptoms may be relevant here.
Integumentary
Skin rash could point to an allergic or infectious cause of these symptoms.
Allergic/Immune
Assessing for a history of allergic reaction is valuable in this patient with acute airway compromise.

Examinations Scoring

Critical Scores
Airway Exam, Breathing Exam, HEENT Exam
Recommended Scores
Neck Exam, Pulmonary Exam
Unnecessary Scores
None
Harmful Scores
None

Multi-Action Scores
None

Score Explanations
Airway Exam
Assess the severity of acute airway compromise.
Breathing Exam
Assessing breathing in this patient with acute airway compromise is essential to rule out a pulmonary cause.
HEENT Exam
Assessing for ENT findings is critical, but may be limited due to this patient's acute distress. Be careful not to
be too aggressive in examining the oropharynx - this could precipitate acute airway occlusion.
Neck Exam
Assessing for neck masses or tracheal deviation in this patient with acute airway compromise is important.
Pulmonary Exam
Assessing for focal lung sounds in this patient with acute respiratory distress is important, but the cause is
elsewhere.

Stabilizations Scoring

Critical Scores
Attach Monitor, Non-Rebreather Mask
Recommended Scores
None
Unnecessary Scores
Normal Saline 10cc/kg, Normal Saline 20cc/kg, D5 NS 20cc/kg, D5 1/2 NS maintenance infusion, Lactated
Ringer's 20cc/kg, Normal Saline maintenance infusion, Lactated Ringer's maintenance infusion
Harmful Scores
Start Chest Compressions, Rapid Sequence Intubation, Non-Invasive Positive Pressure Ventilation,
Defibrillate, Cardiac Pacing, Synchronized Cardioversion, Unsynchronized Cardioversion, Lidocaine bolus,
Midazolam bolus, Etomidate bolus, Ketamine bolus, Propofol bolus, Succinylcholine bolus, Rocuronium bolus,
Position for Intubation, Suction

Multi-Action Scores
None

Score Explanations
Insert IV
Be careful agitating this patient - although IV access would be valuable, her airway is paramount. Causing her
to cry may precipitate airway occlusion and death.
Rapid Sequence Intubation
Manipulation of the airway via typical video or direct laryngoscopy risks complete loss of the airway requiring
emergency needle cricothyroidotomy to prevent arrest. Given the airway swelling, a careful approach using
fiberoptic and/or awake intubation strategies in the operating room is warrented.
Nasal Cannula Oxygen
Application of supplemental oxygen is reasonable but this is not the best choice.
Non-Rebreather Mask
Address the patient's hypoxia on arrival. This passive method of oxygenation will also pre-oxygenate the
patient should she acutely lose her airway and need crash intubation.
Bag Valve Mask
A bag-valve mask (BVM) is used to provide oxygenation and manual positive pressure ventilation to patients
who are not breathing or not breathing adequately prior to establishment of a more definitive airway. Its use is
generally reserved for unconscious or unresponsive patients; it should not typically be used for patients who
are awake and alert.
Normal Saline 10cc/kg
Fluid administration is not relevant to addressing the underlying issue in this case.
Normal Saline 20cc/kg
Fluid administration is not relevant to addressing the underlying issue in this case.
D5 NS 20cc/kg
Fluid administration is not relevant to addressing the underlying issue in this case.
Lactated Ringer's 20cc/kg
Fluid administration is not relevant to addressing the underlying issue in this case.
Succinylcholine bolus
RSI should not be performed in this patient.
Rocuronium bolus
RSI should not be performed in this patient.
Position for Intubation
This patient may arrest if you lie her down.
Suction
Suctioning this patient may trigger complete airway occlusion and death.

Investigations Scoring

Critical Scores
XR - Lateral Soft Tissue Neck
Recommended Scores
None
Unnecessary Scores
Doppler, Basic Serum Tox Panel, Blood Type & Screen, Calcium (ionized), Calcium Level, Coagulation Panel, D-
Dimer, Lactate, Lipase, Liver Function Tests (LFTs), Magnesium Level, Phosphate Level, pro-BNP, Troponin-T,
Acetaminophen Level, Amylase, Blood Culture x 2, Creatine Kinase (CK), CSF Cell Count, CSF Glucose, CSF
Gram Stain, CSF Protein, Ethanol Level (EtOH), Lactate dehydrogenase (LDH), Osmolality, Peripheral smear,
Salicylate (Aspirin) Level, Serum HCG (quantitative), TSH, Uric Acid, Urine Culture, Urine HCG (qualitative),
Urine Tox Screen, CT - Abdomen, CT - Head, XR - Pelvis
Harmful Scores
CT - C-spine

Multi-Action Scores
None

Score Explanations
Ultrasound - Cardiac
This will immediately provide diagnostic information - look for EF and pericardial effusion in the setting of
hypotension.
Ultrasound - Lung
This will immediately provide diagnostic information - B-lines would be concerning for pneumonia or edema.
Ultrasound - Renal
This will immediately provide diagnostic information - hydronephrosis might signify an infected obstructing
kidney stone causing sepsis.
Ultrasound - RUQ
This will immediately provide diagnostic information - gallstones or biliary dilation might signify a cause for
infection.
Ultrasound - Soft Tissue
This will immediately provide diagnostic information if there is an area of swelling concerning for skin
infection.
Basic Chemistry (Chem 7)
Pre-op labs area reasonable to obtain in this critically ill patient.
Complete Blood Count (CBC)
Pre-op labs area reasonable to obtain in this critically ill patient.
COVID-19 test
Given need for intervention in the OR and admission, a screening COVID swab can be considered but caution
should be used not to agitate the patient or manipulate the airway.
CT - C-spine
Although this will provide similar information and can also diagnose the underlying process, sending the
patient outside the department and laying them flat for scan risks potential airway compromise and arrest.
XR - Chest
Given respiratory symptoms, it is reasonable to obtain a chest X-ray. However, that's not the main issue...
XR - Lateral Soft Tissue Neck
Imaging can help diagnosis this patient and determine the next course of action to save her from obstructing
her airway completely.

Interventions Scoring

Critical Scores
Racemic Epinephrine Neb
Recommended Scores
None
Unnecessary Scores
C-Collar, Decontaminate (Hazmat activation), Factor IX, Factor VIII, Intravenous Immunoglobulin,
Prothrombin Complex Concentrate, Transfuse FFP, Transfuse Platelets, Transfuse pRBC, Acetaminophen,
Ipratropium, Esomeprazole bolus, Famotidine bolus, Glucagon, Metoclopramide, Octreotide bolus/infusion,
Acyclovir, Amphotericin, Azithromycin, Ciprofloxacin, Fluconazole, Levofloxacin, Metronidazole,
Diphenhydramine, Activated Charcoal, Digoxin immune Fab, Fomepizole, Intralipid, N-Acetylcystiene, Na-
Bicarbonate bolus, Na-Bicarbonate infusion, Naloxone bolus, Pralidoxime (2-PAM), Thiamine, Haldol,
Olanzapine, Ziprasidone, Calcium Chloride bolus, D50 bolus, fos-Phenytoin, Furosemide bolus,
Hydrocortisone bolus, Levetiracetam bolus, Magnesium Sulfate bolus, Mannitol bolus, Potassium Chloride
(KCI), Potassium Iodide & Iodine, Propylthiouracil, TDaP, Tranexamic acid (TXA)
Harmful Scores
Apply Pelvic Binder, Arterial Line, Central Venous Catheter (cordis), Central Venous Catheter (triple lumen),
Lower Head of Bed, Perform Lumbar Puncture, Place Orogastric Tube, Alteplase (tPA), Atropine bolus,
Epinephrine bolus, Vasopressin bolus, Dopamine infusion, Epinephrine infusion, Esmolol infusion, Labetalol
bolus, Labetalol infusion, Nicardipine infusion, Nitroglycerin infusion, Nitroprusside infusion, Norepinephrine
infusion, Phenylephrine infusion, Etomidate bolus, Fentanyl bolus, Ibuprofen, Ketamine bolus, Ketamine
infusion, Lorazepam bolus, Morphine bolus, Propofol bolus, Propofol infusion, Adenosine bolus, Amiodarone
bolus/infusion, Aspirin, Diltiazem bolus, Heparin bolus/drip, Metoprolol bolus, Nitroglycerin, Procainamide
drip, Propranolol bolus, Lidocaine bolus, Midazolam bolus, Rocuronium bolus, Succinylcholine bolus,
Amoxicillin, Doxycycline, Oseltamivir, Prednisone, Flumazenil, Colchicine, Hypertonic saline (25%) bolus,
Hypertonic saline (3%) infusion, Insulin bolus, Insulin infusion

Multi-Action Scores
None

Score Explanations
Apply Pelvic Binder
Any noxious stimuli may cause acute airway compromise leading to respiratory arrest!
Arterial Line
Any noxious stimuli may cause acute airway compromise leading to respiratory arrest!
Central Venous Catheter (cordis)
Any noxious stimuli may cause acute airway compromise leading to respiratory arrest!
Central Venous Catheter (triple lumen)
Any noxious stimuli may cause acute airway compromise leading to respiratory arrest!
Lower Head of Bed
Lying this patient down may precipitate acute airway occlusion.
Perform Lumbar Puncture
Performing any noxious procedure, or lying the patient down, may cause acute airway occlusion.
Place Orogastric Tube
Any noxious stimuli may cause acute airway compromise leading to respiratory arrest!
Don Personal Protective Equipment
Appropriate PPE should be used whenever there is concern for a transmissible infection.
Acetaminophen
This can help with fever, but giving anything orally to this patient may cause airway occlusion so be careful.
Giving rectally may also be a noxious stimulus that may cause acute airway compromise leading to respiratory
arrest!
Fentanyl bolus
Sedating medications may cause this patient to acutely obstruct her airway!
Ibuprofen
Avoid giving anything orally to this patient given their potential for airway compromise.
Lorazepam bolus
Sedating medications may cause this patient to acutely obstruct her airway!
Morphine bolus
Sedating medications may cause this patient to acutely obstruct her airway!
Propofol infusion
Sedating medications may cause this patient to acutely obstruct her airway!
Aspirin
Aspirin in an acutely febrile child may cause Reye's syndrome. Additionally, oral medication are
contraindicated in this patient given her acute airway compromise.
Albuterol
This may help with bronchodilation, but the upper airway effects are limited.
Ipratropium
This medication has no effect on the upper airway.
Racemic Epinephrine Neb
Racemic epinephrine, a combination of the L- and D-epinephrine enantiomers (the latter 6% as effective as the
former), is used to treat upper airways edema via nebulizer administration.
Rocuronium bolus
RSI should not be performed in this patient.
Succinylcholine bolus
RSI should not be performed in this patient.
Ondansetron
If you are giving this in orally dissolvable form be cautious about precipitating gagging that might cause airway
obstruction from her underlying disease.
Amoxicillin
It is reasonable to give empiric antibiotics for this condition, but oral medications are contraindicated in this
patient with acute airway compromise.
Ampicillin
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Cefazolin
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Cefepime
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Cefotaxime
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Clindamycin
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Doxycycline
It is reasonable to give empiric antibiotics for this condition, but oral medications are contraindicated in this
patient with acute airway compromise.
Gentamicin
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Oseltamivir
It is reasonable to give empiric antibiotics for this condition, but oral medications are contraindicated in this
patient with acute airway compromise.
Piperacillin-tazobactam
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Vancomycin
It is reasonable to give empiric antibiotics for this condition, but starting an IV may be a noxious stimulus that
can cause this patient to acutely obstruct her airway.
Diphenhydramine
This is not an allergic reaction.
Epinephrine Intramuscular
Any noxious stimulus may cause acute airway occlusion. There are alternative choices that are better than this
medication.
Methylprednisolone bolus
Oral medications are contraindicated in this patient with acute airway compromise and starting an IV in this
patient may cause agitation leading to acute airway compromise.
Prednisone
It is reasonable to give steroids for this condition, but oral medications are contraindicated in this patient with
acute airway compromise.

Communications Scoring

Critical Scores
Airway Management
Recommended Scores
None
Unnecessary Scores
Consult Cardiology, Consult Endocrinology, Consult Gastroenterology, Consult Heme/Onc, Consult
Neurology, Consult Neurosurgeon, Consult Orthopedics, Consult Psychiatry, Consult Pulmonology, Consult
Renal, Consult Toxicology
Harmful Scores
None

Multi-Action Scores
Airway Management
Consult Anesthesia, Consult Otolaryngology

Score Explanations
Airway Management
This patient needs an emergent airway established in the OR!

Hints

Review of Systems Hint:

Assess for constitutional, ENT, and pulmonary symptoms that might help clarify why the patient is having
difficulty breathing.
Exam Hint:
A careful examination should be focused on the airway, throat, and lungs to assess the location causing the
patient's difficulty breathing. But remember that oral manipulation can cause problems for her!
Stabilzations Hint:
This patient is critically ill and needs their airway swelling addressed. BE CAREFUL - any painful procedure, or
oral medication, could cause the patient to obstruct her airway!
Investigations Hint:
An imaging test can confirm the diagnosis.
Interventions Hint:
Don't do too much to this patient until an airway can be established in a safe location.
Communications Hint:
This patient needs an emergent procedure from a consultant to save her life.

Detailed Debrief

This patient is suffering from epiglottitis with the potential for acute airway occlusion from her edematous
epiglottis and associated potential laryngospasm.

The history is consistent with a rapidly progressive process, causing swelling in the upper airways. Her fever is
suggestive of acute infection, in this case likely due to haemophilus influenzae type B (HiB) given her lack of
previous immunization. However streptococci are also potential causes (especially in immunized individuals).
While epiglottitis can occur at any age, adults typical tolerate the swelling of the upper airway (epiglottis,
aryepiglottic folds, and arytenoids) much better than children due to their increased airway caliber. In
children, the swelling can be rapidly fatal if not addressed by establishing a definitive airway quickly and
carefully.

The differential diagnosis includes croup, bacterial tracheitis, retropharyngeal abscess, and aspirated foreign
body. While both epiglottitis and croup share symptoms of inspiratory stridor, retractions and hoarseness,
croup will also typically present with a classic barking cough without drooling and dysphagia (Tibbals et al
2011) as seen in this patient. Her refusal to swallow points to the acute inflammation in the epiglottic region
(as opposed to the subglottic tissues for croup) which, when compressed by swallowing, cause significant pain.

On presentation, the patient is sitting upright and drooling with stridor noted on exam. This body positioning
(tripoding) is assumed to maximize airflow across the narrowed airway and should prompt immediate concern
for upper airway edema. On examination, she is unable to open her mouth and any attempts at oral
examination are contraindicated due to the potential to trigger laryngospasm leading to respiratory arrest.

Stabilization should be initiated carefully, avoiding any noxious or painful stimuli that might cause the patient
to cry or become agitated leading to loss of her airway. A non-rebreather mask should be used to address the
patient's hypoxia on arrival. This passive method of oxygenation will also pre-oxygenate the patient should she
acutely lose her airway and need crash intubation. Additionally, nebulized racemic epinephrine should be
given to reduce her airway edema as a temporizing measure pending emergent evaluation by anesthesia for
intubation in the operative room using inhalational anesthetics.

The diagnosis can be confirmed with a lateral neck X-ray which demonstrates the classic thumbprint sign of
the swollen epiglottis obliterating the vallecular space. These finding heralds imminent clinical
decompensation in conjunction with the patient's concerning clinical presentation.

After consultation with anesthesia or otolaryngology (ENT), the patient must be transferred emergently to the
OR for airway management.

References:

Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi J Anaesth. 2012;6(3):279-281.
doi:10.4103/1658-354X.101222

Chan KO, Pang YT, Tan KK. Acute epiglottitis in the tropics: is it an adult disease? J Laryngol Otol. 2001 Sep;
115(9):715-8.

Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health.
2011;47:77–82. [PubMed] [Google Scholar]