Case studies · ENT · 22 October 2026

Acute epiglottitis case study

The case

Patient: A 4‑year‑old boy, previously healthy, fully immunised (including Haemophilus influenzae type b vaccine).

Presenting complaint: Sudden onset of fever, sore throat and difficulty swallowing for 12 hours.

History of presenting illness:

• The child was playing at home when he developed a high‑grade fever (peak 39.8 °C) and complained of a “sore throat”.
• Within 4 hours he became increasingly irritable, drooled excessively and refused to drink water.
• Parents note a “muffled” voice and a “hot potato” feeling when the child tries to speak.
• No cough, rhinorrhoea, or recent upper‑respiratory infection.
• No known sick contacts, recent travel, or exposure to smoke.

Past medical history: Unremarkable. No previous episodes of tonsillitis or adenoid hypertrophy.

Medications: None.

Allergies: No drug allergies.

Family history: Non‑contributory.

Social history: Lives with parents and a 2‑year‑old sister. Attends a local preschool.

Examination (performed in the emergency department, child in a sitting position, with a trained ENT specialist present):

Initial investigations (drawn before any airway manipulation):

The child is transferred to the pediatric intensive care unit (PICU) for airway monitoring and definitive management.

Questions

1. What is the most likely diagnosis?
2. Which clinical and investigation findings point specifically to this diagnosis, and why are they important?
3. Outline the immediate airway management steps recommended by current guidelines (2023‑2024).
4. What are the appropriate antimicrobial therapy choices, including dosage, route, and duration, according to the latest IDSA (2022) and NICE (2023) recommendations?
5. List the possible complications of this condition and the measures to prevent or monitor for them.

Answers

1. What is the most likely diagnosis?

Acute epiglottitis (also called supraglottitis) – an acute, potentially life‑threatening inflammation of the epiglottis and adjacent supraglottic structures, most commonly caused by Haemophilus influenzae type b (Hib) in unvaccinated children, but increasingly due to Streptococcus pneumoniae, Staphylococcus aureus, and viral agents in vaccinated populations.

2. Which clinical and investigation findings point specifically to this diagnosis, and why are they important?

These findings together create a classic picture of acute epiglottitis, allowing rapid recognition before catastrophic airway collapse occurs.

3. Outline the immediate airway management steps recommended by current guidelines (2023‑2024).

Key principle: Secure the airway early, in a controlled environment, while avoiding agitation that could precipitate sudden obstruction.

1. Do not attempt blind oral or nasal instrumentation (e.g., routine throat swab, nasopharyngeal suction) in the emergency department.
2. Call for a multidisciplinary airway team – pediatric anaesthetist, ENT surgeon, and ICU nurse.
3. Prepare for rapid sequence induction (RSI) and endotracheal intubation:
   • Pre‑oxygenate with 100 % O₂ via a tight‑fitting mask for 3–5 minutes.
   • Use a gentle, short‑acting induction agent (e.g., ketamine 1–2 mg/kg IV) because it preserves spontaneous respiration.
   • Avoid muscle relaxants unless the airway is already secured; if needed, use a short‑acting agent (e.g., succinylcholine 1–2 mg/kg).
   • Have a videolaryngoscope or rigid fibre‑optic bronchoscope ready; a size‑appropriate cuffed endotracheal tube (ETT) (e.g., 4.5 mm internal diameter for a 4‑year‑old).
4. If intubation fails or the child deteriorates:
   • Immediate cricothyrotomy (in children < 8 years, a surgical tracheostomy is preferred; however, emergency cricothyrotomy can be performed as a temporising measure).
   • Have a surgical airway kit on the bedside.
5. Post‑intubation care:
   • Sedation and analgesia (e.g., dexmedetomidine infusion 0.2–0.7 µg/kg/h).
   • Maintain head‑up (30–45°) positioning to reduce edema.
   • Continue humidified oxygen (≥ 30 L/min) and monitor cuff pressure (≤ 20 cm H₂O).
6. Observation: Children intubated for epiglottitis are usually kept in PICU for 24–48 h; extubation is considered only after resolution of edema (clinical improvement, repeat flexible laryngoscopy showing < 50 % obstruction).

These steps follow the American Academy of Pediatrics (AAP) 2023 airway algorithm for acute supraglottitis and the NICE 2023 guideline on “Acute airway obstruction in children”.

4. What are the appropriate antimicrobial therapy choices, including dosage, route, and duration, according to the latest IDSA (2022) and NICE (2023) recommendations?

Choice of agent: In a child with no β‑lactam allergy and low MRSA prevalence, ceftriaxone alone is sufficient. If local epidemiology shows high MRSA rates or the child appears severely ill, add vancomycin until culture results are available.

Monitoring: Check renal function (creatinine) and liver enzymes (ALT/AST) every 48 h while on ceftriaxone; adjust vancomycin dosing based on trough levels.

Guideline references:

• IDSA Clinical Practice Guidelines for the Management of Acute Bacterial Meningitis and Related Infections (2022) – Section on epiglottitis.
• NICE NG84 (2023) – “Acute epiglottitis and supraglottitis in children and adults”.

5. List the possible complications of this condition and the measures to prevent or monitor for them.

Early recognition, airway control, and timely antimicrobial therapy dramatically reduce the incidence of these complications.

Key learning points

• Acute epiglottitis presents with rapid onset fever, drooling, dysphagia, and a “hot‑potato” voice; children often adopt a tripod posture to maximise airway patency.
• Lateral neck X‑ray may show the classic thumb‑print sign, but direct visualization with flexible nasopharyngolaryngoscopy is the definitive diagnostic tool.
• Never attempt blind oral or nasal instrumentation in a suspected case; always secure the airway in a controlled setting with a skilled team.
• First‑line antimicrobial therapy is IV ceftriaxone (75 mg/kg once daily) for 7–10 days; add vancomycin if MRSA is a concern.
• Airway management follows the AAP/NICE algorithm: pre‑oxygenation, ketamine‑based induction, video‑laryngoscopy, and immediate surgical airway backup.
• Complications include complete airway obstruction, aspiration pneumonia, sepsis, deep neck space infection, meningitis, and long‑term airway stenosis; vigilant monitoring and early intervention are essential.
• Post‑extubation, repeat laryngoscopy is required to confirm resolution of edema before discharge.

Practice MCQs

1. A 5‑year‑old presents with fever, drooling, and a muffled voice. Which of the following bedside findings most strongly suggests acute epiglottitis rather than viral croup?

A. Barking cough
B. Stridor that worsens on inspiration
C. Tripod posture with neck extension
D. Nasal flaring

Answer: C — The tripod posture is a classic compensatory mechanism to keep the supraglottic airway open in epiglottitis. Barking cough and inspiratory stridor are typical of croup, not epiglottitis.

2. According to the 2022 IDSA guidelines, the recommended initial antimicrobial regimen for a child with acute epiglottitis and no β‑lactam allergy is:

A. Oral amoxicillin 50 mg/kg/day for 5 days
B. IV ceftriaxone 75 mg/kg once daily for 7–10 days
C. IV vancomycin 15 mg/kg every 6 h for 14 days
D. Oral azithromycin 10 mg/kg on day 1, then 5 mg/kg daily for 4 days

Answer: B — Ceftriaxone 75 mg/kg IV once daily for 7–10 days is the first‑line therapy for acute epiglottitis in children without β‑lactam allergy.

3. Which of the following is the most appropriate next step after successful intubation of a child with acute epiglottitis?

A. Immediate extubation after 2 hours to reduce sedation exposure.
B. Start high‑flow nasal cannula (HFNC) to wean from the ventilator.
C. Maintain the child in a head‑up (30–45°) position, provide humidified oxygen, and continue IV antibiotics.
D. Perform a routine bronchoscopy to assess lower airway pathology.

Answer: C — After securing the airway, the child should be kept head‑up, receive humidified oxygen, and continue the prescribed IV antibiotics. Early extubation or HFNC is premature, and routine bronchoscopy is unnecessary unless there is suspicion of lower airway disease.

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