High Risk, Low Prevalence: Adult Epiglottitis

Adult epiglottitis is uncommon but dangerous, and a normal throat exam does not make it safe to dismiss. The classic ED trap is severe sore throat with dysphagia, voice change, or drooling despite an unimpressive oropharynx, with diagnosis hinging on airway-aware visualization and imaging.

Adult Epiglottitis Recognition and Management

• Normal throat exam trap: About 90% of adults with epiglottitis have a normal posterior oropharyngeal exam, so pain out of proportion, drooling, and voice change matter more than a reassuring look.
• High risk bounce-back features: Worsening sore throat over 12 to 24 hours, toxic appearance, tripod positioning, or subjective dyspnea should raise concern for impending airway compromise rather than routine pharyngitis.
• Direct visualization diagnosis: Definitive diagnosis comes from seeing the epiglottis with a dental mirror, flexible endoscope, or carefully performed laryngoscopy. We get into the bedside exam tricks in the episode.
• Imaging with airway caution: CT with contrast is the gold-standard test, while lateral neck films can show a thumbprint sign but miss too many cases to rule disease out; road-test supine tolerance before the scanner.
• Antibiotic coverage priorities: Empiric therapy should cover Streptococcus, Staphylococcus, and MRSA with agents such as ceftriaxone or ampicillin-sulbactam plus vancomycin, while routine metronidazole is unnecessary.
• Preferred airway approach: Roughly 13% of patients need intubation, and a flexible intubation endoscope is the preferred ED technique; supraglottic devices are avoided because they can worsen obstruction.

References:

1.  Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Adult epiglottitis. Am J Emerg Med. 2022;57:14-20. PMID: 35489220