Epiglottitis

The epiglottis is a small flap of cartilage at the root of the tongue. Every time you swallow it tips backwards and covers the entrance to the larynx so that food does not go into the airway. If that flap becomes inflamed and swollen it stops being a lid and turns into a plug: the airway narrows on its own, with no swallowing involved. The swelling builds over hours, which is why epiglottitis is not "a very bad sore throat" but an emergency in which an ambulance is called without waiting for morning.

What it looks like

What sets epiglottitis apart from an ordinary sore throat is the mismatch. The person is plainly very unwell and can barely swallow, yet looking into the mouth shows nothing frightening: the tonsils are quiet and there is no coating. All the inflammation sits lower down, out of sight.

This combination should raise the alarm:

• severe throat pain that has built up over hours rather than days;
• a high temperature and a person who looks seriously ill;
• swallowing so painful that saliva is no longer swallowed and drools out of the mouth;
• a muffled voice, as though there were a hot potato in the mouth, rather than the hoarseness of laryngitis;
• fast, noisy breathing with a high-pitched sound on breathing in;
• the person sits leaning forward, propped on the hands with the neck stretched out, and flatly refuses to lie down;
• pale, grey or bluish skin, which on brown and black skin shows up better on the lips, gums, palms and soles;
• marked restlessness and agitation or, conversely, unusual listlessness.

In children it moves fastest of all: within a few hours a well child becomes gravely ill, sits on an adult's lap, will not talk and hardly coughs. That absence of a barking cough is precisely what separates epiglottitis from croup. In adults the onset tends to be a little slower and the complaint is a single one: the throat hurts as it never has before.

This means calling an ambulance

If epiglottitis is suspected, call at once; in Spain, Italy, Portugal, Poland and Ukraine that is the single European number, 112. After that, the point is to do no harm while help is on its way.

• Let them sit up. Lying flat closes off the breathing almost immediately. Hold a child upright in your arms and give an adult something to lean on.
• Do not look into the throat with a spoon, a tongue depressor or a finger, and do not ask for the mouth to be opened wider. Irritating a swollen epiglottis can trigger a spasm and shut the airway completely.
• Give nothing to eat or drink — an anaesthetic is likely to be needed, and swallowing is unsafe in any case.
• Keep them calm. Crying and fear make the breathing worse, so a child should not be changed, examined or taken away from the parent.
• Do not drive them yourself. Breathing can stop in the car with nobody able to help. Tell the call handler that you suspect epiglottitis and they will talk you through what to do until the crew arrives.

What happens in hospital

The order of events here is the reverse of the usual one: the airway is secured first and the cause is sorted out afterwards. The larynx is examined in theatre, with an anaesthetist and an ear, nose and throat surgeon present and everything for an emergency intubation already laid out. If a tube cannot be passed, an opening is made in the trachea; that saves life and heals afterwards.

Oxygen follows, along with antibiotics given into a vein. Medicines to reduce the swelling and nebulised treatments are sometimes added. Blood is taken for culture, and a throat swab only once the airway is protected. An X-ray or a scan of the neck is reserved for someone who is stable and only where the diagnosis is unclear; nobody struggling to breathe is wheeled off for imaging or left alone.

A few days in hospital are usual, the first day or two of them with a breathing tube in place until the swelling settles. With treatment started in time, the great majority recover completely and without lasting effects.

Why it happens

Historically the main cause was a bacterium, Haemophilus influenzae type b, shortened to Hib. It is a bacterium and not a virus: it spreads through the air, in coughs and sneezes, and on objects that saliva has landed on. Since the Hib vaccine entered childhood immunisation schedules, epiglottitis in children has become rare, and today the illness is seen more often in adults.

Besides Hib, the cause may be:

• other bacteria, chiefly streptococci and staphylococcus aureus, which have moved into first place since mass vaccination;
• a burn to the throat from very hot food or drink, or from steam;
• inhaling smoke and hot vapour, including the smoking of crack and other substances drawn through a red-hot pipe;
• swallowing a caustic liquid;
• a direct blow to the throat or an injury caused while trying to retrieve a swallowed object.

The risk is distinctly higher in anyone whose immunity is weakened: blood disorders, organ or bone marrow transplant, poorly controlled diabetes, chemotherapy, a spleen that has been removed. In these people epiglottitis develops faster and runs a more severe course.

How to avoid it

The main protection is the vaccine against Haemophilus influenzae type b infection. It is part of the childhood immunisation schedule in every country we serve; it is given as several doses during the first year of life with a booster afterwards, and the exact timing differs from country to country, so check the local schedule.

Other things worth knowing:

• if a child was not immunised in infancy, catching up later is still possible — ask the doctor which schedule applies;
• for adults the vaccine is specifically recommended after removal of the spleen, in sickle cell disease, in certain disorders of immunity and after a bone marrow transplant;
• if a family member has a confirmed serious Hib infection, the rest of the household is sometimes given a short preventive course of an antibiotic, particularly where there are unvaccinated small children or someone with weakened immunity at home. That decision belongs to the doctor and is not made independently;
• stopping smoking lowers the risk, because a throat lining that is constantly irritated resists infection less well;
• hot drinks are best not left within reach of a small child: a burn to the throat is the cause almost nobody thinks of in advance.

Online consultation

Epiglottitis itself is not treated remotely — this is one of those conditions that needs hands, oxygen and an operating theatre. But a good deal sits around the illness that works well through a screen. Working out whether this is an ordinary sore throat or the set of signs that means calling an ambulance right now. Checking whether a child has been immunised against Hib and what to do if the schedule has slipped. Deciding whether an adult without a spleen or with reduced immunity needs the vaccine. Talking through what the rest of the household should do after a confirmed case at home. And finally the questions that come after discharge: why the throat still hurts a week later, when to go back to work or school, and what to watch for from now on. With difficulty breathing, drooling and an inability to swallow, though, no online appointment is needed — an ambulance is.

This material is for information only and does not replace medical advice.