WALTER E. BERMAN, M.D., and
ALAN E. HOLTZMAN, M.D., Beverly Hills
MANY PHYSICIANS are but little aware of acute epi-
glottitis as a potentially serious and sometimes fatal
disease of infants and children. Although the con-
dition was recognized at the turn of the century,
only in the last five years has it been included as a
distinct entity in pediatric textbooks."2
Acute epiglottitis is not a rare disease. Miller7
said that at one hospital about one case a month is
observed. Berenberg and Kevy2 reported on 42 pa-
tients with the disease observed in an eight-year
period, only one of whom was referred to the hos-
pital with the correct diagnosis. In light of these
facts, it behooves physicians who may be called
upon to attend children to become better acquainted
with this disease and to be prepared to treat it as
REPORT OF A CASE
A six-year-old boy was admitted to the U.C.L.A.
Medical Center with acute upper respiratory tract
obstruction. He had been well until the morning
before admission, when he complained of sore
throat and anorexia. The body temperature gradu-
ally rose. At 2 o'clock in the afternoon the patient
was examined by a physician who noted mild phar-
yngitis and fever and prescribed a tetracycline
That evening at 8 o'clock difficulty in breathing
became apparent and when the physician observed
him the patient was sitting up in bed, drooling and
having moderate inspiratory stridor. The alae nasae
flared, and suprasternal, intercostal and lower sternal
retractions were prominent. The epiglottis, easily
visualized by depressing the tongue with a tongue
blade, was decidedly inflamed and edematous.
Upon arrival at the hospital, the patient was given
chloramphenicol intramuscularly and cold steam
inhalations were started. When his condition did
not improve in two hours, tracheotomy was done.
Breathing immediately became easier and by the
following morning the patient was afebrile and had
no respiratory distress. Chloramphenicol was con-
tinued by mouth and the tracheotomy tube was re-
moved after four days. He was discharged on the
fifth day. The leukocyte content of the blood at the
time of admittance to hospital was 26,900 per cu.
Submitted June 29, 1959.
* Although acute epiglottitis is not a rare disease
and may be very severe or fatal, it is one not fa-
miliar, as it should be, to all physicians dealing
Diagnosis may be confirmed clinically by di-
rect or indirect examination of the epiglottis.
Vaporized cool water is preferable to steam for
reducing the swelling of mucosal tissues that im-
Chloramphenicol is the drug of choice, as the
majority of cases of acute epiglottitis are due to
Tracheotomy must be carried out if necessary
to maintain an airway.
mm.-69 per cent neutrophils, 13 per cent banded
forms and 15 per cent lymphocytes. No significant
organisms grew on cultures of the blood and ma-
terial from the throat, trachea and epiglottis.
Hemophilus influenza, type B, has been generally
considered to be the causative agent in acute epi-
glottitis. This organism has been the most common
one recovered from the throat and from the blood
of patients with this disease, although other bacteria
have grown on cultures in some instances.
believe that this disease,
along with most infections of the respiratory tract,
is brought about by some precursor disease, most
commonly a viral infection, with secondary com-
plications caused by organisms which may be pres-
ent in the respiratory tract at the time.
This condition usually affects children between
two and six years of age and commonly occurs in
the late fall, winter and early spring. Camps5 re-
ported four cases in infants under one year of age.
A very interesting case in a 12-year-old, considered
to have bulbar poliomyelitis, was reported by Gun-
dell.6 Brewer and Rambo3 have reported cases in
The onset of the disease is abrupt, fever and sore
throat being the prominent findings. A younger
child may merely gag when drinking. Early in the
course of the condition the pharynx is mildly hy-
peremic and some of the anterior cervical lymph
nodes slightly tender. Dyspnea may or may not be
VOL. 92. NO. 5* MAY 1960
Figure 1.-Showing the swollen arytenoids and epiglottis, and the position of the epiglottis as it appears to view
when the tongue is pressed down with a blade.
observed early. Any child with soreness of the
throat greater than seems consistent with the visi-
ble condition should be considered as possibly hav-
ing acute epiglottitis.
Pronounced dyspnea, pallor, cyanosis and pros-
tration ensue in a few hours, and by that time there
is usually no question about the diagnosis. Inspira-
tory. stridor with pronounced suprasternal and in-
frasternal retraction occurs. The patient sits up,
leans forward, gasps for air with his mouth opened
wide and his tongue protruding, and drools excess-
ively. There is a muffled quality to the voice rather
than the hoarseness seen with other laryngitides. The
pulse and respiration rates are sharply accelerated.
Usually the diagnosis can be confirmed simply
by looking at the epiglottis, which can be exposed
to view by depressing the tongue or by pulling the
tongue forward. In most children, the mere placing
of the blade on the tongue will cause the swollen,
reddened epiglottis to rise into sight. For an older
child, a mirror may be needed for visualization.
From the pathological viewpoint, probably a bet-
ter name for this disease would be supraglottic
laryngitis or supraglottitis. Inflammation and swell-
ing is usually confined to the epiglottis, the ary-
epiglottis folds and arytenoids. Some superficial
ulceration of the mucosa may be present. Cultures
of the blood or of material from the epiglottis and
pharynx may grow H. Influenzae or other signifi-
Spasmodic croup, one of the diseases to be differ-
entiated from acute epiglottitis, may be preceded by
mild upper respiratory tract symptoms or none at
all. There may be slight temperature elevation, and
typical barking cough is usually present. The epi-
glottis is not swollen or red as it is in epiglottitis.
Spasmodic croup usually responds quickly to in-
creasing the humidity of inspired air.
In acute laryngitis, involvement of the vocal
cords is evidenced by definite hoarseness. There
may be little dyspnea at the onset. Aphonia should
suggest the possibility of diphtheritic laryngitis.
Acute laryngotracheobronchitis is usually slower
in onset than acute epiglottitis, symptoms refer-
rable to the respiratory tract usually not developing
until after a day or two of illness; and when res-
piratory difficulty does develop, usually there is
expiratory as well as inspiratory impairment, as
against inspiratory only in epiglottitis. Rales may
be heard in laryngotracheobronchitis but usually
not in epiglottitis.
Early establishment of an adequate airway is the
primary consideration in dealing with a patient
with acute epiglottitis. There are few times in medi-
cine when a disease may require more exacting or
immediate treatment. When the respiratory obstruc-
tion is not so profound as to require immediate
by-passing of the upper respiratory passages, in-
creasing the humidity of inspired air helps reduce
the swelling of mucosal tissues, vaporized cold water
being superior to steam for this purpose. The ap-
paratus for producing it consists of a nebulizer
through which water may be forced by compressed
air or oxygen with the nozzle placed close enough
to the patient to permit large quantities of the cool
vapor to reach respiratory passages.
Chemotherapy should be started at once-chlor-
amphenicol given intramuscularly in dosages of
100 mg. per kilogram of body weight per 24 hours
for children up to 15 kg. and 1 to 2 gm. per 24 hours
for children over 15 kg. The daily dose is adminis-
tered in three equal injections at eight-hour inter-
vals. After one day of therapy, the drug may be
given orally at a dosage of 50 mg. per kilogram of
body weight per 24 hours.
When the patient has pronounced suprasternal
and intercostal indrawing, or the pulse is increas-
ing at the rate of ten per hour, or the respiratory
rate is increasing, tracheotomy is mandatory. Pass-
ing an endotracheal tube is not desirable because of
the preexisting inflammatory and edematous con-
dition, except as a preliminary measure until a
tracheotomy can be performed. Tracheotomy
preferably performed in the operating room under
general anesthesia after an endotracheal tube is
passed. Occasionally a temporary laryngeal obstruc-
tion may develop in the induction phase, but with
the proper equipment at hand the passage of an
endotracheal tube is not a major problem.
9735 Wilshire Boulevard, Beverly Hills (Berman).
1. Adams, J. M.: Brenneman's practice of pediatrics, 11:
18, revised March 1954.
2. Berenberg, W., and Kevy, S.: Acute epiglottitis in child-
hood; a serious emergency, readily recognized at the bed-
side, N.E.J.M., 258:8704, May 1958.
3. Brewer, D. W., and Rambo, J. H. T.: Influenzal laryn-
gitis, Ann. Otol. Rhin. and Laryng., 57:96-102, March 1948.
4. Brown, J. M.: Acute infectious epiglottitis, Arch. Oto-
laryng., 32:631-641, Oct. 1940.
5. Camps, F. E., and Jones, H. M.: Acute epiglottitis:
Supraglottitis, Practitioner, 178:223-229, Feb. 1957.
6. Gundell, K. M.: H. influenza epiglottitis in a 12-year-old
child, J.C.M.A., 80:321, April 1954.
7. Miller, A. H.: Acute epiglottitis: Acute obstructive
supraglottic laryngitis in small children caused by H. influ-
enza, Tr. Am. Acad. Ophth., 53:519-526, May-June 1949.
8. Nelson, W. E.: Nelson's Practice of Pediatrics, 804-807,
VOL. 92, NO.
* MAY 1960