Rule Out Epiglottitis
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 19
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
A 2 year old boy is brought to the emergency
department at 2:30 a.m. complaining of throat pain, not
drinking, drooling, difficulty swallowing, coughing, nasal
congestion, and fever. The throat pain, difficulty
drinking, and drooling started in the afternoon and have
worsened over the night. He has had the coughing and
nasal congestion for 3 days now. He was given some
oral acetaminophen 45 minutes ago, but he could not
swallow it. His past history is significant for frequent
ear infections. His immunizations are "up to date".
At triage, the nurse notes that he is tired in
appearance, but alert. He is given 14 mg/kg of
Exam VS T38.6 (rectal), P143, R28, BP not taken,
oxygen saturation 100% in room air. He is active and
alert. Not toxic. Not irritable. Drooling is noted but he
is not tripodding. Eyes clear. TM's normal. Nose with
thick mucus. Oral pharynx slightly red. The palate,
gums, and oral mucosa were clear of any ulcers or
petechiae. No tonsillar enlargement. No exudates.
The epiglottis could not be seen. Neck supple, small
nodes. Heart regular without murmurs. Lungs clear.
No stridor. Good aeration. No retractions. He coughs
occasionally and the sound of the cough is not croupy.
Abdomen benign. Color and perfusion are good.
Although he does not look toxic and his airway
function is assessed as being good, a lateral neck
radiograph is ordered at 3:00 a.m. to look for a
retropharyngeal abscess or epiglottitis.
View lateral neck radiograph.
The original radiograph displayed here was
excessively dark. It was read with the assistance of a
hot light. This scanned image shown here shows the
radiograph scanned using standard light intensities and
another view scanned using a hot light. Thus the image
on the right shows the soft tissue structures better while
overexposing the bony structures. The pre-vertebral
soft tissue space is not widened. This essentially rules
out a significant retropharyngeal abscess. The black
arrow points to the tip of the epiglottis and the white
arrow points to the pre-epiglottic space (vallecula). The
shape of the epiglottis is better seen on the
overexposed (whiter) image on the right. The epiglottis
should normally be thin or triangular in appearance. In
this view, it appears to be rounded and somewhat
thumb-like, which is similar to the classic radiographic
description of epiglottitis. The pre-epiglottic space is
fairly well preserved but it is slightly shallow. In
epiglottitis, the pre-epiglottic space is obliterated or very
shallow due to the inflammation of the epiglottis. The
positioning of the patient does not show his neck well
It was felt that this patient probably did not have
epiglottitis, but the radiograph was suspicious enough
to worry the physician. A tongue depressor was used
to visualize the epiglottis, but it still could not be seen.
He was sent back to the imaging department to repeat
his lateral neck radiograph with better positioning.
View repeat lateral neck radiograph.
This radiograph was again somewhat dark. The
epiglottis still appeared to be enlarged (thumb-like) and
the pre-epiglottic space was still shallow. At 3:30, it
was decided to get a radiologist's consultation by
teleradiology. The patient was given IM ceftriaxone
while waiting for the radiologist's call. The radiologist
reviewed both radiographs and agreed that they
appeared to show epiglottitis.
The child continued to look good. No stridor was
noted, but he continued to drool. VS at 3:40 a.m. T37.8
(rectally), P145, R40, BP not done, oxygen saturation
100% in room air.
The physician was still convinced that the child did
not have epiglottitis. After a discussion with his mother,
the physician looked at the epiglottis using a
laryngoscope. The epiglottis was swabbed for a
culture. The epiglottis was not enlarged, but it was
At 4:30 a.m., an ENT surgeon was called. He felt
that it was satisfactory to hospitalize the child in a floor
bed for observation. He did not feel that intubation was
indicated, nor admission to a more advanced or
intensive care unit for observation.
Although the epiglottis was somewhat erythematous,
its anatomic shape and size were normal. How could a
structurally normal epiglottis, cast an abnormal
radiographic shadow ? One could only conclude that
the examiner did not view the epiglottis correctly during
laryngoscopy or that the radiographic appearance is
due to some type of artifact that is appearing on two
Over the next few hours, the patient did not worsen.
The ENT surgeon reviewed the radiographs and agreed
that the epiglottis appeared to be enlarged. Fiberoptic
laryngoscopy carried out later that morning showed 3+
adenoid hypertrophy, mucopurulent discharge, a
non-enlarged epiglottis, 3+ edema of the vocal cords,
and a clear subglottic region.
A second radiologist who looked at the radiographs
felt that both radiographs showed a normal epiglottis.
The epiglottis can appear to be rounded if the lateral
neck is taken at an oblique angle.
In this case, I thought that it would be very difficult to
view the epiglottis with a laryngoscope in an awake 2
year old without sedation. However, it was surprisingly
easy. With the patient supine, it was only necessary to
use the laryngoscope blade to push down the posterior
aspect of his tongue. It was not necessary to insert the
blade all the way to the epiglottis or the vallecula. He
gagged a little, but it was so easy to see the epiglottis
that it was not necessary to leave the laryngoscope
blade in place as one would need to for intubation. The
normal size and shape of the epiglottis on direct
visualization in this case should have effectively ruled
out epiglottitis. The slight erythema of the epiglottis
may have been due to a viral infection such as
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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine