The ideal approach to the diagnosis of epiglottitis varies depending on the practice environment. Each institution should have a written "Suspected Epiglottitis Management Protocol" (Fig 129-1). Themes necessary in all protocols include:

1. Immediate recognition and triage to a resuscitation area

2. Continuous monitoring by someone trained in the management of the difficult airway

3. Rapid consultation of appropriate colleagues

4. Consideration and risk-benefit analysis of patient transfer with appropriate personnel present during the transfer

5. Bedside radiology without disturbing patient or, if moved to the x-ray suite, constant monitoring by a physician with appropriate airway equipment

Lateral neck radiographs are usually unnecessary in patients with a classic presentation for epiglottitis. When the diagnosis is uncertain, radiographs should be taken with the neck extended during inspiration using a high-kilovolt soft tissue technique. The child typically holds its head in the sniffing position and has prolonged inspiration, already making it quite easy to obtain these radiographs. False-positive findings may occur due to normally widened retropharyngeal space structures if the radiograph is taking during expiration or with the head flat. Lateral neck radiographs are not required if the patient is already intubated, and often the typical findings for epiglottitis will not be seen in such cases. False-negative radiographic evaluations do occur. Direct visualization of the epiglottis should occur prior to discharge if suspicion for the diagnosis still exists.

In evaluating lateral neck radiographs, the epiglottis, vallecula, hypopharynx, tracheal air column, arytenoids, and retropharyngeal or prevertebral space should be checked. The epiglottis is normally tall and thin, projecting up into the hypopharynx ( Fig 129-2). Normally there is a poorly delineated space between the epiglottis and the anteriormost aspect of the hypopharynx. In epiglottitis, the epiglottis is swollen and appears squat and flat, like a thumbprint at the base of the hypopharynx

(Fig 129-3). Commonly, the vallecular airspace is obscured. Another common finding is ballooning of the hypopharynx just above the area of the larynx. This is illustrated by the different sizes of the hypopharynx in Fig 129-2 and Fig, 1.29.-3. While not specific for epiglottitis, this distention does indicate significant obstruction of the upper respiratory tract. The retropharyngeal space is normally 3 to 4 mm wide. Commonly it is stated that it should be less than the width of the adjacent vertebral body. The tracheal air column should be of uniform width without densities.

FIG. 129-2. A normal lateral neck x-ray.

FIG. 129-3. Lateral neck view of a child with epiglottitis.

In some scenarios, gentle direct visualization can be attempted. Most proponents of this practice would agree that it should be performed only at sites where experts in pediatric airway management are present with appropriate equipment to maintain the airway by whatever means necessary. Typically this is done in the following stepwise manner. In his or her position of comfort, the child is asked to open its mouth wide. If the epiglottis is not seen, the child is asked to stick its tongue out, with a tongue blade used to depress the anterior aspect of the tongue in the hope of visualizing the epiglottis. If the epiglottis is still not seen, as is more common, fiberoptic laryngoscopy by an operator skilled in the techique, and with the ability to intubate over the scope, is the safest next step.

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