Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Epiglottitis and deep-neck-space infection
Infectious diseases, microbiology and sexual health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Threatened upper airway
Drooling, stridor, tripod posture, muffled voice, severe odynophagia, rapidly progressive neck swelling or toxic appearance can precede complete obstruction.
Action: Keep the patient upright and calm, give high-flow oxygen if tolerated, summon senior anaesthesia and ENT immediately and prepare a controlled difficult-airway plan. Do not force throat examination, lie the patient flat or send an unstable patient unescorted to imaging.
Overview
Recognise impending upper-airway obstruction, avoid destabilising examination, secure the airway with senior anaesthetic and ENT expertise, and combine intravenous antimicrobials with drainage of deep collections.
Epiglottitis is supraglottic inflammation caused by bacteria, less often viral or non-infective injury. Vaccination has reduced Haemophilus influenzae type b disease, but streptococci, staphylococci and H influenzae still cause adult infection. Deep-neck-space infection develops when oral organisms cross tissue planes after tonsillar, dental, salivary or traumatic inoculation.
The shared danger is anatomy: small increases in oedema can narrow the supraglottic airway, while fascial spaces permit infection to track around carotid sheath, jugular vein and mediastinum. Treatment therefore pairs airway control with source control and tissue-active antimicrobials; antibiotics alone cannot drain a mature collection or reverse mechanical obstruction.
Key points
Airway safety comes before diagnostic certainty; keep a distressed patient upright and avoid procedures that may precipitate obstruction.
Adult epiglottitis often presents with severe throat pain, dysphagia, muffled voice and minimal oropharyngeal findings;
Practice
Two practice questions
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Question 1 of 2
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Infectious diseases, microbiology and sexual healthOriginal SBA
Threatened airway
An adult sits forward, drools and has severe throat pain with inspiratory stridor but little visible tonsillar inflammation. What is the safest immediate action?
Sources and review status3 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Deep-neck infection follows tonsillar, dental, salivary, traumatic or instrument-related infection and may spread between fascial planes into the mediastinum.
Flexible nasendoscopy is performed only by an experienced team where immediate airway rescue is available; unstable patients proceed to controlled airway management.
Contrast CT neck and chest maps deep collections after the airway is secure; imaging must not delay intervention in a deteriorating patient.
Start intravenous ceftriaxone-based or local broad oral-flora treatment after blood cultures when safe, adding anaerobic and resistant-organism cover by source and exposure.
A mature parapharyngeal, retropharyngeal or odontogenic abscess usually requires drainage and removal of the dental or other source.
Review frequently for increasing oxygen need, secretion intolerance, swelling, cranial neuropathy, jugular thrombosis and mediastinal extension.
Aetiology
01
Respiratory bacterial infection
H influenzae, streptococci and staphylococci infect supraglottic tissue, with organism probability shaped by vaccination, age and immune status.
02
Dental and tonsillar spread
Odontogenic disease, tonsillitis, salivary infection, trauma and instrumentation seed polymicrobial oral flora into deep fascial spaces.
Pathophysiology
1
Supraglottic oedema
Inflammation expands the epiglottis and aryepiglottic tissues within a narrow airway, sharply increasing resistance and work of breathing.
2
Fascial-plane propagation
Loose connective planes allow pus and gas to track around pharynx, carotid sheath and mediastinum beyond visible surface disease.
3
Pressure and necrosis
A walled collection impairs perfusion and antibiotic delivery, while tissue pressure and toxins promote necrosis, thrombosis and sepsis.
Clinical features and red flags
Epiglottic phenotypeRed flag
Severe odynophagia, drooling, quiet muffled speech and preference to sit forward with little visible pharyngeal inflammation is a high-risk pattern.
Peritonsillar spreadRed flag
Unilateral throat pain, hot-potato voice, uvular deviation and trismus suggests a peritonsillar collection requiring ENT drainage assessment.
Stridor, drooling, inability to swallow secretions or exhaustion indicates critical airway narrowing requiring immediate expert control.
Trismus, floor-of-mouth elevation, tongue displacement or rapidly spreading submandibular swelling suggests Ludwig angina and difficult intubation.
Neck swelling with chest pain, crepitus or sepsis can indicate descending mediastinitis and needs urgent cross-sectional imaging after airway safety.
Investigations
01Continuous airway and physiological assessmentFirst step
Why
Detect deterioration before complete obstruction.
Interpretation and limitations
Increasing stridor, secretion intolerance, fatigue, hypoxia or hypercapnia mandates immediate airway intervention; normal saturation does not reassure early.
02Senior flexible nasendoscopy
Why
Visualise supraglottic oedema in a controlled setting.
Interpretation and limitations
A swollen erythematous epiglottis supports diagnosis, but examination must stop if distress worsens and must have rescue capability.
03Contrast CT neck and chest
Why
Map abscess, gas, vascular thrombosis and mediastinal spread.
Interpretation and limitations
Perform only after airway stability. A rim-enhancing collection or descending extension changes drainage and operative planning.
04Blood and deep cultures
Why
Identify bacteraemia and guide narrowing from representative material.
Interpretation and limitations
Take blood cultures before antibiotics when safe and send aspirate or operative tissue; superficial throat swabs do not represent deep infection.
Differential diagnosis
01
Anaphylaxis or angioedema
Rapid tongue or laryngeal swelling with urticaria, wheeze or exposure history requires immediate adrenaline rather than infection-only management.
02
Foreign body or tumour
Abrupt choking or progressive dysphagia, weight loss and unilateral findings can obstruct the airway without acute bacterial disease.
03
Severe tonsillitis or croup
Surface tonsillar inflammation and viral laryngotracheal illness can mimic voice change, but secretion intolerance and adult stridor demand broader airway assessment.
Management
01ASSESSProtect the airwayFirst stepUpper-airway infection is suspected from pain, voice, swallowing or neck findings.+
1Keep the patient upright, calm and nil by mouth while experienced anaesthesia and ENT attend with difficult-airway equipment.
2Avoid tongue depression, unnecessary cannulation attempts and unmonitored transfer when obstruction is plausible.
3Obtain rapid observations, glucose and cultures without postponing airway control; use controlled theatre intubation or surgical airway according to anatomy.
4After stabilisation, examine dental, tonsillar, salivary and traumatic sources and choose contrast imaging with the operating team.
02TREATTreat infection and drain the sourceThe airway is secure enough for antimicrobial and source-control treatment.+
1Give intravenous ceftriaxone or a locally approved severe upper-airway regimen promptly, adding metronidazole for anaerobic deep-space infection when indicated.
Complications
01
Complete airway obstruction
Progressive oedema, fatigue and secretions can cause sudden hypoxic arrest, making controlled early airway management lifesaving.
02
Descending mediastinitis
Retropharyngeal infection can enter the chest, causing pleural, pericardial and mediastinal sepsis requiring urgent specialist thoracic drainage.
03
Septic thrombophlebitis
Internal jugular thrombosis can produce persistent bacteraemia, neck pain and pulmonary septic emboli after pharyngeal infection.
Monitoring and follow-up
Observe airway work, voice, swallowing, secretions and oxygenation continuously until the risk of abrupt obstruction has resolved.
Trend fever, inflammatory markers, blood cultures and deep culture results while linking changes to drainage and imaging.
Inspect neck swelling, mouth opening, floor of mouth and cranial nerves and ask about chest pain suggesting descending infection.
Document airway grade, device plan, antimicrobial review, drain care and the clinician responsible for source eradication.
Special situations
Pain can exceed the view
Minimal tonsillar inflammation does not exclude epiglottitis or a deep collection; severe disproportionate odynophagia is a useful warning.
CT follows airway safety
Cross-sectional anatomy is valuable only after the patient can tolerate lying flat and transfer without losing the airway.
Pus needs a route out
Clinical improvement may stall despite susceptible antibiotics when pressure and devitalised tissue remain behind fascial barriers.
Extubation is another airway decision
Removing a secured tube requires evidence that supraglottic swelling and secretions have improved, not merely a lower fever.
Common pitfalls
01
Forcing oral examination in a distressed stridulous patient and precipitating complete airway obstruction.
02
Sending an unstable patient supine to CT without senior airway escort and rescue equipment.
03
Treating a rim-enhancing deep collection with antibiotics alone despite persistent fever and mass effect.
04
Ignoring dental source, internal jugular thrombosis or mediastinal extension after initial throat symptoms improve.
Severe pain with little visible tonsillar change can reflect epiglottitis or a deep parapharyngeal process rather than uncomplicated pharyngitis.
2Drain accessible abscesses and remove the diseased tooth, device or necrotic focus through ENT, maxillofacial or thoracic teams.
3Use ICU observation after airway intervention and extubate only after oedema, leak and endoscopic assessment support safety.
4Narrow antimicrobial therapy to deep cultures and define duration from drainage adequacy, bacteraemia and mediastinal or bone involvement.
03REVIEWReassess anatomy and complicationsSymptoms or physiology fail to improve promptly or new regional signs appear.+
1Repeat airway, neck, cranial-nerve, chest and sepsis assessment at short intervals rather than waiting for routine ward review.
2EscalationEscalate persistent fever or swelling to repeat CT and surgical review for an undrained pocket, thrombophlebitis or mediastinitis.
3Check renal, hepatic and concentration monitoring for chosen agents and transition to oral therapy only after swallowing and anatomy recover.
4Arrange dental or tonsillar source follow-up and vaccination or public-health action when the recovered organism makes it relevant.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
Provides broad activity against H influenzae, streptococci and susceptible respiratory organisms.
Ceftriaxone for severe epiglottic infection
Give ceftriaxone 2 g intravenously once daily in adults, using meningitis dosing if central nervous system infection is suspected.
Check immediate beta-lactam allergy, biliary disease, renal and liver context and local resistance; airway control must never wait for antibiotic effect.
Covers oral streptococci, beta-lactamase producers and anaerobes while drainage is arranged.
Co-amoxiclav for polymicrobial deep-neck infection
Give co-amoxiclav 1.2 g intravenously every 8 hours for severe odontogenic or polymicrobial deep-neck infection when local guidance supports it.
Avoid in immediate penicillin allergy or previous co-amoxiclav liver injury, adjust for renal function and do not let treatment postpone drainage.
Adds activity against anaerobes in dental and deep fascial-space infection.
Metronidazole anaerobic component
Give metronidazole 500 mg intravenously every 8 hours when the selected beta-lactam does not provide adequate anaerobic cover.
Review liver disease, warfarin and neurological toxicity and avoid alcohol during treatment and for 48 hours afterwards.