Materiały źródłowe

• #1

  https://www.amerikanhastanesi.org/mayo-clinic-care-network/mayo-clinic-health-information-library/diseases-conditions/epiglottitis

  Epiglottitis happens when the epiglottis a small cartilage „lid” that covers the windpipe swells. The swelling blocks the flow of air into the lungs. Epiglottitis can be deadly. […] Many factors can cause the epiglottis to swell. These factors include infections, burns from hot liquids and injuries to the throat. […] The most common cause of epiglottitis in children was infection with Haemophilus influenzae type b (Hib) bacteria. […] An infection or injury causes epiglottitis. […] In the past, a common cause of swelling and inflammation of the epiglottis and surrounding tissues was infection with Haemophilus influenzae type b (Hib) bacteria. […] In adults, other bacteria and viruses also can cause the epiglottis to swell. […] Rarely, physical injury, such as a blow to the throat, can cause epiglottitis. So can burns from drinking very hot liquids and breathing in smoke from a fire.

• #2 Epiglottitis (supraglottitis): Clinical features and diagnosis – UpToDate

  https://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis

  Epiglottitis refers to inflammation of the epiglottis and adjacent supraglottic structures, primarily due to infection. Without treatment, epiglottitis can progress to life-threatening airway obstruction. […] Epiglottitis is most frequently caused by infection, although caustic ingestion, thermal injury, and local trauma are important noninfectious etiologies. Infectious epiglottitis is a cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissues. It results from bacteremia and/or direct invasion of the epithelial layer by the pathogenic organism. […] The posterior nasopharynx is the primary source of pathogens in epiglottitis. Microscopic trauma to the epithelial surface (eg, mucosal damage during a viral infection or from food during swallowing) may be a predisposing factor. Less frequently, noninfectious conditions cause local burns or ecchymosis of the epiglottis and adjacent structures.

• #3 Epiglottitis – Wikipedia

  https://en.wikipedia.org/wiki/Epiglottitis

  Epiglottitis was historically mostly caused by infection by H. influenzae type b (commonly referred to as „Hib”). […] With vaccination, it is now more often caused by other bacteria, most commonly Streptococcus pneumoniae, Streptococcus pyogenes, or Staphylococcus aureus. […] Predisposing factors include burns and trauma to the area. […] Epiglottitis is primarily caused by an acquired bacterial infection of the epiglottis. […] Historically it was most often caused by Haemophilus influenzae type B, but with the availability of immunization this is no longer the case. […] Presently, the bacteria most often causing infection are other encapsulated organisms including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. […] While the overall incidence of epiglottitis has decreased, the incidence of cases caused by Streptococcus pneumoniae has increased in adults.

• #4 Epiglottitis – TeachMePaediatrics

  https://teachmepaediatrics.com/ent/throat/epiglottitis/

  Acute epiglottitis is an acute, life-threatening condition, most commonly caused by infection. […] Infectious causes of epiglottitis are more common that non-infectious causes, though both are listed below. As already discussed, Haemophilus influenza type B used to be by far the most common cause of epiglottitis amongst children, accounting for 75-90% of cases. Bacteria still predominate in the list of causes, with the majority post the introduction of the HiB vaccine being caused by streptococcus species. Viruses have been implicated, though are less common, and can encourage a superimposed bacteria to invade and cause epiglottitis. […] Haemophilus influenzae and streptococcus pneumoniae are commensal bacteria which may locally invade the epiglottis, resulting in inflammation in 75-90% of cases. Rarely, epiglottitis may be due to non-infectious causes such as trauma or thermal/chemical damage.

• #5 Epiglottitis – Ear, Nose, and Throat Disorders – Merck Manual Consumer Version

  https://www.merckmanuals.com/home/ear-nose-and-throat-disorders/mouth-and-throat-disorders/epiglottitis

  Epiglottitis is a bacterial infection of the epiglottis and surrounding tissues. […] Sometimes the epiglottis becomes infected with bacteria. […] Epiglottitis caused by Haemophilus influenzae type B used to be most common among children, but routine vaccination against Haemophilus has almost eliminated this infection in children. Now more cases of epiglottitis occur in adults. However, children may get epiglottitis caused by other bacteria, and adults and unvaccinated children can still be infected by Haemophilus influenzae type B. […] The swelling caused by this infection may block the airway and lead to difficulty breathing and death. […] Because children have a smaller airway than adults, epiglottitis is much more dangerous in children but can also be fatal in adults. […] All adults and children with epiglottitis are given antibiotics (such as ceftriaxone).

• #6 Epiglottitis: Practice Essentials, Etiology, Epidemiology

  https://emedicine.medscape.com/article/763612-overview

  In adults, the most common organisms that cause acute epiglottitis are Haemophilus influenzae (25%), followed by H parainfluenzae, Streptococcus pneumoniae, and group A streptococci. Less common infectious etiologies include other bacteria (eg, Staphylococcus aureus, mycobacteria, Bacteroides melaninogenicus, Enterobacter cloacae, Escherichia coli, Fusobacterium necrophorum, Klebsiella pneumoniae, Neisseria meningitidis, Pasteurella multocida), herpes simplex virus (HSV), other viruses, infectious mononucleosis, Candida (in immunocompromised patients), and Aspergillus (in immunocompromised patients). […] Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is becoming an increasingly important pathogen; as of 2007, MRSA rarely causes epiglottitis. […] Noninfectious causes of epiglottitis are not uncommon and produce similar disease. Etiologies include thermal causes (including those associated with crack cocaine smoking and marijuana smoking, as well as throat burns affecting the epiglottis of bottle-fed infants), caustic insults (eg, automatic dishwasher soap ingestion), and foreign body ingestion (eg, following ingestion and expulsion of a bottle cap). Epiglottitis may also occur as a reaction to head and neck chemotherapy.

• #7 Epiglottitis: Practice Essentials, Etiology, Epidemiology

  https://emedicine.medscape.com/article/963773-overview

  In adults, the most common organisms that cause acute epiglottitis are Haemophilus influenzae (25%), followed by H parainfluenzae, Streptococcus pneumoniae, and group A streptococci. Less common infectious etiologies include other bacteria (eg, Staphylococcus aureus, mycobacteria, Bacteroides melaninogenicus, Enterobacter cloacae, Escherichia coli, Fusobacterium necrophorum, Klebsiella pneumoniae, Neisseria meningitidis, Pasteurella multocida), herpes simplex virus (HSV), other viruses, infectious mononucleosis, Candida (in immunocompromised patients), and Aspergillus (in immunocompromised patients). […] Noninfectious causes of epiglottitis are not uncommon and produce similar disease. Etiologies include thermal causes (including those associated with crack cocaine smoking and marijuana smoking, as well as throat burns affecting the epiglottis of bottle-fed infants), caustic insults (eg, automatic dishwasher soap ingestion), and foreign body ingestion (eg, following ingestion and expulsion of a bottle cap). Epiglottitis may also occur as a reaction to head and neck chemotherapy.

• #8 Epiglottitis – Ear, Nose, and Throat Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/ear-nose-and-throat-disorders/oral-and-pharyngeal-disorders/epiglottitis

  Epiglottitis used to primarily affect children and usually was caused by Haemophilus influenzae type B. Now, because of widespread vaccination, it has been almost eradicated in children (more cases occur in adults). Causal organisms in children and adults include Streptococcus pneumoniae, Staphylococcus aureus, nontypeable H. influenzae, Haemophilus parainfluenzae, beta-hemolytic streptococci, Branhamella catarrhalis, and Klebsiella pneumoniae. H. influenzae type B is still a cause in adults and unvaccinated children. […] Bacteria that have colonized the nasopharynx spread locally to cause supraglottic cellulitis with marked inflammation of the epiglottis, vallecula, aryepiglottic folds, arytenoids, and laryngeal ventricles. With H. influenzae type B, infection may spread hematogenously. […] Epiglottitis caused by H. influenzae type B can be effectively prevented with the H. influenzae type B (HiB) conjugate vaccine.

• #9 Epiglottitis: Causes, Symptoms, and Treatment | Doctor

  https://patient.info/doctor/epiglottitis-pro

  Epiglottitis causes (aetiology)4 […] In a series of 308 epiglottitis patients, the causative organism in the majority of cases was Streptococcus spp.5 . […] Other bacterial causes include Staphylococcus aureus, Haemophilus influenzae type b (Hib), Pseudomonas spp., Moraxella catarrhalis and Mycobacterium tuberculosis. […] Viruses include herpes simplex virus, with bacterial superinfection. […] Candida spp. and Aspergillus spp. in immunocompromised patients. […] Non-infectious causes of epiglottitis reported include thermal causes (eg, steam, crack cocaine smoking), caustic insults (eg, dishwasher pellets), foreign bodies and trauma, including traditional Chinese gua sha therapy6 . […] Reactive epiglottitis may also occur as a reaction to head and neck chemotherapy.

• #10 Epiglottitis

  https://mobile.fpnotebook.com/Lung/Airway/Epgltts.htm

  Uncommon, but adults comprise most cases since the 1987 introduction of Hib Vaccine […] Young children were historically the primary cohort for Epiglottitis prior to the Hib Vaccine […] Previously most common cause of Epiglottitis in children […] No longer a common cause in United States (due to Hib Vaccine) […] More common in adults than children now with waning Vaccination Immunity and failed Herd Immunity […] Common Bacterial Causes […] Group A beta hemolytic Streptococcus (Streptococcus Pyogenes) […] Streptococcus Pneumoniae […] Staphylococcus Aureus […] Moraxella catarrhalis […] Haemophilus Influenzae Type B […] Other Bacterial Causes […] Viridans Streptococcus […] Streptococcus agalactiae […] Neisseria Meningitidis […] Kingella kingae […] Bacteroides […] Non-Bacterial Causes […] Herpes Simplex Virus […] Candida albicans […] Thermal airway Burn Injury.

• #11 Epiglottitis: Causes, Symptoms, Diagnosis and Treatment

  https://www.webmd.com/a-to-z-guides/epiglottitis-infection-inflammation

  Epiglottitis usually comes from an infection. You’re more likely to get it if you have immune system problems, or if you haven’t had the Hib vaccine. The most common causes are bacteria, including: […] Less often, the infection that leads to epiglottitis can be caused by a fungus, particularly a yeast called Candida albicans or a mold called Aspergillus. That’s more likely in people with immune system problems. […] Sometimes, being sick with a virus allows a bacterial infection to take hold. You might get epiglottitis after you’ve had chickenpox or been infected with herpes simplex or Epstein-Barr. […] Another, less common, cause is a burn or other injury to the back of the throat. This can come from: […] Epiglottitis can also be a side effect of cancer treatment or another disease. […] The main cause of epiglottitis is the Haemophilus influenzae type b (Hib) bacteria. You’re most at risk if you haven’t been vaccinated against it or if you have a weakened immune system.

• #12 Epiglottitis: Causes, Symptoms, and Diagnosis

  https://www.healthline.com/health/epiglottitis

  A bacterial infection is the most common cause of epiglottitis. Bacteria can enter your body when you breathe it in. It can then infect your epiglottis. […] The most common strain of bacteria that causes this condition is Haemophilus influenzae type b, also known as Hib. You can catch Hib by inhaling the germs spread when an infected person coughs, sneezes, or blows their nose. […] Other bacterial strains that can cause epiglottitis include Streptococcus A, B, or C and Streptococcus pneumoniae. Streptococcus A is the type of bacteria that can also cause strep throat. Streptococcus pneumoniae is a common cause of bacterial pneumonia. […] Additionally, viruses such as those that cause shingles and chickenpox, along with those that cause respiratory infections, can also result in epiglottitis. Fungi, such as those that cause diaper rash or yeast infections, may also contribute to inflammation of the epiglottis. […] Other causes of this condition include: smoking crack cocaine, inhaling chemicals and chemical burns, swallowing a foreign object, burning your throat from steam or other sources of heat, experiencing throat injury from trauma, such as a stabbing or gunshot wound.

• #13 Epiglottitis: When to Call 911 for Windpipe Swelling

  https://www.verywellhealth.com/epiglottitis-7510173

  Blunt trauma to the throat, a throat blockage, and an allergic reaction are additional causes. Allergic reactions can cause the epiglottis to become inflamed and swell up. […] COVID-19 is a viral respiratory illness associated with many complications within and outside the respiratory tract. According to a 2021 report, COVID-19 has been found to affect the larynx, including the epiglottis. Epiglottitis linked to severe COVID-19 can reduce the ability for intubation, leading to a need for an emergent surgical airway. […] Causes include infections and injury or trauma to the throat.

• #14 Epiglottitis: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17844-epiglottitis

  Epiglottitis is inflammation and swelling of your epiglottis. The most common cause is bacterial infection. […] Bacterial infections are the most common cause of epiglottitis. In children, Haemophilus influenzae type b (Hib) bacteria is the most common cause. In adults, bacterial infections usually come from non-Hib sources. These include Streptococcus pneumoniae and Staphylococcus bacteria. […] Other possible epiglottitis causes include: Viral infections. Viruses like varicella-zoster virus and herpes simplex virus can make you vulnerable to bacterial infections that may lead to epiglottitis. Fungal infections. Candida infections, particularly in people with a weak immune system, have been linked to epiglottitis. Injury to your throat. The injury may involve things like a physical blow, swallowing a foreign object or drinking a very hot liquid. Smoking. This includes vaping or smoking substances like crack cocaine. Chemical burns. Epiglottitis can develop from ingesting a harmful chemical. This is called corrosive epiglottitis.

• #15 Infectious and Noninfectious Causes of Epiglottitis in Adults, Review of 24 Patients

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5791800/

  The present study reports the etiological differences, clinical features, management, and patient outcomes between infectious and noninfectious causes of epiglottitis in adult patients. […] Although epiglottitis is mainly caused by bacterial infections, noninfectious agents such as viral, caustic, and thermal injuries can also be causes. […] The existing literature indicates that noninfectious causes such as thermal and caustic injuries, autoimmune diseases, epiglottic ulcers, and angioedema are implicated in the etiology of epiglottitis. […] In our study, although 16 patients had the infectious cause of epiglottitis, eight patients had noninfectious causes. Among noninfectious epiglottitis cases, two patients had angioedema, two had experienced organophosphate ingestion, one had experienced hot water aspiration, one had experienced hot milk aspiration, one had experienced foreign body aspiration (fishbone), and one had epiglottitis due to Behets disease. […] Although adult epiglottitis is usually bacterial, some cases have been reported in which no pathogen could be isolated; therefore, viral agents have been suspected in their etiology.

• #16 Epiglottitis: When to Call 911 for Windpipe Swelling

  https://www.verywellhealth.com/epiglottitis-7510173

  Epiglottitis is more common in children but can also affect adults. Causes of epiglottitis include infections and injuries or burns to the throat. […] Bacterial, fungal, and viral infections are the most common cause of epiglottitis. The most common infectious causes are Haemophilus influenzae, Streptococcus pneumoniae and other strep species, and respiratory tract viruses. There have also been cases of epiglottitis linked to COVID-19. […] It is also possible to experience epiglottitis following heat damage. Thermal epiglottitis can occur after ingesting hot liquids or eating very hot foods. […] There are also incidences of thermal epiglottitis related to recreational drug use. This could occur from accidentally inhaling heated objects, such as broken crack pipes or tips of marijuana cigarettes. E-cigarettes can also cause epiglottitis, especially in adolescents.

• #17 Epiglottitis – Larynx Diseases – Respirology – Diseases – McMaster Textbook of Internal Medicine

  https://empendium.com/mcmtextbook/chapter/B31.II.3.24.

  2. Etiology: Epiglottitis may be either infectious or noninfectious. Infectious epiglottitis has historically been related to Haemophilus influenzae type b (Hib) infection. However, since the introduction of Hib vaccination, Hib infection is rare in vaccinated populations. Data on relevant pathogens in the vaccine era are incomplete; nontype b Haemophilus influenzae and Streptococcus species appear to be the most prevalent pathogens, although a wide variety of bacteria have been implicated. Staphylococcus aureus can rarely be a causative organism. […] Noninfectious epiglottitis can be caused by a number of factors, among which trauma is the most common. Thermal trauma of the epiglottis is especially common in patients using makeshift filters to smoke crack cocaine but may occur with any type of inhalation burn. Blunt trauma to the neck may cause swelling of the supraglottic structures. Iatrogenic trauma, typically from a traumatic intubation, also causes injury to supraglottic structures. Finally, external beam radiation treatments for cancers of the upper aerodigestive tract often cause long-standing inflammation of the supraglottis.

• #18 Epiglottitis – Larynx Diseases – Respirology – Diseases – McMaster Textbook of Internal Medicine

  https://empendium.com/mcmtextbook/chapter/B31.II.3.24.

  Angioedema is another potential noninfectious cause of epiglottitis. Angioedema of the epiglottitis may be caused by a hypersensitivity reaction, various protein deficiencies (sometimes lumped together under the term hereditary angioedema), or medications, such as angiotensin-converting enzyme inhibitors.

• #19 Epiglottitis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/epiglottitis?embed_domain=hackmd.io%252525252525252f%2525252525252540yipuafecsl2jsu8smr5njq%252525252525252fbnjhjgjghjghjghradiopaedia-icon-144.png&lang=us

  Epiglottitis, also known as supraglottitis, is a life-threatening condition caused by inflammation of the epiglottis and aryepiglottic folds, which can lead to acute airway obstruction. […] Haemophilus influenzae type B used to be the most common responsible organism but group A beta-hemolytic Streptococci is now more common due to the effectiveness of Haemophilus influenzae type B vaccinations. Less common infections include Staphylococcus aureus, Neisseria meningitidis, TB and viruses. […] Epiglottitis can be caused by direct extension of infection from other adjacent head and neck regions, such as dental infection, tonsillitis, laryngopyocele and skin cellulitis. […] Non-infectious causes include: sarcoidosis which usually spares the true vocal cords with their sparse lymphatic system, trauma, thermal injury, chemical irritation, recreational drugs, chemotherapy, and radiotherapy.

• #20 Epiglottitis (supraglottitis): Clinical features and diagnosis – UpToDate

  https://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis/print

  Epiglottitis refers to inflammation of the epiglottis and adjacent supraglottic structures, primarily due to infection. […] Epiglottitis is most frequently caused by infection, although caustic ingestion, thermal injury, and local trauma are important noninfectious etiologies. […] Infectious epiglottitis is a cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissues. It results from bacteremia and/or direct invasion of the epithelial layer by the pathogenic organism. […] The posterior nasopharynx is the primary source of pathogens in epiglottitis. […] Microscopic trauma to the epithelial surface (eg, mucosal damage during a viral infection or from food during swallowing) may be a predisposing factor. […] Less frequently, noninfectious conditions cause local burns or ecchymosis of the epiglottis and adjacent structures.

• #21 Epiglottitis: Practice Essentials, Etiology, Epidemiology

  https://emedicine.medscape.com/article/763612-overview

  A retrospective study by Suzuki et al indicated that risk factors for severe epiglottitis in adults includes older age, a body mass index of over 25.0 kg/m2, and the presence of diabetes mellitus, epiglottic cyst, or pneumonia, at admission. The study included 6072 patients with epiglottitis, including 9.4% with a severe form of the condition. […] A Taiwanese study by Hsu et al indicated that an association exists between epiglottitis and the autoimmune disease Sjgren syndrome, with the likelihood of finding preexisting Sjgren syndrome in patients with epiglottitis being greater than in controls (adjusted odds ratio [aOR] = 2.37). Moreover, the investigators also reported a link between polyautoimmunity and the existence of epiglottitis (aOR = 2.08), especially in patients aged 50 years or older (aOR = 2.61). This author might conjecture that in Sjgren syndrome, alteration in mucosa caused by dryness, along with immunomodulating therapies, could predispose to invasive disease.

• #22

  https://journals.lww.com/jcsr/fulltext/2020/09020/acute_epiglottitis___a_life_threatening_clinical.8.aspx

  In adults in addition to H. influenzae, S. pneumoniae, haemolytic streptococci and Staphylococcus aureus are also seen in throat or blood culture samples obtained from AE patients. […] Immunocompromised patients are more prone to AE, and there should be a low threshold of suspicion for the diagnosis of epiglottitis along with presenting symptoms and neutropenia. […] The risk factors for AE are middle- or elderly-age caucasians, tobacco smoking and co-morbid situations such as diabetes mellitus. […] The other risk factors for AE are male sex, pre-existing epiglottic cyst, obesity and impaired immunity of the host. […] Impaired immunity and epiglottic cysts have been reported to enhance the risk for recurrent episodes of AE. […] Adults with AE often have pre-existing medical conditions such as diabetes mellitus, hypertension and alcohol abuse which usually weaken the immunity of the patients and lead to susceptibility of the infections such as AE.

• #23 Epiglottitis: Old Problem, New Patients | Emergency Physicians Monthly

  https://epmonthly.com/article/epiglottitis-old-problem-new-patients/

  Epiglottitis can be a life-threatening condition caused by an acute inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds. […] Prior to the introduction of the vaccine, the ratio of incidence in children to adults was 2.6:1.1 In 1993 this ratio has decreased to 0.4:1; therefore, making the disease more prevalent in adults.1 The incidence in the adult population ranges from 0.97 to 3.1 in 100000 per year,3 with a mortality of 7%.4 In contrast, the mortality in children with epiglottitis has decreased to 1%.1 […] The microbiologic approach is important to ensure that the organism is sensitive to the antibiotic regimen being used. […] Type B Hemophilus Influenzae type B (Hib) is almost always the cause in children, but it is only found in as few as 17% of adults.7 However, in adult cases where Hib is identified as the pathogen, the disease tends to be more severe. Other pathogens in adults include haemophilus parainfluenzae, streptococcus pneumoniae and group A streptococci. […] Adult epiglottitis, as previously mentioned, is caused by a variety of organisms.

• #24 Epiglottitis | Boston Children’s Hospital

  https://www.childrenshospital.org/conditions/epiglottitis

  Epiglottitis is a bacterial infection, which is spread through the upper respiratory tract. The bacteria is usually Haemophilus influenzae type B (Hib). No one really knows why some children develop the disease, while others don’t. […] Epiglottitis caused by the bacteria Hib can be prevented with vaccines that start at the age of 2 months. Epiglottitis caused by other organisms can’t be prevented at this time, but are much less common.

• #25 Epiglottitis – Harvard Health

  https://www.health.harvard.edu/a_to_z/epiglottitis-a-to-z

  Epiglottitis can occur at any age. […] Until 1985, epiglottitis occurred most commonly in children aged 3 to 7, but with the development of a vaccine against Haemophilus influenzae type b (Hib), epiglottitis is now increasingly rare in vaccinated children. […] Blood tests and/or throat swabs are done to determine which organism is causing the infection. […] Most cases of epiglottitis in children can be prevented by having children vaccinated against Hib and pneumococcal infections. […] Antibiotics should be started immediately after breathing is stabilized and blood samples and throat swabs are taken.

• #26 Epiglottitis — Pediatric EM Morsels

  https://pedemmorsels.com/epiglottitis/

  Anything that causes edema of the epiglottis can lead to the condition. [Richards, 2016] […] Infection […] Haemophilus influenza type B […] Was the most common cause prior to initiation of Hib vaccinations […] Now it accounts for ~1 case per 100,000 kids. […] Group A and F Streptococci [Faden, 2006] […] Strep pneumonia […] Klebsiella sp […] Staphyloccocus aureus (including MRSA) […] Thermal Burn […] Can be due to inhaled hot steam. [Kudchadkar, 2014] […] Trauma […] Caustic Ingestions […] Epiglottitis is not always caused by infection. Thermal burns, trauma, and caustic burns can lead to airway disasters also!

• #27 Epiglottitis – RCEMLearning

  https://www.rcemlearning.co.uk/modules/acute-stridor/lessons/other-causes-of-acute-stridor-in-children/topic/epiglottitis/

  Following the introduction of the Haemophilus influenza type b (Hib) vaccination in 1992, childhood epiglottitis has become rare. […] It can also be caused by the same aerobes that cause peri-tonsillar abscesses. […] However, children who are fully immunised can still get Hib culture positive epiglottitis.

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