Introduction: Adult epiglottitis is a disease process distinct from pediatric epiglottitis in microbiology, presentation, and clinical course. While traditionally considered more indolent and benign than in children, adult epiglottitis remains a cause of acute airway compromise with a mortality rate from 1-20%. Our objective was to characterize the disease course and evaluate the rate and type of airway management in this population at a tertiary, academic referral center. Methods: We conducted a retrospective chart review of all adult patients (age ≥ 18) who were definitively diagnosed with infectious “epiglottitis,” “supraglottitis,” or “epiglottic abscess” by direct or indirect laryngoscopy during a nine-year period. Double data abstraction and a standardized data collection form were used to assess patient demographic characteristics, presenting features, and clinical course. The primary outcome was airway intervention by intubation, cricothyroidotomy, or tracheostomy, and the secondary outcome was mortality related to the disease. Results: Seventy patients met inclusion criteria. The mean age was 50.2 years (standard deviation ± 16.7), 60% of the patients were male, and 14.3% were diabetic. Fifty percent had symptoms that were present for ≥ 48 hours; 38.6% had voice changes, 13.1% had stridor, 12.9% had fever, 45.7% had odynophagia, and 47.1% had dysphagia noted in the ED. Twelve patients (17.1%) received an acute airway intervention including three who underwent emergent cricothyroidotomy, and one who had a tracheostomy. Two patients died and one suffered anoxic brain injury related to complications following difficult airway management. Conclusion: In this case series the majority of patients (82.9%) did not require airway intervention, but a third of those requiring intervention (5.7% of total) had a surgical airway performed with two deaths and one anoxic brain injury. Clinicians must remain vigilant to identify signs of impending airway compromise in acute adult epiglottitis and be familiar with difficult and failed airway algorithms to prevent morbidity and mortality in these patients.