Introduction Acute epiglottitis is a rare but potentially life-threatening Ear, Nose and Throat condition. Little data exists on the management of these patients in a rural environment. Aims The primary objective was to review the demographics, presentation, investigation and management for patients presenting with acute epiglottitis. The secondary objective was to analyse factors implicated in need for airway intervention. Methods A retrospective review was undertaken of all patients with acute epiglottitis over a 10-year period from 2014 to 2023 across two rural base hospitals in Western New South Wales Local Health District. Results There were 29 adult patients identified over the search period. The median age was 45 years (IQR 32-57), with a slight male predominance (n=16, 55%). Sixteen patients presented through the emergency department and 13 were transferred from peripheral hospitals. Six patients were transferred more than 100 kilometres to a base hospital. The most common symptoms were sore throat (n=28, 97%), odynophagia (n=25, 86%), dysphonia (n=17, 59%), dysphagia (n=17, 59%) and fever (n=12, 41%). Streptococcus species were cultured in four (14%) patients, with no Haemophilus-influenzae type-B cultured. Twelve patients (41%) required airway intervention, seven with awake fibreoptic nasotracheal intubation, four via direct laryngoscopy and one failed intubation requiring emergency cricothyroidotomy. Twenty-four (83%) of patients were admitted to the Intensive Care Unit for monitoring and there was one death (3%) in the cohort. Factors associated with airway intervention included drooling (OR 13, 95% CI 1.7-390, p=0.011), stridor (OR 6.7, 95% CI 1.1-62, p=0.038), higher temperature (37.8 degrees verse 36.8 degrees, p=0.041), higher heart rate (116 per minute verse 94 per minute, p=0.049) and higher respiratory rate (24 per minute verse 18 per minute, p=0.034). Conclusion This rural cohort had a high rate of airway intervention.