Epiglottitis

A child who suddenly refuses to swallow, sits bolt upright and drools is telling you something critical — look in their throat and you could kill them.

Epiglottitis is acute bacterial inflammation of the epiglottis, most commonly caused by Haemophilus influenzae type B (Hib), though incidence has dropped dramatically since Hib vaccination. It strikes rapidly — a child can progress from onset to complete airway obstruction in hours, not days. The classic presentation is the four Ds: dysphagia, drooling, distress, and dysphonia (muffled "hot potato" voice). The child assumes a tripod position — sitting upright, leaning forward, chin thrust out, mouth open — to maximize the airway. High fever (often >39°C/102.2°F) with a toxic appearance distinguishes this from croup's gradual, barky onset. The cardinal nursing rule: never inspect the throat with a tongue depressor or attempt direct visualization. Any stimulation of the inflamed epiglottis can trigger complete laryngospasm and fatal obstruction. Keep the child calm, upright, and with the caregiver. Emergency intubation equipment and a tracheostomy tray must be at bedside. A lateral neck X-ray showing the classic "thumbprint sign" of a swollen epiglottis supports the diagnosis; definitive airway management (intubation) is performed in a controlled setting (OR). Treatment includes IV antibiotics (typically a third-generation cephalosporin such as ceftriaxone) and airway management.

Key Distinctions

Don't confuse epiglottitis with croup: epiglottitis is sudden, high fever, no barky cough, drooling, and tripod positioning; croup is gradual, low-grade fever, seal-bark cough, and steeple sign on AP X-ray. The thumbprint sign is seen on lateral neck X-ray (epiglottitis); the steeple sign is seen on AP X-ray (croup) — these are opposite ends of the airway. Students commonly think throat inspection is appropriate — it is absolutely contraindicated.

Clinical Pearl

The three "no's" of epiglottitis: no tongue blade, no throat inspection, no laying the child down. Keep them upright, keep them calm, keep them alive.