History
Epiglottitis is characterized by the abrupt onset of severe symptoms. Without airway control and medical management, symptoms may rapidly progress to respiratory obstruction and death in a matter of hours.
Usually, no prodromal symptoms occur in children. Fever is usually the first symptom, and temperatures often reach 40°C. This is rapidly followed by stridor and labored breathing. Dysphagia, refusal to eat, muffled (ie, guttural) or hoarse voice, sore throat, and anxiety are common. Cough and ear pain are less frequent.
The clinical triad of drooling, dysphagia, and distress is the classic presentation. Fever with associated respiratory distress or air hunger occurs in most patients. Drooling occurs in up to 80% of cases.
If the cause of epiglottitis is not infectious, the presentation may vary. A child presenting with upper airway respiratory distress without an obvious source or fever should be questioned regarding the possibility of ingestion of a toxic or hot liquid, or a traumatic event such as falling on an object with an open mouth or swallowing or having a foreign body removed. [12]
Physical Examination
The child appears toxic; shock may occur early in the course of the disease. Marked restlessness, irritability, and extreme anxiety are common.
The child may sit with his or her chin hyperextended and body leaning forward (ie, tripod or sniffing position) to maximize air entry and improve diaphragmatic excursion (see the following image).
The mouth may be open wide and the tongue may protrude; an affected child often drools, because swallowing is difficult or painful.
An erythematous and classic swollen, cherry red epiglottis can often be seen during careful examination of the oropharynx, although this examination should not be attempted if it may compromise respiratory effort.
Early on, the child may have stridulous respirations, but as the disease progresses, airway sounds may diminish. Stridor can occur with marked suprasternal, subcostal, and intercostal retractions.
Anterior neck examination may reveal tender adenopathy. In the older child, pain may be noted on movement of the hyoid bone. [13]
Cyanosis, which occurs late in the course of the condition, indicates a poor prognosis.
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Swollen epiglottis with characteristic thumbprint sign.
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Comparison of a normal pediatric airway (bottom) and airway from a child who died from epiglottitis (top).
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Child assuming the sniffing position with upper airway obstruction.
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Swollen epiglottis with characteristic thumbprint sign.
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Radiograph of a child with acute epiglottitis; note the hypopharyngeal dilatation, obliteration of the vallecula, and thickened aryepiglottic folds—a positive thumb sign.
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Correct positioning for a cricothyroid needle insertion
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Child with acute epiglottitis after intubation. Note cherry red epiglottis. This image was taken in 2008 and the child was completely immunized and grew HiB from surface culture.
