Epiglottitis and bacterial tracheitis: Case

This toddler presents with the classic picture of acute epiglottitis: a rapid onset over hours, a toxic and terrified child who sits upright drooling and refuses to lie down, a muffled voice, and soft inspiratory stridor without a barking cough. His incomplete immunisation record, in a child recently arrived from overseas, places Haemophilus influenzae type b firmly back in the differential. This is an airway emergency, and the entire early management is organised around not distressing the child and securing a definitive airway under controlled conditions. ^[1]

Clinical findings

The key findings are the toxic appearance, the tripod posture with drooling, the muffled voice, and the soft stridor, all of which point to supraglottic obstruction rather than the subglottic narrowing of croup. The candidate should recognise that the child must be assessed observationally, from a distance, without lying him flat, examining his throat, or cannulating him, because any of these could precipitate complete obstruction. The absence of a barking cough and the presence of drooling help separate epiglottitis from croup and bacterial tracheitis. ^[1]

The candidate should describe watching for the ominous transition from an agitated, struggling child to a quiet, drowsy one with softening stridor and bradycardia, which signals imminent complete obstruction rather than improvement. The immunisation history should be explored gently with the parents, but not at the expense of delaying the airway team, and the uncertain or incomplete record should raise the suspicion of Hib disease rather than reassure. ^[2]