Review Question - QID 105400

This patient's presentation is consistent with epiglottitis. Among the choices, drooling is the physical finding most specific for epiglottitis.

Epiglottitis is a serious and rapidly progressive infection of the epiglottis and contiguous structures that affects children from age 3-7. It presents with fever, tachypnea, stridor, drooling, the "tripod position," and the "thumbprint sign" on lateral neck radiograph. It is classically caused by H. influenzae type B (Hib) but S. aureus and Streptococcus are now common causative agents due to the Hib vaccine. Epiglottitis is is a true airway emergency and requires immediate intubation in the OR. Patients remain intubated while receiving IV antibiotics for up to 72 hours. It must be differentiated from croup, which presents similarly and is not immediately life-threatening; croup shows the "steeple sign" on CXR and presents with cough and a lack of drooling.

Clark et al. compare epiglottitis and laryngotracheobronchitis (croup): "Unlike epiglottitis, laryngotracheobronchitis is very common. While both diseases may present with stridor and signs of respiratory obstruction, it is important to distinguish between them because the management strategies differ. Laryngotracheobronchitis usually responds to humidification. Epiglottitis requires an artificial airway and intensive antibiotics."

Tibballs et al. conducted a study of 203 children in which they identified drooling as a sign specific for epiglottitis vs. croup. Both diseases present with stridor, but drooling was 79% sensitive and 94% specific for epiglottitis. Cough was 100% sensitive and 98% specific for croup. "Additional reliable signs of epiglottitis were a preference to sit, refusal to swallow and dysphagia."

Illustration A shows lateral neck radiographs of a normal epiglottis (left) and epiglottitis (right). The top images show the original radiographs while the bottom images mark the location of the epiglottis. Note the presence of the classic "thumbprint sign." Illustration B provides an additional similar example of epiglottitis. Illustration C is a radiograph demonstrating the "steeple sign" of croup that is NOT present in epiglottitis.
Image A, provided in the question stem, is identical to the upper right panel in Illustration A.

Incorrect answers:
Answer 1: The presence of cough is specific for croup.
Answer 2: Patients with epiglottitis are classically "toxic-appearing", but the literature points to drooling as a more specific sign of the disease.
Answers 4 and 5: Rhinorrhea and conjunctivitis are not typically present in epiglottitis.