Acute Epiglottitis
The most likely diagnosis is A. Acute epiglottitis, based on the classic presentation of a toxic-appearing child with the "tripod" positioning (sitting upright, leaning forward with mouth open), drooling, dysphagia, high fever, and rapid progression of symptoms.
Clinical Presentation Analysis
This child demonstrates the pathognomonic features of acute epiglottitis:
Toxic appearance with tripod positioning: The child sitting upright in a chair, opening his mouth and drooling saliva represents the classic "sniffing position" or tripod posture that children adopt to maximize airway patency 1, 2, 3
Drooling and dysphagia: Difficulty swallowing food with excessive salivation indicates supraglottic obstruction, which is characteristic of epiglottic inflammation rather than subglottic pathology 1, 3, 4
High fever (39-40°C): This degree of fever combined with the toxic appearance distinguishes epiglottitis from viral croup, which typically presents with lower-grade fever and less systemic toxicity 2, 3
Rapid progression: The transition from mild upper respiratory symptoms (12-hour history of cough and runny nose) to severe airway compromise within one day is typical of acute epiglottitis 1, 3
Why Not the Other Diagnoses
Viral croup (C) is excluded because:
- Croup typically presents with a barking cough, hoarseness, and inspiratory stridor without drooling 5
- Children with croup do not appear toxic and do not adopt the tripod position 5
- Croup has a more gradual onset over several days with progressive respiratory symptoms 5
Bacterial tracheitis (B) is less likely because:
- Bacterial tracheitis usually follows several days of viral croup symptoms with secondary bacterial superinfection
- While it can present with toxic appearance, the absence of preceding croup symptoms and the presence of drooling/dysphagia favor epiglottitis 3
Critical Management Considerations
This is a medical emergency requiring immediate action:
Do NOT examine the throat or agitate the child: Any manipulation can precipitate complete airway obstruction 1, 3, 4
Maintain the child in a position of comfort: Allow the child to remain in the tripod position with a parent present 3, 4
Secure the airway in the operating room: Nasotracheal intubation under controlled conditions with anesthesia and ENT backup is the standard of care 1, 2, 3
Lateral neck radiograph can confirm diagnosis if the child is stable enough for imaging, showing the classic "thumb sign" of epiglottic swelling, though direct visualization in the OR is definitive 2, 3
Blood cultures should be obtained after airway is secured: Haemophilus influenzae type b is isolated in 96-97% of cases 2, 3
Common Pitfalls to Avoid
The most dangerous error is attempting to visualize the epiglottis in an awake child or forcing the child to lie supine, which can trigger complete airway obstruction and death 1, 3, 4. Even in infants as young as 7 months, epiglottitis should be suspected with this presentation, as it can occur at any age despite being more common in older children 4.