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]

Management

The child needs controlled airway management in the operating theatre. The most senior anaesthetist, an ear, nose and throat surgeon, and paediatric intensive care should be called simultaneously, and the child taken to theatre for a gas induction with him sitting up and maintaining spontaneous ventilation, with the surgeon scrubbed and ready for rigid bronchoscopy or an emergency tracheostomy should intubation fail. Once the airway is secured, blood cultures are taken and intravenous antibiotics started. A third-generation cephalosporin such as ceftriaxone is the empiric choice, covering Haemophilus influenzae, streptococci, and staphylococci, with vancomycin added where meticillin-resistant Staphylococcus aureus is a concern. [3]

Direct visualisation at intubation of a cherry-red, swollen epiglottis confirms the diagnosis. The child is managed in the paediatric intensive care unit while intubated and is usually extubated within twenty-four to forty-eight hours once a leak develops around the tube and the swelling has settled, after which a short course of antibiotics is completed. Investigations serve to confirm the diagnosis and identify the pathogen and must never have delayed the airway. [1]

Complications and follow-up

Epiglottitis caused by invasive Haemophilus influenzae can be complicated by bacteraemia, meningitis, septic arthritis, and epiglottic abscess, and the child should be observed for these during recovery. The most feared complication, complete airway obstruction with hypoxic injury, is prevented by the disciplined do-no-harm approach and early airway control. Post-obstructive pulmonary oedema can occasionally develop after relief of the obstruction and is managed supportively. [2]

Follow-up must address public health as well as recovery. The child's immunisation should be caught up after recovery, and, if invasive Haemophilus influenzae type b is confirmed, household and close contacts may require rifampicin prophylaxis according to local public health guidance, a step that is easily forgotten. The family should receive a clear, interpreter-supported safety-net to return promptly for any recurrence of fever with stridor, drooling, or difficulty breathing, and the arrival-related barriers to care should be addressed to ensure the immunisation catch-up actually happens. [2]