A 7.5-year-old presents with inspiratory stridor, drooling, and a fever of 105F. He insists on sitting up during the exam. What is your diagnosis?

A 7.5-year-old presents with inspiratory stridor, drooling, and a fever of 105F. He insists on sitting up during the exam. What is your diagnosis?

• A. Foreign body aspiration
• B. Reactive airway disease
• C. Croup
• D. Epiglottitis

Answer: (D)

This scenario points to an upper airway emergency, where drooling, difficulty swallowing, and a very high fever raise strong concern for epiglottitis. The child’s inspiratory stridor reflects airway obstruction at the level of the epiglottis, and the need to sit upright or forward-leaning usually indicates trying to keep the airway open. Drooling occurs because swallowing is painful and swallowing saliva becomes difficult, so the child cannot manage secretions well. Epiglottitis is a medical emergency because swelling can progress rapidly and shut the airway. Management hinges on avoiding agitation or throat exams that could worsen the airway blockage. Secure the airway in a controlled setting with experienced personnel, keep the child calm and seated, obtain IV access, and start appropriate antibiotic therapy and supportive care. To place this in context, croup tends to present with a barking cough and hoarseness, with fever that is typically lower and no drooling. Foreign body aspiration usually has a sudden choking event and may show unilateral wheeze or decreased breath sounds rather than drooling. Reactive airway disease would present with wheeze and cough without the severe drooling or such high fever.

This scenario points to an upper airway emergency, where drooling, difficulty swallowing, and a very high fever raise strong concern for epiglottitis. The child’s inspiratory stridor reflects airway obstruction at the level of the epiglottis, and the need to sit upright or forward-leaning usually indicates trying to keep the airway open. Drooling occurs because swallowing is painful and swallowing saliva becomes difficult, so the child cannot manage secretions well. Epiglottitis is a medical emergency because swelling can progress rapidly and shut the airway.

Management hinges on avoiding agitation or throat exams that could worsen the airway blockage. Secure the airway in a controlled setting with experienced personnel, keep the child calm and seated, obtain IV access, and start appropriate antibiotic therapy and supportive care.

To place this in context, croup tends to present with a barking cough and hoarseness, with fever that is typically lower and no drooling. Foreign body aspiration usually has a sudden choking event and may show unilateral wheeze or decreased breath sounds rather than drooling. Reactive airway disease would present with wheeze and cough without the severe drooling or such high fever.