A 3-year-old boy is brought to the emergency department due to a sore throat. The boy woke up with the sore throat this morning and has refused to eat. His mother gave him acetaminophen, but it did not relieve his pain. Temperature is 38.7 C (101.7 F) and respirations are 28/min. The patient is sitting still on his mother's lap and appears scared. He has a hoarse voice, rhinorrhea, and mild stridor. Tympanic membranes are clear bilaterally. Examination of the posterior pharynx shows no erythema or tonsillar exudate. The anterior neck is tender to palpation. Lung examination reveals transmitted upper airway sounds that are equal bilaterally without crackles or wheezes. Lateral neck x-ray is shown below: Which of the following is the most likely diagnosis in this patient?

Question

A 3-year-old boy is brought to the emergency department due to a sore throat.  The boy woke up with the sore throat this morning and has refused to eat.  His mother gave him acetaminophen, but it did not relieve his pain.  Temperature is 38.7 C (101.7 F) and respirations are 28/min.  The patient is sitting still on his mother's lap and appears scared.  He has a hoarse voice, rhinorrhea, and mild stridor.  Tympanic membranes are clear bilaterally.  Examination of the posterior pharynx shows no erythema or tonsillar exudate.  The anterior neck is tender to palpation.  Lung examination reveals transmitted upper airway sounds that are equal bilaterally without crackles or wheezes.  Lateral neck x-ray is shown below:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d653_dd30_bc81_23cf30fdf7b9_MD0003_00 Epiglottitis is a rare, potentially fatal infection that presents with acute onset of fever, sore throat, and signs of upper airway obstruction (eg, stridor, drooling). Symptoms often develop over hours without a notable prodrome, as seen in this patient. Impending signs of respiratory failure include anxiety, worsening stridor, and a muffled/hoarse, "hot potato" voice. Patients may display tripod positioning (leaning forward, neck hyperextension) to maximize airway diameter. The anterior neck near the hyoid bone may be tender, and oropharyngeal examination is typically normal other than pooled oral secretions. tripod positioning X-ray is not required for diagnosis if clinical suspicion is high, but lateral view shows an enlarged epiglottis, suggestive of edema. Diagnosis is confirmed via direct visualization of an edematous epiglottis. However, detailed oropharyngeal examination is often deferred in children due to risk of laryngospasm from provoked aggravation. Direct laryngoscopy during intubation (a controlled setting to secure the airway) is often preferred for diagnosis and management. (Choices A and B) Bacterial tracheitis presents with fever, stridor, and respiratory distress. Croup presents with a "barky" cough, hoarseness, stridor, and fever. In both conditions, onset is gradual (over days), and neck x-ray (posterioanterior view) reveals subglottic narrowing (eg, steeple sign) and a normal epiglottis. This patient has a thickened epiglottis on x-ray, a finding consistent only with epiglottitis. steeple sign (Choice D) Foreign body aspiration most commonly presents with acute onset of wheezing, stridor, and/or respiratory distress without fever. X-ray may reveal a foreign body if the object is radiopaque (eg, coin). Examination typically shows unilateral wheezing or asymmetric breath sounds, neither of which are found in this case. (Choice E) Peritonsillar abscess is most common in older children and adolescents; it presents with gradual onset of fever, muffled voice, and unilateral tonsillar swelling with uvular deviation. This patient's age, normal oropharyngeal examination, and acute symptom onset make this diagnosis unlikely. (Choice F) Retropharyngeal abscess presents with fever, dysphagia, drooling, stridor, and a stiff neck in young children. Examination reveals swelling of the posterior pharyngeal wall (not seen in this case), and x-ray shows widening of the retropharyngeal space, not a thickened epiglottis. Retropharyngeal abscess Educational objective: Epiglottitis is a rare but potentially fatal infection that presents with acute onset of fever, sore throat, and signs of upper airway obstruction (eg, stridor, drooling). Plain x-rays may help confirm the diagnosis by revealing an enlarged epiglottis (thumb sign). References: Epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/28613691)

A 3-Year-Old Boy Is Brought to the Emergency Department Due