Epiglottitis typically presents with a rapid onset of symptoms that progressively worsen over hours. The classic signs include high fever, severe sore throat, drooling, difficulty swallowing, a muffled "hot potato" voice, and inspiratory stridor, often summarized as the four Ds: drooling, dysphagia, dysphonia, and distress. A barking cough is characteristically absent, which helps distinguish epiglottitis from croup. Patients often exhibit a characteristic "tripod position" (sitting forward with their hands on their knees and chin thrust forward), which helps to maximize airway patency. In young children, increased agitation, reluctance to lie down, and muffled speech are common signs. Importantly, agitation and anxiety can exacerbate symptoms, leading to quicker airway obstruction, so patients must be kept calm to avoid worsening the condition.
The rapid progression of symptoms means that any delay in securing the airway can have fatal consequences. The most alarming feature is the risk of complete airway obstruction, which can occur without warning. Therefore, once epiglottitis is suspected, the patient should not undergo any invasive airway assessments, such as oral exams or endoscopy in a non-controlled setting, as these could provoke laryngospasm or exacerbate airway swelling. Similarly, unnecessary movement, including transport to radiology, should be avoided unless absolutely essential for diagnosis or treatment planning.
When imaging is obtained in a stable patient, a lateral neck radiograph shows the swollen epiglottis as the classic "thumb sign" (thumbprint sign), often with thickened aryepiglottic folds and loss of the vallecular air space; croup, by contrast, produces subglottic narrowing seen as the "steeple sign" on an anteroposterior film. Imaging must never delay airway management, and the definitive diagnosis is made by direct visualization of a swollen, cherry-red epiglottis in a controlled setting.
