Croup - UpToDate

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Croup: Clinical features, evaluation, and diagnosis

Author: Charles R Woods, MD, MS
Section Editors: Gregory Redding, MD, Anna H Messner, MD, Sheldon L Kaplan, MD
Deputy Editor: Carrie Armsby, MD, MPH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2019. | This topic last updated: Jun 15, 2018.
INTRODUCTION
Croup is a respiratory illness characterized by inspiratory stridor, cough, and hoarseness. These
symptoms result from inflammation in the larynx and subglottic airway. A barking cough is the hallmark of
croup among infants and young children, whereas hoarseness predominates in older children and adults.
Although croup usually is a mild and self-limited illness, significant upper airway obstruction, respiratory
distress, and, rarely, death, can occur.
The clinical features, evaluation, and diagnosis of croup will be discussed here. The management of
croup is discussed separately. (See "Management of croup".)
DEFINITIONS
The term "croup" has been used to describe a range of upper respiratory conditions in children. For the
purpose of this topic review, we will use the term "croup" to refer to viral laryngotracheitis as defined
below.
Laryngotracheitis (croup) — Croup is a respiratory illness characterized by inspiratory stridor, barking

cough, and hoarseness. These symptoms result from inflammation in the larynx and subglottic airway [1].
Viral croup — Viral croup (also called classic croup) refers to the typical croup syndrome that occurs
commonly in children six months to three years of age. As the name implies, it is caused by respiratory
viruses and so viral symptoms (eg, nasal congestion, fever) are usually present. Viral croup is usually a
self-limited illness; the cough typically resolves within three days [2]. (See 'Clinical presentation' below.)
Spasmodic croup — Spasmodic croup also occurs in children six months to three years of age [1].
Spasmodic croup always occurs at night. The onset and cessation of symptoms are abrupt and the
duration of symptoms is short, often with symptoms subsiding by the time of presentation for medical
attention. Fever is typically absent, but mild upper respiratory tract symptoms (eg, coryza) may be
present. Episodes can recur within the same night and for two to four successive evenings [3]. A striking
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feature of spasmodic croup is its recurrent nature, hence the alternate descriptive term, "frequently
recurrent croup." There may be a familial predisposition to spasmodic croup, and it may be more common
in children with a family history of allergies [4]. Because there is some clinical overlap with atopic
diseases, it is sometimes referred to as "allergic croup."
Early in the clinical course, spasmodic croup may be difficult to distinguish from viral croup. As the course
progresses, the episodic nature of symptoms and relative wellness of the child between attacks
differentiate spasmodic croup from viral croup, in which the symptoms are continuous.
Although the initial presentation can be dramatic, the clinical course is usually benign. Symptoms are
almost always relieved by comforting the anxious child and administering humidified air.
Other related terms — The following conditions are related to croup, but we consider these distinct
clinical entities:
● Laryngitis – Laryngitis refers to inflammation limited to the larynx and manifests itself as hoarseness
[1]. It usually occurs in older children and adults and, similar to croup, is frequently caused by a viral
infection. The etiology, management, and evaluation of other causes of hoarseness are discussed in
detail separately. (See "Common causes of hoarseness in children" and "Hoarseness in children:
Evaluation".)
● Laryngotracheobronchitis (LTB) – LTB occurs when inflammation extends into the bronchi,
resulting in lower airway signs (eg, wheezing, crackles, air trapping, increased tachypnea) and
sometimes more severe illness than laryngotracheitis alone [1]. This term commonly is used
interchangeably with laryngotracheitis, and the entities overlap clinically. Extension of inflammation
further into the lower airways results in laryngotracheobronchopneumonitis, which can be
complicated by bacterial superinfection (ie, pneumonia).
● Bacterial tracheitis – Bacterial tracheitis (sometimes called "bacterial croup") is an invasive

exudative bacterial infection of the soft tissues of the trachea (picture 1). In some cases, there is
extension to the subglottic laryngeal structures or the upper bronchial tree. Bacterial tracheitis may
occur as a primary infection or as a complication of viral croup. With secondary infection, patients
typically present with symptoms of viral croup and then have marked worsening with high fevers,
toxic appearance, and severe respiratory distress. Bacterial tracheitis is discussed in greater detail
separately. (See "Bacterial tracheitis in children: Clinical features and diagnosis".)
ETIOLOGY
Croup is usually caused by viruses. Bacterial infection may occur secondarily, as described above.
Parainfluenza virus type 1 is the most common cause of acute laryngotracheitis, especially the fall and
winter epidemics [5-7]. Parainfluenza type 2 sometimes causes croup outbreaks, but usually with milder
disease than type 1. Parainfluenza type 3 causes sporadic cases of croup that often are more severe than
those due to types 1 and 2. In multicenter surveillance of children <5 years who were hospitalized with
febrile or acute respiratory illnesses, 43 percent of children with confirmed parainfluenza infection were

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diagnosed with croup [8]. Croup was the most common discharge diagnosis for children with confirmed
parainfluenza 1 (42 percent) and parainfluenza 2 (48 percent) infections but was only diagnosed in 11
percent of children with confirmed parainfluenza 3 infections. Compared with types 1 to 3, infection
caused by parainfluenza virus type 4 is less likely to be associated with stridor and croup in children [9].
The microbiology, pathogenesis, and epidemiology of parainfluenza infections are discussed separately.
(See "Parainfluenza viruses in children".)
A number of other viruses that typically cause lower respiratory tract disease also can cause upper
respiratory tract symptoms, including croup, as described below [7].
● Respiratory syncytial virus and adenoviruses are relatively frequent causes of croup. The
laryngotracheal component of disease is usually less significant than that of the lower airways. (See
"Respiratory syncytial virus infection: Clinical features and diagnosis", section on 'Clinical
manifestations' and "Pathogenesis, epidemiology, and clinical manifestations of adenovirus infection",
section on 'Clinical presentation'.)
● Human coronavirus NL63 (HCoV-NL63), first identified in 2004, has been implicated in croup and
other respiratory illnesses [10-12]. The prevalence of HCoV-NL63 varies geographically. (See
"Coronaviruses", section on 'Respiratory'.)
● Measles is an important cause of croup in areas where measles remains prevalent. (See "Measles:
Clinical manifestations, diagnosis, treatment, and prevention".)
● Influenza virus is a relatively uncommon cause of croup. However, children hospitalized with
influenzal croup tend to have longer hospitalization and greater risk of readmission for relapse of
laryngeal symptoms than those with parainfluenzal croup. (See "Seasonal influenza in children:
Clinical features and diagnosis", section on 'Pneumonia and respiratory tract complications'.)
● Rhinoviruses, enteroviruses (especially Coxsackie types A9, B4, and B5, and echovirus types 4, 11,
and 21), and herpes simplex virus are occasional causes of sporadic cases of croup that are usually
mild. (See "Enterovirus and parechovirus infections: Clinical features, laboratory diagnosis,
treatment, and prevention" and "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus
infections".)
● Metapneumoviruses cause primarily lower respiratory tract disease similar to RSV, but upper
respiratory tract symptoms have been described in some patients [13]. (See "Human
metapneumovirus infections".)
Croup also may be caused by bacteria. Mycoplasma pneumoniae has been associated with mild cases of
croup. In addition, secondary bacterial infection may occur in children with laryngotracheitis,
laryngotracheobronchitis, or laryngotracheobronchopneumonitis. The most common secondary bacterial
pathogens include Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus pneumoniae
[14].

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EPIDEMIOLOGY
Croup most commonly occurs in children six months to three years of age. It is seen in younger infants
(as young as three months) and in preschool children, but it is uncommon in children >6 years old [14,15].
It is more common in boys, with a male:female ratio of approximately 1.4:1 [14-17].
Family history of croup is a risk factor for croup and recurrent croup. In a case-control study, children
whose parents had a history of croup were 3.2 times as likely to have an episode of croup and 4.1 times
as likely to have recurrent croup as children with no parental history of croup [18]. Parental smoking, a
well-recognized risk factor for other respiratory tract infections in children, does not appear to increase the
risk of croup [18,19]. (See "Secondhand smoke exposure: Effects in children", section on 'Respiratory
symptoms and illness'.)
Most cases of croup occur in the fall or early winter, with the major incidence peaks coinciding with
parainfluenza type 1 activity (often in October) and minor peaks occurring during periods of respiratory
syncytial virus or influenza virus activity. (See "Respiratory syncytial virus infection: Clinical features and
diagnosis", section on 'Seasonality' and "Seasonal influenza in children: Clinical features and diagnosis",
section on 'Influenza activity'.)
Emergency department (ED) visits for croup are most frequent between 10:00 PM and 4:00 AM [20].
However, children seen for croup between noon and 6:00 PM are more likely to be admitted to the
hospital [5,21]. A morning peak between 7:00 AM and 11:00 AM in ED visits for croup also has been
noted [17].
Hospital admissions for croup have declined steadily since the late 1970s. In an analysis of data from the
National Hospital Discharge Surveys from 1979 through 1997, the estimated number of annual
hospitalizations for croup decreased from 48,900 to 33,500 [6]. Estimates of annual hospitalization rates
for croup caused by parainfluenza virus types 1 to 3 from 1994 to 1997 were 0.4 to 1.1 per 1000 children
for children younger than one year and 0.24 to 0.61 per 1000 children for children between one and four
years. Approximately one-half of these hospitalizations were attributed to parainfluenza type 1.
In a six-year (1999 to 2005) population-based study, 5.6 percent of children with a diagnosis of croup in
the ED required hospital admission. Among those discharged home, 4.4 percent had a repeat ED visit
within 48 hours [17].
PATHOGENESIS
The viruses that cause croup typically infect the nasal and pharyngeal mucosal epithelia initially and then
spread locally along the respiratory epithelium to the larynx and trachea.
The anatomic hallmark of croup is narrowing of the subglottic airway, the portion of the larynx immediately
below the vocal folds. The cricoid cartilage of the subglottis is a complete cartilaginous ring, unlike the
tracheal rings which are horseshoe shaped. Because it is a complete ring, the cricoid cannot expand,
causing significant airway narrowing whenever the subglottic mucosa becomes inflamed. In addition to

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this "fixed" obstruction, dynamic obstruction of the extrathoracic trachea below the cartilaginous ring may
occur when the child struggles, cries, or becomes agitated. The dynamic obstruction occurs as a result of
the combination of high negative pressure in the distal extrathoracic trachea and the floppiness of the
tracheal wall in children.
Laryngoscopic evaluation of patients during acute laryngotracheitis shows redness and swelling in the
area just below the vocal folds (picture 2). In severe cases, the subglottic airway may be reduced to a
diameter of 1 to 2 mm. In addition to mucosal edema and swelling, fibrinous exudates and, occasionally,
pseudomembranes can build up on the tracheal surfaces and contribute to airway narrowing. The vocal
folds and laryngeal tissues also can become swollen, and cord mobility may be impaired [1,22-24].
Autopsy studies in children with laryngotracheitis show infiltration of histiocytes, lymphocytes, plasma
cells, and neutrophils into edematous lamina propria, submucosa, and adventitia of the larynx and trachea
[25-27].
In spasmodic or recurrent croup, findings on direct laryngoscopy may demonstrate noninflammatory

edema [22]. This suggests that there is no direct viral involvement of the tracheal epithelium. In a
retrospective case series of 197 children with recurrent croup who underwent endoscopy at a single
center from 2002 to 2012, 21 percent had evidence of subglottic stenosis and 20 percent had abnormal
esophageal biopsies (including evidence of reflux esophagitis, eosinophilic esophagitis, and candidal
esophagitis) [28]. Children with subglottic stenosis tended to be younger compared with those without
(mean age 35 versus 58 months). In another case series of 103 children with recurrent croup who
underwent endoscopy at a single center from 2004 to 2013, 44 percent had a history of prior intubation,
subglottic stenosis, or a previous airway procedure [29]. Other common underlying conditions included
asthma (64 percent), gastroesophageal reflux (60 percent), and seasonal allergies (48 percent).
Endoscopy was normal in 65 percent of the children in this series; 9 percent of children had moderate to
severe findings (including subglottic stenosis, cyst, and hemangioma).
Patients with bacterial tracheitis have a bacterial superinfection that causes thick pus to develop within the
lumen of the subglottic trachea (picture 1). Ulcerations, pseudomembranes, and microabscesses of the
mucosal surface occur. The supraglottic tissues usually are normal. (See "Bacterial tracheitis in children:
Clinical features and diagnosis", section on 'Pathogenesis and pathology'.)
Host factors — Only a small fraction of children with a parainfluenza viral infection develop overt croup.
This suggests that host (or genetic) factors play a role in the pathogenesis. Host factors that may
contribute to the development of croup include functional or anatomic upper airway narrowing, variations
in immune response, and predisposition to atopy [17].
Underlying host factors that predispose to clinically significant narrowing of the upper airway include:
● Congenital anatomic narrowing of the airway, such as subglottic stenosis due to an elliptical cricoid
cartilage [30]. (See "Congenital anomalies of the larynx", section on 'Laryngeal atresia'.)
● Hyperactive airways, perhaps aggravated by atopy or gastroesophageal reflux, as suggested in some

children with spasmodic croup or recurrent croup [4,31,32].
● Acquired airway narrowing from a post-intubation subglottic cyst or stenosis, or rarely from

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respiratory tract papillomas (human papillomavirus). Subglottic hemangiomas (picture 3 and picture
4) grow in the first few months of life and the patients will typically present with symptoms mimicking
croup (ie, stridor and a barking cough). (See "Congenital anomalies of the larynx", section on 'Cysts'
and "Congenital anomalies of the larynx", section on 'Subglottic hemangiomas'.)
The potential role of the immune response was demonstrated in studies that demonstrated increased
production of parainfluenza virus-specific immunoglobulin E (IgE) and increased lymphoproliferative
response to parainfluenza virus antigen, and diminished histamine-induced suppression of lymphocyte
transformation responses to parainfluenza virus in children with parainfluenza virus and croup compared
with those with parainfluenza virus without croup [33,34].
CLINICAL PRESENTATION
Croup typically occurs in children six months to three years of age. Symptoms usually begin with nasal
discharge, congestion, and coryza and progress over 12 to 48 hours to include fever, hoarseness, barking
cough, and stridor. There is minimal, if any, pharyngitis. As airway obstruction progresses, stridor
develops, and there may be mild tachypnea with a prolonged inspiratory phase. Respiratory distress
increases as upper airway obstruction becomes more severe. Rapid progression or signs of lower airway
involvement suggests a more serious illness (eg, bacterial tracheitis or pneumonia).
The severity of upper airway obstruction is evident on physical examination, as described below (see
'Severity assessment' below). Biphasic stridor (stridor heard on both inspiration and expiration) at rest is a
sign of significant upper airway obstruction. As upper airway obstruction progresses, the child may
become restless or anxious. When airway obstruction becomes severe, suprasternal, subcostal, and
intercostal retractions may be seen. Breath sounds can be diminished. Agitation, which generally is
accompanied by increased inspiratory effort, exacerbates the subglottic narrowing by creating negative
pressure in the airway. This can lead to further respiratory distress and agitation.
Croup is usually a self-limited illness and the cough typically resolves within three days [2]. Other
symptoms may persist for seven days with a gradual return to normal [1]. Deviation from this expected
course should prompt consideration of diagnoses other than laryngotracheitis. (See 'Differential diagnosis'
below.)
EVALUATION
Overview — The evaluation of children with suspected croup is aimed at promptly identifying patients
with severe upper airway obstruction or at risk for rapid progression of upper airway obstruction and
excluding other conditions with presentations similar to croup that require specific evaluations and/or
interventions. (See 'Differential diagnosis' below.)
During the evaluation, efforts should be made to make the child as comfortable as possible. The
increased inspiratory effort that accompanies anxiety and fear in young children can exacerbate subglottic
narrowing, further diminishing air exchange and oxygenation. (See 'Pathogenesis' above.)

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Rapid assessment and initial management — Rapid assessment of general appearance (including the
presence of stridor at rest), vital signs, pulse oximetry, airway stability, and mental status is necessary to
identify children with severe respiratory distress and/or impending respiratory failure (table 1). Children
who have severe respiratory distress require immediate pharmacologic treatment (including
administration of nebulized epinephrine and systemic or nebulized corticosteroids) and respiratory
support. (See "Management of croup", section on 'Moderate to severe croup' and "Management of croup",
section on 'Respiratory care'.)
In addition, the child's hydration status should be assessed. Moderate to severe croup may be associated
with decreased oral intake and increased insensible losses from fever and tachypnea, resulting in
dehydration. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children".)
Once treatment is under way and the child is more stable, the remainder of the evaluation can proceed.
History — The history should include a description of the onset, duration, and progression of symptoms.
Factors that are associated with increased severity of illness include:
● Sudden onset of symptoms

● Rapidly progressing symptoms (ie, symptoms of upper airway obstruction after fewer than 12 hours
of illness)
● Previous episodes of croup
● Underlying abnormality of the upper airway
● Medical conditions that predispose to respiratory failure (eg, neuromuscular disorders)
Aspects of the history that are helpful in distinguishing croup from other causes of acute upper airway
obstruction include [14,35]:
● Fever – The absence of fever from onset of symptoms to the time of presentation is suggestive of
spasmodic croup or other noninfectious etiology (eg, subglottic cyst, subglottic hemangioma).
● Barking cough – The classic physical finding in a patient with subglottic narrowing is a barky seal-like
cough.
● Hoarseness – Hoarseness may be present in croup, particularly in older children, whereas

hoarseness is not a typical finding in epiglottitis or foreign body aspiration.
● Difficulty swallowing – Difficulty swallowing may occur in acute epiglottitis. Rarely, a large, ingested
foreign body may lodge in the upper esophagus, where it distorts and narrows the upper trachea,
thus mimicking the croup syndrome (including barking cough and inspiratory stridor).
● Drooling – Drooling may occur in children with peritonsillar or retropharyngeal abscesses,

retropharyngeal cellulitis, and epiglottitis. In an observational study, drooling was present in
approximately 80 percent of children with epiglottitis, but only 10 percent of those with croup [35].
● Throat pain – Complaints of dysphagia and sore throat are more common in children with epiglottitis
than croup (approximately 60 to 70 percent versus <10 percent) [35].

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The differential diagnosis of croup is discussed in greater detail below. (See 'Differential diagnosis' below.)
Examination — The objectives of the examination of the child with croup include assessment of severity
of upper airway obstruction and exclusion of other infectious and non-infectious causes of acute upper
airway obstruction, both of which are necessary in making management decisions.
The initial examination often can be accomplished by observing the child in a comfortable position with
the caretaker. Every effort should be made to measure the child's weight and vital signs.
Severity assessment — The severity of croup is determined by the presence or absence of stridor at
rest, the degree of chest wall retractions, air entry, the presence or absence of pallor or cyanosis, and the
mental status. There are a number of validated clinical scoring systems that are used to assess croup
severity. The Westley croup score has been the most extensively studied (table 1) (calculator 1) [36].
● Mild croup (Westley croup score of ≤2) − Children with mild croup have no stridor at rest (although
stridor may be present when upset or crying), a barking cough, hoarse cry, and either no, or only
mild, chest wall/subcostal retractions [14,37,38].
● Moderate croup (Westley croup score of 3 to 7) − Children with moderate croup have stridor at
rest, have at least mild retractions, and may have other symptoms or signs of respiratory distress, but
little or no agitation [14,37,38].
● Severe croup (Westley croup score of ≥8) − Children with severe croup have significant stridor at
rest, although the loudness of the stridor may decrease with worsening upper airway obstruction and
decreased air entry [14,37,38]. Retractions are severe (including indrawing of the sternum) and the
child may appear anxious, agitated, or pale and fatigued.
● Impending respiratory failure (Westley croup score of ≥12) − Croup occasionally results in
significant upper airway obstruction with impending respiratory failure, heralded by the following signs
[14,37,38]:
• Fatigue and listlessness

• Marked retractions (although retractions may decrease with increased obstruction and
decreased air entry)
• Decreased or absent breath sounds
• Depressed level of consciousness
• Tachycardia out of proportion to fever
• Cyanosis or pallor
Prompt recognition and treatment of children with severe croup are paramount. (See "Management of
croup", section on 'Moderate to severe croup'.)
Assessing for other causes — Components of the physical examination that are useful in
distinguishing croup from other causes of acute upper airway obstruction and respiratory distress include
[35,37]:
● Preferred posture – Children with epiglottitis usually prefer to sit up in the "tripod" or "sniffing position"

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(neck is mildly flexed, and head is mildly extended) (picture 5A-B).
● Quality of the voice – Children with croup may have a hoarse voice or diminished cry. A muffled "hot
potato" voice is suggestive of epiglottitis, retropharyngeal abscess, or peritonsillar abscess.
● Examination of the oropharynx for the following signs:
• Pharyngitis, typically minimal in croup, may be more pronounced in epiglottitis or laryngitis.
• Excessive salivation, suggestive of acute epiglottitis, peritonsillar abscess, parapharyngeal

abscess or retropharyngeal abscess.
• Diphtheritic membrane.
• Tonsillar asymmetry or deviation of the uvula suggestive of peritonsillar abscess.
• Midline or unilateral swelling of the posterior pharyngeal wall suggestive of retropharyngeal

abscess.
• Cherry red, swollen epiglottis, suggestive of epiglottitis.
For most patients who have a clinical picture consistent with viral croup, direct visualization of the
epiglottis is not necessary and cautious examination of the child's throat is sufficient. The approach
to diagnosing epiglottitis, including which patients should undergo attempts at direct visualization, is
discussed separately. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on
'Examining children'.)
● Examination of the cervical lymph nodes, which can be enlarged in patients with retropharyngeal or
peritonsillar abscesses.
● Lung examination – Expiratory wheezing suggests small or medium airway obstruction (eg, asthma
or bronchiolitis). Crackles (rales) suggests lower respiratory tract disease (eg, pneumonia).
● Other physical findings may be present, depending on the particular inciting virus. As an example,
rash, conjunctivitis, exudative pharyngitis, and adenopathy are suggestive of adenovirus infection.
● Otitis media (acute or with effusion) may be present as a primary viral or secondary bacterial
process.
The differential diagnosis of croup is discussed in greater detail below. (See 'Differential diagnosis' below.)
Imaging
Indications — Radiographic confirmation of acute laryngotracheitis is not required in the vast majority
of children with croup. Radiographic evaluation of the chest and/or upper trachea is indicated if the
diagnosis is in question, the course is atypical, an inhaled or swallowed foreign body is suspected
(although the majority are not radio-opaque), croup is recurrent, and/or there is a failure to respond as
expected to therapeutic interventions. (See 'Differential diagnosis' below and "Management of croup".)

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Findings — In children with croup, a posterior-anterior chest radiograph demonstrates subglottic
narrowing, commonly called the "steeple sign" (image 1). The lateral view may demonstrate
overdistention of the hypopharynx during inspiration [39] and subglottic haziness (image 2). The epiglottis
should have a normal appearance.
In contrast, the lateral radiograph in virtually all children with epiglottitis demonstrates swelling of the
epiglottis, sometimes called the "thumb sign" (image 3). (See "Epiglottitis (supraglottitis): Clinical features
and diagnosis", section on 'Radiographic features'.)
The lateral radiograph in children with bacterial tracheitis may demonstrate only nonspecific edema or
intraluminal membranes and irregularities of the tracheal wall (image 4) [40].
Laboratory studies — Laboratory studies are rarely indicated in children with croup and are of limited
diagnostic utility.
Blood tests — The white blood cell (WBC) count can be low, normal, or elevated; WBC counts
>10,000 cells/microL are common. Neutrophil or lymphocyte predominance may be present on the
differential [41,42]. A large number of band-form neutrophils is suggestive of primary or secondary
bacterial infection. Croup is not associated with any specific alterations in serum chemistries but children
with dehydration may have low serum bicarbonate and/or elevated blood urea nitrogen (BUN). (See
"Clinical assessment and diagnosis of hypovolemia (dehydration) in children", section on 'Laboratory
testing'.)
Microbiology — Confirmation of etiologic diagnosis is not necessary for most children with croup,
since croup is a self-limited illness that usually requires only symptomatic therapy. When an etiologic
diagnosis is necessary, viral culture and/or rapid diagnostic tests that detect viral antigens are performed
on secretions from the nasopharynx or throat. (See 'Etiologic diagnosis' below.)
DIAGNOSIS
Clinical diagnosis — The diagnosis of croup is clinical, based on the presence of a barking cough and
stridor, especially during a typical community epidemic of one of the causative viruses. (See 'Etiology'
above.)
Neither radiographs nor laboratory tests are necessary to make the diagnosis. However, radiographs may
be helpful in excluding other causes if the diagnosis is in question. (See 'Differential diagnosis' below.)
Etiologic diagnosis — Although not typically required in most cases of croup, identification of a specific
viral etiology may be necessary to make decisions regarding isolation for patients requiring hospitalization
or for public health/epidemiologic monitoring purposes. Testing for influenza is indicated if the results will
influence decisions regarding treatment, prophylaxis of contacts, or performance of other diagnostic tests;
laboratory confirmation should not delay the initiation of antiviral therapy for influenza when clinical and
seasonal considerations are compatible with influenza as the potential etiology of croup. (See "Seasonal
influenza in children: Prevention and treatment with antiviral drugs", section on 'Timing of treatment' and
"Seasonal influenza in children: Clinical features and diagnosis", section on 'Whom to test'.)

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Diagnosis of a specific viral etiology can be made by viral culture of secretions from the nasopharynx or
throat. Rapid tests that detect viral antigens in these secretions are commercially available for many
respiratory viruses. The diagnosis of specific viral infections is discussed in detail in individual topic
reviews:
● Parainfluenza (see "Parainfluenza viruses in children", section on 'Diagnosis')
● Influenza (see "Seasonal influenza in children: Clinical features and diagnosis", section on
'Diagnosis')
● Respiratory syncytial virus (see "Respiratory syncytial virus infection: Clinical features and diagnosis",
section on 'Laboratory confirmation')
● Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on

'Diagnostic tests of choice for different adenovirus syndromes')
● Measles (see "Measles: Clinical manifestations, diagnosis, treatment, and prevention", section on
'Diagnosis')
● Enteroviruses (see "Enterovirus and parechovirus infections: Clinical features, laboratory diagnosis,
treatment, and prevention", section on 'Laboratory diagnosis')
● Metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')
● Coronavirus (see "Coronaviruses", section on 'Diagnosis')
Multiplex tests (eg, respiratory viral panel), which simultaneously assess the presence of multiple agents
in one specimen (typically using polymerase chain reaction) are widely available [43,44].
RECURRENT CROUP
A child who has recurrent episodes of classic viral croup may have an underlying condition that
predisposes him or her to develop clinically significant narrowing of the upper airway. Recurrent episodes
of croup-like symptoms occurring outside the typical age range for "viral croup" (ie, six months to three
years) and recurrent episodes that do not appear to be simple "spasmodic croup" should raise suspicion
for airway lesions, gastroesophageal reflux or eosinophilic esophagitis, or atopic conditions [28-30,45-48].
(See 'Differential diagnosis' below.)
Children who have recurrent croup should be referred to an otolaryngologist. Radiographic evaluation,
laryngoscopy, bronchoscopy, and/or esophagoscopy may be warranted. (See 'Imaging' above and
"Assessment of stridor in children".)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of croup includes other causes of stridor and/or respiratory distress. The primary
considerations are those with acute onset, particularly those that may rapidly progress to complete upper

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airway obstruction, and those that require specific therapy. Underlying anatomic anomalies of the upper
airway also must be considered, since they may contribute to more severe disease. (See 'Host factors'
above.)
Important considerations include [14,15]:
● Acute epiglottitis – Epiglottitis, which is rare in the era of vaccination against Haemophilus
influenzae type b, is distinguished from croup by the absence of barking cough and the presence of
anxiety that is out of proportion to the degree of respiratory distress. Onset of symptoms is rapid, and
because of the associated bacteremia, the child is highly febrile, pale, toxic, and ill-appearing.
Because of the swollen epiglottis, the child will have difficulty swallowing and is often drooling. The
children usually prefer to sit up and seldom have observed cough [35]. Epiglottitis occurs infrequently,
and there is no predominant etiologic pathogen. (See "Epiglottitis (supraglottitis): Clinical features
and diagnosis".)
● Peritonsillar, parapharyngeal, or retropharyngeal abscesses – Children with deep neck space

abscesses, cellulitis of the cervical prevertebral tissues, or other painful infections of the pharynx may
present with fever, drooling, neck stiffness, lymphadenopathy, and varying degrees of toxicity. Barking
cough is usually absent. (See "Peritonsillar cellulitis and abscess", section on 'Typical presentation'.)
● Foreign body – In foreign body aspiration, there often is a history of the sudden onset of choking
and symptoms of upper airway obstruction in a previously healthy child. If an inhaled foreign body
lodges in the larynx, it will produce hoarseness and stridor. If a large foreign body is swallowed, it
may lodge in the upper esophagus, resulting in distortion of the adjacent soft extrathoracic trachea,
producing a barking cough and inspiratory stridor. Ingestion of a non-obstructive but subsequently
erosive foreign bodies such as a button battery may produce stridor more remote from the time of
ingestion that persist or recur [49]. (See "Airway foreign bodies in children" and "Foreign bodies of the
esophagus and gastrointestinal tract in children".)
● Allergic reaction or acute angioneurotic edema – Allergic reaction or acute angioneurotic edema
has rapid onset without antecedent cold symptoms or fever. The primary manifestations are swelling
of the lips and tongue, urticarial rash, dysphagia without hoarseness, and sometimes inspiratory
stridor [14,15]. There may be a history of allergy or a previous attack. (See "An overview of
angioedema: Clinical features, diagnosis, and management", section on 'Clinical features'.)
● Upper airway injury – Injury to the airway from smoke or thermal or chemical burns should be
evident from the history. The child typically does not have fever or a viral prodrome. (See "Inhalation
injury from heat, smoke, or chemical irritants".)
● Anomalies of the airway – Hoarseness and stridor caused by anomalies of the upper airway (eg,
laryngeal webs, laryngomalacia, vocal cord paralysis, congenital subglottic stenosis, subglottic
hemangioma) and laryngeal papillomas have a more chronic course with absence of fever and
symptoms of upper respiratory tract illness, unless the presentation is due to exacerbation of airway
narrowing from the impact of a concomitant viral infection. Subglottic hemangioma (picture 3 and
picture 4) should be considered in any young infant who presents with a barking cough and no other

Page 12 of 30
signs of a viral infection. Often these infants will respond temporarily to the usual treatment for croup
(steroids and nebulized epinephrine) however the symptoms will recur within a few days of
completion of treatment. (See "Assessment of stridor in children" and "Common causes of
hoarseness in children" and "Congenital anomalies of the larynx".)
● Other potential mimickers of croup – Other potential mimickers of croup include bronchogenic cyst
(which can cause airway compression) and early Guillain-Barré syndrome (involvement of the
laryngeal nerve may cause vocal cord paralysis) [50,51]. (See "Congenital anomalies of the
intrathoracic airways and tracheoesophageal fistula", section on 'Bronchogenic cyst' and "Guillain-
Barré syndrome in children: Epidemiology, clinical features, and diagnosis", section on 'Clinical
features' and "Common causes of hoarseness in children", section on 'Vocal fold paralysis'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Croup".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are
written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Croup (The Basics)")

● Beyond the Basics topic (see "Patient education: Croup in infants and children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Croup is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness
resulting from inflammation in the larynx and subglottic airway. Croup is usually caused by viruses,
most commonly parainfluenza virus type 1. Bacterial infection may occur secondarily. (See
'Definitions' above and 'Etiology' above.)
● Croup most commonly occurs in children six months to three years of age. Most cases occur in the
fall or early winter. Host factors that may contribute to the development of croup include functional or

Page 13 of 30
anatomic susceptibility to upper airway narrowing. (See 'Epidemiology' above and 'Host factors'
above.)
● Symptoms usually begin with nasal discharge, congestion, and coryza and progress over 12 to 48
hours to include fever, hoarseness, barking cough, and stridor. Respiratory distress increases as
upper airway obstruction becomes more severe. Croup is usually a self-limited illness and the cough
typically resolves within three days. (See 'Clinical presentation' above.)
● The objectives of the evaluation of the child with croup include assessment of severity (table 1)
(calculator 1) and exclusion of other causes of upper airway obstruction. Rapid assessment of
general appearance, vital signs, pulse oximetry, airway stability, and mental status are necessary to
identify children with severe respiratory distress and/or impending respiratory failure. (See
'Evaluation' above and 'Rapid assessment and initial management' above.)
● The diagnosis of croup is clinical, based upon the presence of a barking cough and stridor. Neither
radiographs nor laboratory tests are necessary to make the diagnosis. However, radiographs may be
helpful in excluding other causes if the diagnosis is in question. (See 'Diagnosis' above.)
● The differential diagnosis of croup includes other causes of stridor and/or respiratory distress. The
primary considerations are those with acute onset, particularly those that may rapidly progress to
severe upper airway obstruction, and those that require specific therapy. Important considerations
include acute epiglottitis, peritonsillar and retropharyngeal abscesses, foreign body aspiration, acute
angioneurotic edema, upper airway injury, and congenital anomalies of the upper airway. (See
'Differential diagnosis' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Tovar Padua LJ, Cherry JD. Croup (laryngitis, laryngotracheitis, spasmotic croup, laryngotracheobro
nchitis, bacterial tracheitis, and laryngotracheobranchopneumonitis) and epiglottitis (supraglottitis). I
n: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 8th Ed, Cherry JD, Harrison GJ, K
aplan SL, Steinbach WJ, Hotez PJ (Eds), Elsevier, Philadelphia 2019. p.175.
2. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in
children: systematic review. BMJ 2013; 347:f7027.
3. Cherry JD. The treatment of croup: continued controversy due to failure of recognition of historic,
ecologic, etiologic and clinical perspectives. J Pediatr 1979; 94:352.
4. Hide DW, Guyer BM. Recurrent croup. Arch Dis Child 1985; 60:585.
5. Peltola V, Heikkinen T, Ruuskanen O. Clinical courses of croup caused by influenza and

parainfluenza viruses. Pediatr Infect Dis J 2002; 21:76.

Page 14 of 30
6. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations
among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
7. Rihkanen H, Rönkkö E, Nieminen T, et al. Respiratory viruses in laryngeal croup of young children. J
Pediatr 2008; 152:661.
8. Weinberg GA, Hall CB, Iwane MK, et al. Parainfluenza virus infection of young children: estimates of
the population-based burden of hospitalization. J Pediatr 2009; 154:694.
9. Frost HM, Robinson CC, Dominguez SR. Epidemiology and clinical presentation of parainfluenza
type 4 in children: a 3-year comparative study to parainfluenza types 1-3. J Infect Dis 2014;
209:695.
10. Kuypers J, Martin ET, Heugel J, et al. Clinical disease in children associated with newly described
coronavirus subtypes. Pediatrics 2007; 119:e70.
11. Sung JY, Lee HJ, Eun BW, et al. Role of human coronavirus NL63 in hospitalized children with
croup. Pediatr Infect Dis J 2010; 29:822.
12. van der Hoek L, Sure K, Ihorst G, et al. Croup is associated with the novel coronavirus NL63. PLoS
Med 2005; 2:e240.
13. Døllner H, Risnes K, Radtke A, Nordbø SA. Outbreak of human metapneumovirus infection in
norwegian children. Pediatr Infect Dis J 2004; 23:436.
14. Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
15. Bjornson CL, Johnson DW. Croup. Lancet 2008; 371:329.
16. Segal AO, Crighton EJ, Moineddin R, et al. Croup hospitalizations in Ontario: a 14-year time-series
analysis. Pediatrics 2005; 116:51.
17. Rosychuk RJ, Klassen TP, Metes D, et al. Croup presentations to emergency departments in
Alberta, Canada: a large population-based study. Pediatr Pulmonol 2010; 45:83.
18. Pruikkonen H, Dunder T, Renko M, et al. Risk factors for croup in children with recurrent respiratory
infections: a case-control study. Paediatr Perinat Epidemiol 2009; 23:153.
19. Salzman MB, Filler HF, Schechter CB. Passive smoking and croup. Arch Otolaryngol Head Neck
Surg 1987; 113:866.
20. Lee DR, Lee CH, Won YK, et al. Clinical characteristics of children and adolescents with croup and
epiglottitis who visited 146 Emergency Departments in Korea. Korean J Pediatr 2015; 58:380.
21. Marx A, Török TJ, Holman RC, et al. Pediatric hospitalizations for croup (laryngotracheobronchitis):
biennial increases associated with human parainfluenza virus 1 epidemics. J Infect Dis 1997;
176:1423.
22. DAVISON FW. Acute laryngeal obstruction in children. J Am Med Assoc 1959; 171:1301.

Page 15 of 30
23. Davison FW. Acute obstructive laryngitis in children. Penn Med J 1950; 53:250.
24. Szpunar J, Glowacki J, Laskowski A, Miszke A. Fibrinous laryngotracheobronchitis in children. Arch

Otolaryngol 1971; 93:173.
25. MORGAN EA, WISHART DE. Laryngotracheo-bronchitis (a statistical review of 549 cases). Can
Med Assoc J 1947; 56:8.
26. Orton HB, Smith EL, Bell HO, et al. Acute laryngotracheobronchitis: analysis of sixty-two cases with
report of autopsies in eight cases. Arch Otolaryngol 1941; 33:926.
27. Richards L. A further study of the pathology of acute laryngo-tracheobronchitis in children. Ann Otol
Rhinol Laryngol 1938; 47:326.
28. Hodnett BL, Simons JP, Riera KM, et al. Objective endoscopic findings in patients with recurrent
croup: 10-year retrospective analysis. Int J Pediatr Otorhinolaryngol 2015; 79:2343.
29. Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup.
Otolaryngol Head Neck Surg 2015; 152:159.
30. Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: association with airway lesions, atopy,
and esophagitis. Otolaryngol Head Neck Surg 2012; 147:209.
31. Van Bever HP, Wieringa MH, Weyler JJ, et al. Croup and recurrent croup: their association with
asthma and allergy. An epidemiological study on 5-8-year-old children. Eur J Pediatr 1999; 158:253.
32. Gilger MA. Pediatric otolaryngologic manifestations of gastroesophageal reflux disease. Curr
Gastroenterol Rep 2003; 5:247.
33. Welliver RC, Sun M, Rinaldo D. Defective regulation of immune responses in croup due to
parainfluenza virus. Pediatr Res 1985; 19:716.
34. Welliver RC, Wong DT, Middleton E Jr, et al. Role of parainfluenza virus-specific IgE in pathogenesis
of croup and wheezing subsequent to infection. J Pediatr 1982; 101:889.
35. Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child
Health 2011; 47:77.
36. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of
croup: a double-blind study. Am J Dis Child 1978; 132:484.
37. Alberta Clinical Practice Guidelines Guideline Working Group. Guidelines for the diagnosis and man
agement of croup. www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on Mar
ch 13, 2015).
38. Clarke M, Allaire J. An evidence-based approach to the evaluation and treatment of croup in
children. Pediatr Emerg Med Pract 2012; 9:1.
39. Mills JL, Spackman TJ, Borns P, et al. The usefulness of lateral neck roentgenograms in
Page 16 of 30
laryngotracheobronchitis. Am J Dis Child 1979; 133:1140.
40. Bernstein T, Brilli R, Jacobs B. Is bacterial tracheitis changing? A 14-month experience in a pediatric
intensive care unit. Clin Infect Dis 1998; 27:458.
41. Cherry JD. Newer respiratory viruses: their role in respiratory illnesses of children. In: Advances in P
ediatrics, Vol 20, Schulman I (Ed), Mosby Year Book, Chicago 1973. p.225.
42. Denny FW, Clyde WA Jr. Acute lower respiratory tract infections in nonhospitalized children. J
Pediatr 1986; 108:635.
43. McCulloh RJ, Andrea S, Reinert S, Chapin K. Potential Utility of Multiplex Amplification Respiratory
Viral Panel Testing in the Management of Acute Respiratory Infection in Children: A Retrospective
Analysis. J Pediatric Infect Dis Soc 2014; 3:146.
44. Couturier MR, Barney T, Alger G, et al. Evaluation of the FilmArray® Respiratory Panel for clinical
use in a large children's hospital. J Clin Lab Anal 2013; 27:148.
45. Duval M, Tarasidis G, Grimmer JF, et al. Role of operative airway evaluation in children with
recurrent croup: a retrospective cohort study. Clin Otolaryngol 2015; 40:227.
46. Rankin I, Wang SM, Waters A, et al. The management of recurrent croup in children. J Laryngol Otol
2013; 127:494.
47. Jabbour N, Parker NP, Finkelstein M, et al. Incidence of operative endoscopy findings in recurrent
croup. Otolaryngol Head Neck Surg 2011; 144:596.
48. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol
Rhinol Laryngol 2009; 118:495.
49. Gohil R, Culshaw J, Jackson P, Singh S. Accidental button battery ingestion presenting as croup. J
Laryngol Otol 2014; 128:292.
50. Lin CY, Chi H, Shih SL, et al. A 4-year-old boy presenting with recurrent croup. Eur J Pediatr 2010;
169:249.
51. Hsia SH, Lin JJ, Wu CT, et al. Guillain-Barré syndrome presenting as mimicking croup. Am J Emerg
Med 2010; 28:749.e1.
Topic 6002 Version 28.0

Page 17 of 30
GRAPHICS
Bacterial tracheitis: Tracheobronchoscopy
Note the adherent mucopurulent membranes within the trachea.
Courtesy of Glenn C Isaacson, MD, FAAP.
Graphic 55364 Version 5.0

Page 18 of 30
Laryngoscopy in a child with croup
(Panel A) Endoscopic view of the larynx and subglottic airway seen from above the vocal cords in a
child with viral croup. The vocal cords are swollen, there is marked subglottic swelling (arrow), and the
opening of subglottic airway is narrow.
(Panel B) Endoscopic image of a normal pediatric larynx.
VC: vocal cord.
Courtesy of Glenn C Isaacson, MD, FAAP.

Page 19 of 30
Subglottic hemangioma in a young child
(Panel A) Subglottic hemangioma (arrow) seen from above the vocal cords. There is near complete obstruction of the
subglottic airway.
(Panel B) Normal pediatric larynx.
AC: arytenoid cartilage; AF: aryepiglottic fold; E: epiglottis; VC: vocal cord.
(Panel A) Courtesy of Anna Messner, MD.

(Panel B) Reproduced with permission from: Nagdev A. Airway, breathing, circulation: Normal airway. In: Greenberg's Text-Atlas of
Emergency Medicine, Greenberg MI, Hendrickson RG, Silverberg M, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2005.
Copyright © 2005 Lippincott Williams & Wilkins. www.lww.com.

Page 20 of 30
Endoscopic view of subglottic hemangioma
Note the red-blue sessile lesion in the posterolateral subglottis.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.

Page 21 of 30
Westley croup severity score
Clinical feature Assigned score Score Severity Description Management
Level of consciousness Normal, including sleep = 0 ≤2 Mild Occasional Home treatment:

barky cough, Symptomatic
Disoriented = 5
no stridor at care including
Cyanosis None = 0 rest, mild or no antipyretics,
With agitation = 4 retractions mist, and oral
fluids
At rest = 5
Outpatient
Stridor None = 0
treatment:
With agitation = 1 Single dose of
At rest = 2 oral
dexamethasone *
Air entry Normal = 0 0.15 to 0.6
Decreased = 1 mg/kg
(maximum 16
Markedly decreased = 2
mg) or oral
Retractions None = 0 prednisolone (1
Mild = 1 mg/kg)
Moderate = 2 3 to 7 Moderate Frequent barky Single dose of

cough, stridor oral
Severe = 3
at rest, and dexamethasone
mild to 0.6 mg/kg
moderate (maximum 16
retractions, but mg)*
no or little
Nebulized
distress or
epinephrine ¶
agitation
Hospitalization is
generally not
needed, but may
be warranted for
persistent or
worsening
symptoms after
treatment with
glucocorticoid
and nebulized
epinephrine
8 to 11 Severe Frequent barky Single dose of

cough, stridor oral/IM/IV
at rest, marked dexamethasone
retractions, 0.6 mg/kg
significant (maximum 16
distress and mg)*
agitation Repeated doses
of nebulized
epinephrine ¶
may be needed
Inpatient
admission is
generally
required unless
marked
improvement
occurs after
treatment with
glucocorticoid
and nebulized
epinephrine
≥12 Impending Depressed Single dose of

respiratory level of IM/IV
failure consciousness, dexamethasone
stridor at rest, 0.6 mg/kg

Page 22 of 30
severe (maximum 16
retractions, mg)
poor air entry, Repeated doses
cyanosis or of nebulized
pallor
epinephrine ¶
may be needed
Intensive care
unit admission is
generally
required
Consultation with
anesthesiologist
or ENT surgeon
may be
warranted to
arrange for
intubation in a
controlled setting
IV: Intravenous; IM: intramuscular; ENT: ear, nose, throat.

* The intravenous preparation of dexamethasone (4 mg per mL) can be given orally; mix with flavored syrup.
¶ Nebulized epinephrine has an onset of effect within 10 minutes. Nebulized racemic epinephrine is administered as 0.05 mL/kg
per dose (maximum of 0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline. Racemic epinephrine is
commercially available in the United States and some other countries as a nebulizer preparation (ie, single-use preservative-free
bullets [ampules]). Nebulized L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1 mg/mL (1:1000)
preservative-free solution. L-epinephrine is the same type of epinephrine used in other medical indications (eg, IM injection for
anaphylaxis) and is widely available as a parenteral preparation. Use of either product by nebulization is acceptable and may be
determined by availability and institutional protocol. Refer to topic for detail.
References:
1. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind
study. Am J Dis Child 1978; 132:484.
2. Toward Optimized Practice (TOP) Working Group for Croup. Guidelines for the diagnosis and management of croup
(revised 2008). Available at www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on March 13, 2015).
3. Clarke M, Allaire J. An evidence-based approach to the evaluation and treatment of croup in children. Pediatric Emergency
Medicine Practice 2012; 9:1.

Page 23 of 30
Epiglottitis: Tripod posture
This child's "tripod" positioning (trunk leaning forward, neck hyperextended,

chin thrust forward) is caused by epiglottitis and represents the patient's
attempt to maximize the patency of a significantly obstructed upper airway.
Also, note the child's toxic appearance.
Tripod positioning may also be seen in other causes of respiratory

distress, such as severe asthma.
Reproduced with permission from: M Douglas Baker, MD.

Page 24 of 30
Child with classic presentation of acute epiglottitis
This 4-year-old girl has epiglottitis caused by Haemophilus influenzae type b.

(A) She prefers to sit and appears anxious.
(B) The child assumes the characteristic sniffing position to maximize the
patency of her airway.
Reproduced with permission from: Fleisher GR, Ludwig W, Baskin MN. Atlas of
Pediatric Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2004.
Copyright © 2004 Lippincott Williams & Wilkins.

Page 25 of 30
Croup: Anteroposterior radiograph with "steeple sign"
The anteroposterior (AP) view demonstrates tapering of the upper trachea,

known as the "steeple sign" of croup. Note that the finding can be simulated
by differing phases of respiration even in normal children.
Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

Page 26 of 30
Lateral neck radiograph of a child with croup
Lateral neck radiograph showing subglottic narrowing (arrow) and distended

hypopharynx (arrowheads) consistent with acute laryngotracheitis.
Courtesy of Joe Black, Diagnostic Imaging, Texas Children's Hospital.

Page 27 of 30
Epiglottitis: Lateral radiograph
Lateral neck radiograph demonstrating swollen epiglottis (arrow) and

aryepiglottic folds (asterisks) in a child with epiglottitis due to Haemophilus
influenzae type b. The swollen epiglottis is often called a "thumb sign."
Courtesy of Evelyn Y Anthony, MD, Wake Forest University School of Medicine.

Page 28 of 30
Bacterial tracheitis: Lateral neck radiograph
Lateral neck radiograph showing intraluminal membranes and tracheal wall

irregularity consistent with bacterial tracheitis.
Courtesy of R Paul Guillerman, MD, Department of Radiology, Baylor College of

Medicine.

Page 29 of 30
Contributor Disclosures
Charles R Woods, MD, MS Nothing to disclose Gregory Redding, MD Nothing to disclose Anna H Messner,
MD Nothing to disclose Sheldon L Kaplan, MD Grant/Research/Clinical Trial Support: Pfizer [Streptococcus
pneumoniae (PCV13, linezolid)]; Merck [Staphylococcus aureus (Tedizolid)]; MeMed Diagnostics [Bacterial and viral
infections]. Consultant/Advisory Board: Pfizer [Staphylococcus aureus]. Other Financial Interest: Pfizer [Speaker on
PCV13, linezolid]; Medscape [Video discussion on bacterial meningitis]; Elsevier [Co-editor (Feigin and Cherry Textbook
of Pediatric Infectious Diseases)]. Carrie Armsby, MD, MPH Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy

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Croup: Clinical features, evaluation, and diagnosis

Laryngotracheitis (croup) — Croup is a respiratory illness characterized by inspiratory stridor, barking

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● Bacterial tracheitis – Bacterial tracheitis (sometimes called "bacterial croup") is an invasive

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In spasmodic or recurrent croup, findings on direct laryngoscopy may demonstrate noninflammatory

● Hyperactive airways, perhaps aggravated by atopy or gastroesophageal reflux, as suggested in some

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● Sudden onset of symptoms

● Hoarseness – Hoarseness may be present in croup, particularly in older children, whereas

● Drooling – Drooling may occur in children with peritonsillar or retropharyngeal abscesses,

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• Fatigue and listlessness

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● Examination of the oropharynx for the following signs:

• Pharyngitis, typically minimal in croup, may be more pronounced in epiglottitis or laryngitis.

• Excessive salivation, suggestive of acute epiglottitis, peritonsillar abscess, parapharyngeal

• Tonsillar asymmetry or deviation of the uvula suggestive of peritonsillar abscess.

• Midline or unilateral swelling of the posterior pharyngeal wall suggestive of retropharyngeal

• Cherry red, swollen epiglottis, suggestive of epiglottitis.

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● Parainfluenza (see "Parainfluenza viruses in children", section on 'Diagnosis')

● Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on

● Metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')

● Coronavirus (see "Coronaviruses", section on 'Diagnosis')

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Important considerations include [14,15]:

● Peritonsillar, parapharyngeal, or retropharyngeal abscesses – Children with deep neck space

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SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Croup (The Basics)")

SUMMARY AND RECOMMENDATIONS

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Use of UpToDate is subject to the Subscription and License Agreement.

5. Peltola V, Heikkinen T, Ruuskanen O. Clinical courses of croup caused by influenza and

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15. Bjornson CL, Johnson DW. Croup. Lancet 2008; 371:329.

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24. Szpunar J, Glowacki J, Laskowski A, Miszke A. Fibrinous laryngotracheobronchitis in children. Arch

Topic 6002 Version 28.0

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Bacterial tracheitis: Tracheobronchoscopy

Note the adherent mucopurulent membranes within the trachea.

Courtesy of Glenn C Isaacson, MD, FAAP.

Graphic 55364 Version 5.0

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VC: vocal cord.

Courtesy of Glenn C Isaacson, MD, FAAP.

Graphic 108046 Version 1.0

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(Panel A) Courtesy of Anna Messner, MD.

Graphic 108045 Version 2.0

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Note the red-blue sessile lesion in the posterolateral subglottis.

Courtesy of Glenn C Isaacson, MD, FAAP, FACS.

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