Croup - Clinical Features, Evaluation, and Diagnosis - UpToDate

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Croup: Clinical features, evaluation, and diagnosis

Author: Charles R Woods, MD, MS
Section Editors: Anna H Messner, MD, Sheldon L Kaplan, MD, Joshua Nagler, MD, MHPEd
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: Dec 2022. | This topic last updated: Jan 13, 2023.
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. 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.)
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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 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.
Over time, 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.
Recurrent episodes of croup also are labeled "atypical croup" or "recurrent croup," with
varying definitions and etiologic considerations [5]. (See 'Recurrent croup' below.)
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. Laryngitis is discussed separately. (See "Common
causes of hoarseness in children", section on 'Laryngitis'.)
● Laryngotracheobronchitis – Laryngotracheobronchitis 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
● Viral causes – Croup is usually caused by viruses [6]:
• Parainfluenza viruses – Parainfluenza virus type 1 is the most common cause of

acute laryngotracheitis, especially during fall and winter epidemics [6-8].
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 diagnosed with
croup [9]. 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 [10,11].The
microbiology, pathogenesis, and epidemiology of parainfluenza infections are
discussed separately. (See "Parainfluenza viruses in children".)
• Respiratory syncytial virus (RSV) and adenoviruses – RSV 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'.)
• Influenza – 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'.)
• Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – The SARS-CoV-2

virus has been reported to cause croup in case series and case reports [12-15].
Croup was an uncommon manifestation of earlier variants but may be more
common with the Omicron variant [14-16]. Some studies have reported more severe
symptoms and/or poor response to treatment in children with croup caused by
SARS-CoV-2 compared with other viral etiologies [12,14]. However, in the largest
case series (n = 75 children), most patients (88 percent) responded well to standard
croup treatments and were discharged from the emergency department [15]. (See
"COVID-19: Clinical manifestations and diagnosis in children".)
• Other human coronaviruses – HCoV-NL63 has been associated with croup and
other respiratory illnesses in children [17-20], as have human coronaviruses OC43
HKU1 [21]. (See "Coronaviruses", section on 'Respiratory syndromes'.)
• Measles – Measles is an important cause of croup in areas where measles remains

prevalent. (See "Measles: Clinical manifestations, diagnosis, treatment, and
prevention".)
• Others – 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 [22].
(See "Human metapneumovirus infections".)
● Bacterial infection – Croup is rarely caused by bacterial infection with the exception of
Mycoplasma pneumoniae, which can cause a mild croup-like illness [23]. (See
"Mycoplasma pneumoniae infection in children", section on 'Other respiratory
manifestations'.)
However, bacterial infection may occur secondarily. The most common bacterial
pathogens in this setting include Staphylococcus aureus, Streptococcus pyogenes, and
Streptococcus pneumoniae [24]. This is discussed in detail separately. (See "Bacterial
tracheitis in children: Clinical features and diagnosis".)
EPIDEMIOLOGY
Croup is one of the most common respiratory illnesses in young children. It occurs mostly in
children ≤6 years old, with a peak incidence between six months to three years of age; it is
uncommon in children >6 years old [24,25]. A study of emergency department (ED) visits in
the United States from 2007 to 2014 estimated that there were approximately 350,000 to
400,000 croup-related ED visits each year, accounting for 1.3 percent of all ED visits [26].
Children <2 years old accounted for 43 percent of the visits, children ages two to seven years
made up 50 percent of visits, and children ≥7 accounted for only 7 percent. Croup is more
common in boys, with reported male:female ratios ranging from 1.4:1 to 2:1 [24-28].
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 [29]. Parental smoking, a well-recognized risk factor for other respiratory tract
infections in children, does not appear to increase the risk of croup [29,30]. (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 "Seasonal
influenza in children: Clinical features and diagnosis", section on 'Influenza activity' and
"Respiratory syncytial virus infection: Clinical features and diagnosis", section on
'Epidemiology'.)
ED visits for croup are most frequent between 10:00 PM and 4:00 AM [31]. However, children
seen for croup between noon and 6:00 PM are more likely to be admitted to the hospital
[7,32]. A morning peak between 7:00 AM and 11:00 AM in ED visits for croup also has been
noted [28].
Hospital admissions for croup have declined steadily since the late 1970s [8]. 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 [28].
PATHOGENESIS
Pathology
● Viral croup – 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 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 is rarely necessary for patients with viral croup, but, when
performed, it typically 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 [1,33-35]. 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 [36-38].
● Spasmodic or recurrent croup – In spasmodic or recurrent croup, findings on direct

laryngoscopy may demonstrate noninflammatory edema, suggesting that there is no
direct viral involvement of the tracheal epithelium in children with this presentation
[33]. 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) [39]. 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 previous airway procedure [40]. Other common
underlying conditions included asthma (64 percent), gastroesophageal reflux disease
(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).
Though a causal relationship between gastroesophageal reflux disease and recurrent

croup has been postulated, the evidence to support this is limited. A systematic review
of observational studies found that a temporal association between treatment with
antireflux medication and reduction of croup symptoms was often reported; however,
the retrospective nature of the data and lack of control group made it difficult to draw
conclusions about causality [41].
● Bacterial tracheitis – 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. This clinical entity is
discussed in greater detail separately. (See "Bacterial tracheitis in children: Clinical
features and diagnosis", section on 'Pathogenesis and pathology'.)
Host factors — Only a small subset 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 [28].
Underlying host factors that predispose to clinically significant narrowing of the upper
airway include:
● Congenital anatomic narrowing of the airway, such as subglottic stenosis [42]. (See
"Congenital anomalies of the larynx", section on 'Congenital subglottic stenosis'.)
● Hyperactive airways, perhaps aggravated by atopy or gastroesophageal reflux, as

suggested in some children with spasmodic croup or recurrent croup [4,43,44].
● Acquired airway narrowing from a postintubation subglottic cyst or stenosis or, rarely,
from 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 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 illustrated in studies that demonstrated
increased production of parainfluenza virus-specific immunoglobulin E (IgE) and increased
lymphoproliferative response to parainfluenza virus antigen as well as 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 [45,46].
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 concurrent 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). In patients with croup, 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 those 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.)
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, as
indicated. (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 underway 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 [24,47]:
● Fever – The absence of fever from onset of symptoms to the time of presentation is
suggestive of spasmodic croup or other noninfectious etiology of stridor (eg, subglottic
cyst, subglottic hemangioma, foreign body aspiration).
● 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 more commonly occurs 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 [47].
● Throat pain – Complaints of dysphagia and sore throat are more common in children
with epiglottitis than croup (approximately 60 to 70 versus <10 percent) [47].
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

noninfectious 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, degree of chest wall retractions, air entry, presence or absence of pallor or
cyanosis, and 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) [48].
● Mild croup (Westley croup score ≤2) – Children with mild croup have a barking cough,
hoarse cry, no stridor at rest (although stridor may be present when upset or crying),
and either no or only mild chest wall/subcostal retractions [24,49,50].
● Moderate croup (Westley croup score 3 to 7) – Children with moderate croup have
stridor at rest. They have at least mild retractions and may have other symptoms or
signs of respiratory distress but little or no agitation [24,49,50].
● Severe croup (Westley croup score ≥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 [24,49,50]. 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 ≥12) – Croup occasionally results
in significant upper airway obstruction with impending respiratory failure, heralded by
the following signs [24,49,50]:
• 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
Croup clinical scores are widely used in clinical practice and in studies evaluating the efficacy
of different treatments for croup. However, it is important to understand that these scores
are somewhat subjective and there can be substantial interobserver variability [51,52].
Alternative objective methods have been proposed as potentially more reliable measures of
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croup severity (eg, methods for quantitatively measuring pulsus paradoxus) [53,54].
Additional data are needed to validate these quantitative methods and demonstrate that
they perform better than croup scores before they can replace them in clinical practice. In
the meantime, the Westley croup score remains a useful guide for assessing severity of
illness and responses to therapies.
Prompt recognition and treatment of children with severe croup are paramount, as
discussed separately. (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 [47,49]:
● Preferred posture – Children with epiglottitis usually prefer to sit up in the "tripod" or
"sniffing position" (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 'Signs of
impending airway obstruction'.)
● 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.)
Radiographs
● 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 course is atypical and/or the diagnosis is in question

• The child has severe symptoms and does not respond as expected to therapeutic
interventions
• There is suspicion for an inhaled or swallowed foreign body (although the majority
are not radiopaque) (see "Airway foreign bodies in children")
• The child has recurrent episodes of croup and has not previously had an airway
evaluation (see 'Recurrent croup' below)
● Findings – In children with croup, a posterior-anterior chest radiograph demonstrates

subglottic narrowing, commonly called the "steeple sign" ( image 1A). The lateral
view may demonstrate overdistention of the hypopharynx during inspiration and
subglottic haziness ( image 1B) [55]. The epiglottis should have a normal
appearance.
In one study, greater degrees of narrowing of the trachea on a frontal or lateral plain
radiograph correlated with increased likelihood of hospitalization and longer hospital stay
[56].
Laboratory studies — Laboratory studies are rarely indicated in children with croup and are
of limited diagnostic utility.
Blood tests — The white blood cell count can be low, normal, or elevated; white blood cell
counts >10,000 cells/microL are common. Neutrophil or lymphocyte predominance may be
present on the differential [57,58]. 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. (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.
However, identification of a specific viral etiology may be necessary to make decisions
regarding isolation. When an etiologic diagnosis is necessary, rapid diagnostic tests are
performed on secretions from the nasopharynx, as discussed below. (See 'Etiologic
diagnosis' below.)
DIAGNOSIS
Clinical diagnosis — Croup is diagnosed clinically, based upon the characteristic 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. In
particular, SARS-CoV-2 testing may be appropriate given the infection control and quarantine
implications. (See "COVID-19: Diagnosis" and "COVID-19: Infection prevention for persons
with SARS-CoV-2 infection".)
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: Management", section on 'Timing' and "Seasonal influenza
in children: Clinical features and diagnosis", section on 'Whom to test'.)
Diagnosis of a specific viral etiology can be made with rapid polymerase chain reaction (PCR),
rapid antigen testing, or viral culture of secretions from the nasopharynx. Multiplex tests (eg,
respiratory viral panel), which simultaneously assess the presence of multiple agents in one
specimen (typically using PCR), are widely available [59,60]. 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')
● Coronavirus (all types) (see "Coronaviruses", section on 'Diagnosis' and "COVID-19:

Clinical manifestations and diagnosis in children", section on 'Laboratory tests for SARS-
CoV-2')
● Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section

on 'Diagnostic tests of choice for different adenovirus syndromes')
● Metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')
● 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')
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 of 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 [39,40,42,61-64]. (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
'Radiographs' above and "Assessment of stridor in children".)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of croup includes other causes of stridor and/or respiratory
distress. (See "Assessment of stridor in children", section on 'Causes of stridor'.)

The primary considerations are those with acute onset (particularly those that may rapidly
progress to complete upper 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 ( table 2 and table 3) [24,25]:
● 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 usually rapid, and when accompanied by 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 [47]. The lateral
radiograph in virtually all children with epiglottitis demonstrates swelling of the
epiglottis, sometimes called the "thumb sign" ( image 2). (See "Epiglottitis
(supraglottitis): Clinical features and diagnosis".)
● Bacterial tracheitis – Bacterial tracheitis (sometimes called "bacterial croup") is an

invasive exudative bacterial infection of the soft tissues of the trachea. It 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. The
lateral radiograph in children with bacterial tracheitis may demonstrate only
nonspecific edema or intraluminal membranes and irregularities of the tracheal wall
( image 3) [65]. (See "Bacterial tracheitis in children: 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 and stridor are
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 and producing a barking cough
and inspiratory stridor. Ingestion of a nonobstructive but subsequently erosive foreign
bodies such as a button battery may produce stridor more remote from the time of

ingestion that persists or recurs [66]. (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 [24,25]. 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 – Stridor can be caused by congenital or acquired anomalies

of the upper airway ( table 2 and table 3), including laryngeal webs,
laryngomalacia, congenital subglottic stenosis, subglottic hemangioma, bronchogenic
cyst, laryngeal papillomas, and vocal cord paralysis (which can be secondary to
laryngeal nerve injury from trauma or surgery or due to neurologic disease [eg,
Guillain-Barré syndrome, brain or spinal cord tumor]). Most of these tend to have a
more chronic course with absence of fever and symptoms of upper respiratory tract
illness, unless the child presents because the airway narrowing is exacerbated by 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 signs of a viral infection, particularly if there is a visible hemangioma present in
the beard distribution. 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 treatment completion. (See "Assessment of stridor in
children" and "Congenital anomalies of the larynx" and "Infantile hemangiomas:
Epidemiology, pathogenesis, clinical features, and complications", section on 'Airway
hemangiomas'.)
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
● Etiology – 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.)
● Epidemiology – Croup is one of the most common respiratory illnesses in young

children. It occurs mostly in children ≤6 years old, with a peak incidence between six
months to three years of age. In temperate climates, most cases occur in the fall or
early winter. Host factors that may contribute to the development of croup include
functional or anatomic susceptibility to upper airway narrowing. (See 'Epidemiology'
above and 'Host factors' above.)
● Clinical presentation – 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.)
● Rapid assessment – 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.)
● Diagnosis – Croup is diagnosed clinically, based upon the characteristic 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 ( image 1A-B). (See 'Diagnosis' above and 'Differential
diagnosis' above.)
● 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 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 ( table 2). (See 'Differential diagnosis' above.)
● Recurrent croup – Recurrent episodes of croup-like symptoms that are atypical for
simple croup (ie, severe or prolonged symptoms) or that occur outside of the typical
age range (ie, earlier than six months or beyond age five or six years) should raise
suspicion for another underlying condition (eg, airway lesions ( table 2),
gastroesophageal reflux, eosinophilic esophagitis, atopic conditions). Children with
recurrent croup should be referred to an otolaryngologist for further evaluation. (See
'Recurrent croup' above and "Assessment of stridor in children".)
Use of UpToDate is subject to the Terms of Use.
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treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
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croup in children. Pediatr Emerg Med Pract 2012; 9:1.
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interobserver variability is the road to perdition. J Crit Care 2013; 28:490.
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54. Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus
Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to
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laryngotracheobronchitis. Am J Dis Child 1979; 133:1140.
56. Yang WC, Hsu YL, Chen CY, et al. Initial radiographic tracheal ratio in predicting clinical
outcomes in croup in children. Sci Rep 2019; 9:17893.
57. Cherry JD. Newer respiratory viruses: their role in respiratory illnesses of children. In: Ad
vances in Pediatrics, Vol 20, Schulman I (Ed), Mosby Year Book, Chicago 1973. p.225.
58. Denny FW, Clyde WA Jr. Acute lower respiratory tract infections in nonhospitalized
children. J Pediatr 1986; 108:635.
59. 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
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60. 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.
61. 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.
62. Rankin I, Wang SM, Waters A, et al. The management of recurrent croup in children. J
Laryngol Otol 2013; 127:494.
63. Jabbour N, Parker NP, Finkelstein M, et al. Incidence of operative endoscopy findings in
recurrent croup. Otolaryngol Head Neck Surg 2011; 144:596.
64. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup.
Ann Otol Rhinol Laryngol 2009; 118:495.
65. 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.
66. Gohil R, Culshaw J, Jackson P, Singh S. Accidental button battery ingestion presenting as
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Topic 6002 Version 34.0

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

Laryngoscopy in a child with croup
(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.
(B) Endoscopic image of a normal pediatric larynx.
VC: vocal cord.
Courtesy of Glenn C Isaacson, MD, FAAP.

Subglottic hemangioma in a young child
(A) Subglottic hemangioma (arrow) seen from above the vocal cords. There is near-complete obstruction
the subglottic airway.
(B) Normal pediatric larynx.
AC: arytenoid cartilage; AF: aryepiglottic fold; E: epiglottis; VC: vocal cord.
Panel A is courtesy of Anna Messner, MD.
Panel B is reproduced with permission from: Nagdev A. Airway, breathing, circulation: Normal airway. In: Greenberg's Text-Atlas o
Emergency Medicine, Greenberg MI, Hendrickson RG, Silverberg M, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2005.
Copyright © 2005 Lippincott Williams & Wilkins. www.lww.com.

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

Westley croup severity score
Clinical Assigned Score Severity Description Management

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

Markedly barky cough, oral
stridor at rest, dexamethasone
decreased = 2
mild to 0.6 mg/kg
Retractions None = 0 moderate (maximum 16
Mild = 1 retractions, mg)*
but no or little
Moderate = 2 Nebulized
distress or
epinephrine ¶
Severe = 3 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 Single dose of

barky cough, oral/IM/IV
stridor at rest, dexamethasone
marked 0.6 mg/kg
retractions, (maximum 16
significant mg)*

distress and Repeated doses

agitation 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
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
IM: intramuscular; IV: intravenous; ENT: ear, nose, throat.
* The IV 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 UpToDate
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.

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.

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.

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.

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.

Congenital anomalies associated with stridor
Malformation Characteristics
Nose* Nasal Choanal atresia or agenesis, septum deformities,

deformities turbinate hypertrophy, vestibular atresia, or stenosis.
Pharynx* Craniofacial Anomalies causing facial retrusion are associated with

anomalies upper airway obstruction, including Crouzon, Pierre
Robin, and Apert syndromes.
Tongue Macroglossia and glossoptosis.
Larynx Laryngomalacia Most common cause of chronic stridor in infants. Almost

all patients present by 6 weeks of age. Symptoms are
more pronounced after upper respiratory infections.
Laryngeal webs 75% located in the glottic area. Complete webs cause
respiratory distress at birth and partial webs produce
stridor, weak cry, and different degrees of respiratory
distress. Associated anomalies are common.
Laryngeal cysts If located in supraglottic area, may cause respiratory

distress and stridor.
Laryngeal clefts Characterized by abnormal communication between the

larynx and pharynx, sometimes extending downward
between the trachea and esophagus. Patients may
present with aspiration, cough, swallowing difficulties,
respiratory distress, hoarse cry, or occasionally with
stridor; often associated with other congenital anomalies.
Subglottic Presents as with stridor and respiratory distress, usually

hemangioma worsening during the first few months of life. Often
associated with cutaneous hemangiomas.
Subglottic May be congenital but more often acquired secondary to

stenosis intubation. Usually located 2 to 3 mm below the glottis.
Vocal cord Idiopathic or secondary to a neurologic disorder

paralysis (including Chiari II malformation, hydrocephalus,
meningomyelocele, hypoxic cerebral palsy, and cerebral
hemorrhage) [1,2] .

Trachea ¶ Tracheal stenosis Usually presents with stridor or both stridor and
wheezing. If stenosis is significant, respiratory distress
occurs.
Vascular rings or 74% of vascular rings are symptomatic. The airway

slings compression usually is intrathoracic, causing expiratory
stridor. Associated anomalies are common.
Tracheomalacia Often associated with other congenital anomalies. May

be secondary to a vascular ring or cysts. Worsens with
upper respiratory infections, crying, coughing, or feeding.
May cause severe spells with cyanosis.
Bronchi and Bronchogenic May occur at any point throughout the tracheobronchial
distal airways ¶ cyst tree. Typically present during childhood with recurrent
coughing, wheezing, or pneumonia, but may become
symptomatic during infancy or adulthood or present as
an incidental finding on chest radiographs.
* Noise generated from the nose or pharynx is typically low in pitch and is referred to as snoring
or stertor.
¶ Noise generated from the trachea, bronchi, or distal airways is mostly wheezing.
References:
1. Nisa L, Holtz F, Sandu K. Paralyzed neonatal larynx in adduction. Case series, systematic review and analysis. Int J
Pediatr Otorhinolaryngol 2013; 77:13.
2. Holinger LD, Holinger PC, Holinger PH. Etiology of bilateral abductor vocal cord paralysis: a review of 389 cases.
Ann Otol Rhinol Laryngol 1976; 85:428.

Noncongenital causes of stridor in children
Typical age of presentation
Infants
Inspirato
Cause and Preschool
School- strido
Neonate toddlers (3 to 5 Adolescents
aged
(6 to 24 years)
months)
Acute or subacute onset
Viral croup X X +
(laryngotracheitis) ¶
Spasmodic croup X X +
Bacterial X X X +
tracheitis ¶
Epiglottitis X X X +

Retropharyngeal X X +
abscess
Peritonsillar X X X +
abscess
Inducible laryngeal X X +
obstruction (vocal
cord dysfunction or
paradoxical vocal
cord motion)
Foreign body X X +
aspiration Δ
Anaphylaxis X X X X +

Airway burn X X X X +
Postextubation X X X X +
Therapeutic X X
hypothermia
Chronic
Congenital X X +/–
anomalies
Vocal cord X X X X X +
paralysis ¶

Subglottic stenosis X X X X X +
Tumor X X X X X +/–
Recurrent X X +
respiratory
papillomatosis

Hypocalcemic X X +/–
laryngeal spasm
+: usually present; +/–: may or may not be present; PICU: pediatric intensive care unit; URI: upper
respiratory tract infection.
* Any obstructive process that leads to a fixed airway narrowing will produce both inspiratory
and expiratory noise.
¶ Onset either acute or subacute/gradual.
Δ Foreign body aspiration can occur in any age group but is most common in toddlers and
preschool-aged children.

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.

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.

Contributor Disclosures
Charles R Woods, MD, MS No relevant financial relationship(s) with ineligible companies to
disclose. Anna H Messner, MD No relevant financial relationship(s) with ineligible companies to
disclose. Sheldon L Kaplan, MD Grant/Research/Clinical Trial Support: MeMed Diagnostics [Bacterial
and viral infections];Merck [Staphylococcus aureus];Pfizer [Streptococcus pneumoniae].
Consultant/Advisory Boards: MeMed Advisory Board [Diagnostics bacterial and viral infections]. Other
Financial Interest: Elsevier [Pediatric infectious diseases];Pfizer [PCV13]. All of the relevant financial
relationships listed have been mitigated. Joshua Nagler, MD, MHPEd No relevant financial
relationship(s) with ineligible companies to disclose. Carrie Armsby, MD, MPH No relevant financial
relationship(s) with ineligible companies 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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17/01/2023 15:42 Croup: Clinical features, evaluation, and diagnosis - UpToDate

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Croup: Clinical features, evaluation, and diagnosis

Croup is a respiratory illness characterized by inspiratory stridor, cough, and hoarseness.

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

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● Laryngotracheobronchitis – Laryngotracheobronchitis occurs when inflammation

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

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bronchial tree. Bacterial tracheitis may occur as a primary infection or as a complication

● Viral causes – Croup is usually caused by viruses [6]:

• Parainfluenza viruses – Parainfluenza virus type 1 is the most common cause of

• Influenza – Influenza virus is a relatively uncommon cause of croup. However,

• Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – The SARS-CoV-2

• Measles – Measles is an important cause of croup in areas where measles remains

Metapneumoviruses cause primarily lower respiratory tract disease similar to RSV,

"fixed" obstruction, dynamic obstruction of the extrathoracic trachea below the

● Spasmodic or recurrent croup – In spasmodic or recurrent croup, findings on direct

Though a causal relationship between gastroesophageal reflux disease and recurrent

● Bacterial tracheitis – Patients with bacterial tracheitis have a bacterial superinfection

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( picture 1). Ulcerations, pseudomembranes, and microabscesses of the mucosal

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

The severity of upper airway obstruction is evident on physical examination, as described

Overview — The evaluation of children with suspected croup is aimed at promptly

Rapid assessment and initial management — Rapid assessment of general appearance

● Sudden onset of symptoms

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

● Difficulty swallowing – Difficulty swallowing may occur in acute epiglottitis. Rarely, a

● Drooling – Drooling more commonly occurs in children with peritonsillar or

Examination — The objectives of the examination of the child with croup include

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Severity assessment — The severity of croup is determined by the presence or absence of

• Fatigue and listlessness

● Examination of the oropharynx for the following signs:

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

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● Lung examination – Expiratory wheezing suggests small or medium airway obstruction

● Indications – Radiographic confirmation of acute laryngotracheitis is not required in

• The course is atypical and/or the diagnosis is in question

● Findings – In children with croup, a posterior-anterior chest radiograph demonstrates

Microbiology — Confirmation of etiologic diagnosis is not necessary for most children with

Clinical diagnosis — Croup is diagnosed clinically, based upon the characteristic barking

Etiologic diagnosis — Although not typically required in most cases of croup, identification

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

● Coronavirus (all types) (see "Coronaviruses", section on 'Diagnosis' and "COVID-19:

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

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

● Measles (see "Measles: Clinical manifestations, diagnosis, treatment, and prevention",

● Enteroviruses (see "Enterovirus and parechovirus infections: Clinical features,

Children who have recurrent croup should be referred to an otolaryngologist. Radiographic

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Important considerations include ( table 2 and table 3) [24,25]:

● Acute epiglottitis – Epiglottitis, which is rare in the era of vaccination against

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

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

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● Allergic reaction or acute angioneurotic edema – Allergic reaction or acute

● Anomalies of the airway – Stridor can be caused by congenital or acquired anomalies

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