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 "Croup: Approach to management" and "Croup: Pharmacologic
and supportive interventions".)
DEFINITIONS The term croup has been used to describe a variety of upper respiratory conditions
in children, including laryngitis, laryngotracheitis, laryngotracheobronchitis, bacterial tracheitis, or
spasmodic croup [1]. These terms are defined below. In the past, the term croup also has been
applied to laryngeal diphtheria (diphtheritic or membranous croup), which is discussed separately.
(See "Epidemiology and pathophysiology of diphtheria" and "Clinical manifestations, diagnosis and
treatment of diphtheria".)
Throughout this review, the term croup will be used to refer to laryngotracheitis.
Laryngotracheobronchitis, laryngotracheobronchopneumonitis, bacterial tracheitis, and spasmodic
croup are designated specifically as such.
Laryngitis refers to inflammation limited to the larynx and manifests itself as hoarseness [2]. 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"Hoarseness in children: Etiology and
management" and "Hoarseness in children: Evaluation".)
Laryngotracheitis (croup) refers to inflammation of the larynx and trachea [2]. Although lower
airway signs are absent, the typical barking cough will be present.
Laryngotracheobronchitis (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 [2]. This term commonly is used
interchangeably with laryngotracheitis, and the entities are often indistinct clinically. Further
extension of inflammation into the lower airways results in laryngotracheobronchopneumonitis,
which sometimes can be complicated by bacterial superinfection. Bacterial superinfection can be
manifest as pneumonia, bronchopneumonia, or bacterial tracheitis.
Bacterial tracheitis (also called bacterial croup) describes bacterial infection of the subglottic
trachea, resulting in a thick, purulent exudate, which causes symptoms of upper airway
obstruction (picture 1). The bronchi and lungs are typically involved, as well (ie, bacterial
tracheobronchitis). Bacterial tracheitis may occur as a complication of viral respiratory infections
(usually those which manifest themselves as LTB or laryngotracheobronchopneumonitis) or as a
primary bacterial infection. (See "Bacterial tracheitis in children: Clinical features and
diagnosis".)
Spasmodic croup is characterized by the sudden onset of inspiratory stridor at night, short
duration (several hours), and sudden cessation [2]. This is often in the setting of a mild upper
respiratory infection, but without fever or inflammation. A striking feature of spasmodic croup is
its recurrent nature, hence the alternate descriptive term, "frequently recurrent croup". Because
of some clinical overlap with atopic diseases, it is sometimes referred to as "allergic croup".
We consider "spasmodic croup" to be distinct from "atypical croup," although the terms are
sometimes used interchangeably. Atypical croup may be defined as recurrent episodes of croup-

like symptoms occurring beyond the typical age range of six months to three years for "viral
croup" or recurrent episodes that do not appear to be simple "spasmodic croup" [3].
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 [4-6]. 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 [7]. 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.
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 [6].
Respiratory syncytial virus (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 "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 [8-10]. 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 "Clinical manifestations and diagnosis of measles".)
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".)
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 appropriate topic reviews).
Metapneumoviruses cause primarily lower respiratory tract disease similar to RSV, but upper
respiratory tract symptoms have been described in some patients [11]. (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 S.
pneumoniae [1].
EPIDEMIOLOGY Croup most commonly occurs in children 6 to 36 months of age. It is seen in
younger infants (as young as three months) and in preschool children, but it is rare beyond age six
years [1,12]. It is more common in boys, with a male:female ratio of about 1.4:1 [1,12-14].

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 [15]. Parental
smoking, a well-recognized risk factor for respiratory tract infections in children, does not appear to
increase the risk of croup [15,16]. (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.
However, children seen for croup between noon and 6:00 PM are more likely to be admitted to the
hospital [4,17]. A morning peak between 7:00 AM and 11:00 AM in ED visits for croup also has been
noted [14].
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 [5]. 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 [14].
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 trachea in the subglottic region. This portion of the
trachea is surrounded by a firm cartilaginous ring such that any inflammation results in narrowing of
the airway. 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 of patients during acute laryngotracheitis shows redness and swelling of the
lateral walls of the trachea. 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 cords and laryngeal tissues also can become swollen, and cord mobility may be impaired [2,1820]. 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 [21-23].
In spasmodic croup, findings on direct laryngoscopy demonstrate noninflammatory edema [18]. This
suggests that there is no direct viral involvement of the tracheal epithelium.

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 parainfluenza virus infections 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 susceptibility to upper
airway narrowing, variations in immune response, and predisposition to atopy [14].
Underlying host factors that predispose to clinically significant narrowing of the upper airway include:
Anatomic narrowing of the airway, from etiologies such as subglottic stenosis, laryngeal webs,
tracheomalacia, laryngomalacia, laryngeal clefts, or subglottic hemangiomas [3]
Hyperactive airways, perhaps aggravated by atopy or gastroesophageal reflux, as suggested in
some children with spasmodic croup or recurrent croup [24-26]
Acquired airway narrowing from respiratory tract papillomas (human papillomavirus), postintubation scarring, or irritation from aspirations associated with gastroesophageal reflux
The potential role of the immune response was demonstrated in studies that demonstrated increased
production of parainfluenza virus-specific 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 [27,28].
CLINICAL PRESENTATION The clinical presentation of croup depends upon the specific croup
syndrome and the degree of upper airway obstruction. Although croup usually is a mild and selflimited illness, specific features of the history and physical examination identify children who are
seriously ill or at risk for rapid progression of disease. (See 'Evaluation' below.)
Laryngotracheitis Laryngotracheitis typically occurs in children three months to three years of age
[2]. The onset of symptoms is usually gradual, beginning with nasal irritation, congestion, and coryza.
Symptoms generally progress over 12 to 48 hours to include fever, hoarseness, barking cough, and
stridor. Respiratory distress increases as upper airway obstruction becomes more severe. Rapid
progression or signs of lower airway involvement suggests a more serious illness. Cough usually
resolves within three days [29]; other symptoms may persist for seven days with a gradual return to
normal [2]. Deviations from this expected course should prompt consideration of diagnoses other than
laryngotracheitis. (See 'Differential diagnosis' below.)
The degree of upper airway obstruction is evident on physical examination, as described below. In
mild cases, the child is hoarse and has nasal congestion. There is minimal, if any, pharyngitis. As
airway obstruction progresses, stridor develops, and there may be mild tachypnea with a prolonged
inspiratory phase. The presence of stridor is a key element in the assessment of severity. Stridor at
rest is a sign of significant upper airway obstruction. As upper airway obstruction progresses, the child
may become restless or anxious. (See 'Severity assessment' below.)
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.

Hypoxia and cyanosis can develop, as can respiratory fatigue from sustained increased respiratory
effort. High respiratory rates also tend to correlate with the presence of hypoxia. Without intervention,
the hypoxia or fatigue can sometimes lead to death.
Spasmodic croup Spasmodic croup also occurs in children three months to three years of age [2].
In contrast to laryngotracheitis, spasmodic croup always occurs at night; the duration of symptoms is
short, often with symptoms subsiding by the time of presentation for medical attention; and the onset
and cessation of symptoms are abrupt. 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 [30]. 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 [24].
Early in the clinical course, spasmodic croup may be difficult to distinguish from laryngotracheitis. As
the course progresses, the episodic nature of spasmodic croup and relative wellness of the child
between attacks differentiate it from classic 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. Rarely,
children may benefit from treatment with corticosteroids and/or nebulized epinephrine [31]. Other
therapies generally are not indicated. (See "Croup: Approach to management".)
Bacterial tracheitis Bacterial tracheitis may present as a primary or secondary infection [32]. In
primary infection, there is acute onset of symptoms of upper airway obstruction with fever and toxic
appearance. In secondary infection, there is marked worsening during the clinical course of viral
laryngotracheitis, with high fever, toxic appearance, and increasing respiratory distress secondary to
tracheal obstruction from purulent secretions. In both of these presentations, signs of lower airway
disease, such as crackles and wheezes, may be present. However, the upper airway obstruction is
the more clinically significant manifestation [2,33]. (See "Bacterial tracheitis in children: Clinical
features and diagnosis", section on 'Clinical features'.)
Recurrent croup A child who has had 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 large airway lesions, gastroesophageal reflux or
eosinophilic esophagitis, or atopic conditions [3,34-38].
Children with recurrent croup may require radiographic evaluation or bronchoscopy. (See 'Host
factors' above and 'Imaging' below.)
EVALUATION
Overview The evaluation of children with suspected croup has several objectives, including prompt
identification of patients with significant upper airway obstruction or at risk for rapid progression of
upper airway obstruction. In addition, there are some conditions with presentations similar to that of
croup that require specific evaluationsand/or interventions; these too must be promptly identified.
(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.
(See "Croup: Approach to management", section on 'Respiratory care'.)
Endotracheal intubation is required in less than 1 percent of children with croup who are seen in the
emergency department. However, the need for endotracheal intubation should be anticipated in
children with progressive respiratory failure so that it can be performed in as controlled a setting as
possible. Respiratory failure is heralded by the following signs [1,39,40]:
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
A tracheal tube that is 0.5 to 1 mm smaller than would typically be used may be required.
(See "Emergency endotracheal intubation in children", section on 'Endotracheal tube'.)
In addition to establishment of an airway, children who have severe respiratory distress require
immediate pharmacologic treatment, including administration of nebulizedepinephrine and systemic or
nebulized corticosteroids. (See "Croup: Approach to management", section on 'Moderate to severe
croup'.)
Once control of the airway is established and pharmacologic treatment, if necessary, is under way, 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 [1,41]:
Fever The absence of fever from onset of symptoms to the time of presentation is suggestive
of spasmodic croup or a noninfectious etiology (eg, foreign body aspiration or ingestion, acute
angioneurotic edema).
Hoarseness and barking cough Hoarseness and barking cough, characteristic findings in
croup, are typically absent in children with acute epiglottitis, foreign body aspiration, and
angioneurotic edema.
Difficulty swallowing Difficulty swallowing may occur in acute epiglottitis and foreign body
aspiration. 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
[41].
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) [41].
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.
Aspects of the examination that are helpful in assessing the degree of upper airway obstruction and
severity of illness include:
Overall appearance Is the child comfortable and interactive, anxious and quiet, or obtunded?
Is there stridor at rest? Stridor at rest is a sign of significant upper airway obstruction. Children
with significant upper airway obstruction may prefer to sit up and lean forward in a "sniffing"
position (neck is mildly flexed, and head is mildly extended). This position tends to improve the
patency of the upper airway.
Quality of the voice Does the child have a hoarse or diminished cry? Is the voice muffled? A
muffled "hot potato" voice is suggestive of epiglottitis, retropharyngeal abscess, or peritonsillar
abscess.
Degree of respiratory distress Signs of respiratory distress include tachypnea, hypoxemia,
and increased work of breathing (intercostal, subcostal, or suprasternal retractions; nasal flaring;
grunting; use of accessory muscles)
Tidal volume Does there appear to be good chest expansion with inspiration, indicating
adequate air entry?
Lung examination Are there abnormal respiratory sounds during inspiration or expiration?
Inspiratory stridor indicates upper airway obstruction, whereas expiratory wheezing is a sign of
lower airway obstruction. If there is stridor, is it present at rest or only with agitation? As
discussed above, stridor at rest is a sign of significant upper airway obstruction. Stridor will be
more obvious on auscultation, since the inspiratory noise is transmitted through the chest. The
presence of crackles (rales) also suggests lower respiratory tract involvement (eg,
laryngotracheobronchitis, laryngotracheobronchopneumonitis, or bacterial tracheitis).
Assessment of hydration status Decreased oral intake and increased insensible losses from
fever and tachypnea may result in dehydration. (See "Clinical assessment and diagnosis of
hypovolemia (dehydration) in children".)
These aspects of the examination are often used in clinical scoring systems to evaluate the severity of
illness and/or in making decisions regarding the need for hospital admission. (See 'Severity
assessment' below and "Croup: Approach to management", section on 'Observation and disposition'.)
Components of the examination that are useful in distinguishing croup from other causes of acute
upper airway obstruction include [39,41]:

Preferred posture Children with epiglottitis usually prefer to sit up in the "tripod" or "sniffing
position" (picture 2A-B).
Examination of the oropharynx for the following signs:
Cherry red, swollen epiglottis, suggestive of epiglottitis
Pharyngitis, typically minimal in laryngotracheitis, may be more pronounced in epiglottitis
or laryngitis
Excessive salivation, suggestive of acute epiglottitis, peritonsillar 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
Concerns have been raised about safety of examining the pharynx in children with upper
airway obstruction and possible epiglottitis since such efforts have been reported to
precipitate cardiorespiratory arrest. However, in two series, each including more than 200
patients with epiglottitis or viral croup, direct examination of the oropharynx was not
associated with sudden clinical deterioration [32,42].
Examination of the cervical lymph nodes, which can be enlarged in patients with
retropharyngeal or peritonsillar abscesses.
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.)
Severity assessment The severity of croup is often determined by the clinical scoring systems.
Although there are a number of validated croup scoring systems, the Westley croup score [43] has
been the most extensively studied; it is described below. No matter which system is used to assess
severity, the presence of chest wall retractions and stridor at rest are the two critical clinical features.
The elements of the Westley croup score describe key features of the physical examination [43]. Each
element is assigned a score, as illustrated below:
Level of consciousness: Normal, including sleep = 0; disoriented = 5
Cyanosis: None = 0; with agitation = 4; at rest = 5
Stridor: None = 0; with agitation = 1; at rest = 2
Air entry: Normal = 0; decreased = 1; markedly decreased = 2
Retractions: None = 0; mild = 1; moderate = 2; severe = 3
Mild croup is defined by a Westley croup score of 2. Typically, these children have a barking cough
and hoarse cry, but no stridor at rest. Children with mild croup may have stridor when upset or crying
(ie, agitated) and either no, or only mild, chest wall/subcostal retractions [1,39].
Moderate croup is defined by a Westley croup score of 3 to 7. Children with moderate croup have
stridor at rest, at least mild retractions, and may have other symptoms or signs of respiratory distress,
but little or no agitation [1,39].

Severe croup is defined by a Westley croup score of 8. Children with severe croup have significant
stridor at rest, although stridor may decrease with worsening upper airway obstruction and decreased
air entry [1,39]. Retractions are severe (including indrawing of the sternum) and the child may appear
anxious, agitated, or fatigued. Prompt recognition and treatment of children with severe croup are
paramount.
Imaging
Indications Radiographic confirmation of acute laryngotracheitis is not required in the vast majority
of children with croup. Radiographic evaluation of the chestand/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 "Croup: Approach to
management".)
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 [44] 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) [45].
Laboratory studies Laboratory studies, which are rarely indicated in children with croup, are of
limited diagnostic utility but may help guide management in more severe cases.
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 [46,47]. The presence of 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.
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: Clinical features and
diagnosis", section on 'Laboratory diagnosis' and "Seasonal influenza in children: Prevention and
treatment with antiviral drugs", section on 'Timing of treatment'.)
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 diagnosis')
Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on
'Diagnostic tests of choice for different adenovirus syndromes')
Measles (see "Clinical manifestations and diagnosis of measles", section on 'Diagnosis')
Enteroviruses (see "Clinical manifestations and diagnosis of enterovirus and parechovirus
infections", section on 'Laboratory diagnosis')
Metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')
Coronavirus (see "Coronaviruses", section on 'Diagnosis')
In addition, multiplex tests, which assess the presence of multiple agents at the same time, and PCRbased tests are becoming more widely available [48].
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 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 [1,12]:
Acute epiglottitis
Peritonsillar and retropharyngeal abscesses
Foreign body aspiration or ingestion
Allergic reaction
Acute angioneurotic edema
Upper airway injury
Congenital anomalies of the upper airway
Laryngeal diphtheria (see "Clinical manifestations, diagnosis and treatment of diphtheria")
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 [41]. Epiglottitis occurs infrequently,

and there is no predominant etiologic pathogen. (See "Epiglottitis (supraglottitis): Clinical features and
diagnosis".)
Peritonsillar or retropharyngeal abscesses Children with deep neck space abscesses, cellulitis
of the cervical prevertebral tissues, or other painful infections of the oropharynx may present with
drooling and neck extension and varying degrees of toxicity. Barking cough is usually absent.
(See "Peritonsillar cellulitis and abscess", section on 'Presentation' and "Retropharyngeal infections in
children", section on '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. (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 [1,12]. 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.
Anomalies of the upper airway Hoarseness and stridor caused by anomalies of the upper airway
(eg, laryngeal webs, laryngomalacia, vocal cord paralysis, congenital subglottic stenosis, and
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. (See "Assessment of stridor in
children" and"Hoarseness in children: Etiology and management" 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-Barr syndrome (involvement of the
laryngeal nerve may cause vocal cord paralysis) [49,50]. (See "Congenital anomalies of the
intrathoracic airways and tracheoesophageal fistula", section on 'Bronchogenic
cyst' and "Epidemiology, clinical features, and diagnosis of Guillain-Barr syndrome in children",
section on 'Clinical features' and"Hoarseness in children: Etiology and management", section on
'Vocal fold paralysis'.)
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 10 th 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 information: Croup (The Basics)")

Beyond the Basics topic (see "Patient information: Croup in infants and children (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
The term croup has been used to describe a variety of upper respiratory conditions in children,
including laryngitis, laryngotracheitis, laryngotracheobronchitis, bacterial tracheitis, or spasmodic
croup. (See 'Definitions' above.)
Croup is usually caused by viruses. Bacterial infection may occur secondarily. Parainfluenza
virus type 1 is the most common cause of croup; other causes include respiratory syncytial virus
and influenza virus. (See 'Etiology' above.)
Croup most commonly occurs in children 6 to 36 months of age. Most cases occur in the fall or
early winter. (See 'Epidemiology' above.)
Host factors that may contribute to the development of croup include functional or anatomic
susceptibility to upper airway narrowing. (See 'Pathogenesis' above.)
The clinical presentation of croup depends upon the specific croup syndrome and the degree of
upper airway obstruction. (See 'Clinical presentation' above.)
The onset of symptoms in laryngotracheitis is gradual, beginning with nasal irritation,
congestion, and coryza. Fever, hoarseness, barking cough, and stridor usually develop during
the next 12 to 48 hours. Rapid progression or signs of lower airway involvement suggest a more
serious illness. (See 'Laryngotracheitis' above.)
The onset of symptoms in spasmodic croup is sudden and always occurs at night. Fever is
typically absent, but mild upper respiratory tract symptoms may be present. (See 'Spasmodic
croup' above.)
Bacterial tracheitis (picture 1 and image 4) may present acutely or as marked worsening during
the course of an antecedent viral upper respiratory infection. Clinical manifestations of bacterial
tracheitis include fever, toxic appearance, and severe respiratory distress. (See 'Bacterial
tracheitis' above and "Bacterial tracheitis in children: Clinical features and diagnosis".)
The objectives of the evaluation of the child with croup include assessment of severity and
exclusion of other causes of upper airway obstruction. (See 'Overview'above.)
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 'Rapid assessment and initial
management' above.)
The history should include a description of the onset, duration and progression of symptoms,
and ascertain whether there are any underlying conditions that predispose to a more severe
course. (See 'History' above.)
Aspects of the examination that are useful in assessing the severity of upper airway obstruction
include overall appearance (including the presence of stridor at rest or only with agitation),
quality of voice, work of breathing, tidal volume and air entry, and the presence of wheezing.
(See 'Examination' 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 complete 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.
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