Croup is a common cause of cough in the pediatric population. It is also referred to as laryngotracheitis. Croup is caused by a variety of viruses, often parainfluenza.

Epidemiology Edit

  • Affects ages 6months - 5 years of age
  • M>F
  • Often during Fall/Winter season

Clinical Presentation Edit

  • History: abrupt onset, barking cough, stridor, hoarseness, respiratory distress, symptoms worse at night and with agitation, often preceded by URTI
  • Physical: ABCs, LOC, work of breathing - stridor, cyanosis, cardiac and resp examination

Westley Croup ScoreEdit

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  • mild <4
  • Moderate 4-6
  • Severe >6

Investigations Edit

  • Clinical diagnosis. R/O other DDX. Consider soft tissue neck/CXR.
  • Neck xray: steeple sign
  • No viral testing

Differential Diagnosis Edit

  • Bacterial croup- includes laryngeal diphtheria, bacterial tracheitis, laryngotracehobronchitis and laryngotracheobronchopneumonitis
    • High fever, toxic,r esp distress, poor response to treatment, elevated WBC
    • Obtain bacterial cultures of tracheal secretions + blood cultures
    • Investigations: AP neck: steeple sign, may mimic foreign body. W/ consultation direct laryngotracheobronchoscopy 
    • Mngt: ABCs, protect airway, consult ENT/ICU
  • Epiglottis - etiology h.influenza type B (vaccination prevention), strep
    • Clinical: fever, sudden onset, toxic, no barky cough, dysphagia, drooling, 'hot potato voice', resp distress
    • Investigations: blood cultures, xray soft tissue lateral neck: thickening + thumb print sign
    • Definitive diagnosis: direct laryngoscopy, nasopharyngoscopy  
    • Mngt: avoid agitation, Antibiotics, humidified blow by-oxygen, call for help (ENT/anesthesia), steroids are controversial
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Epiglottitis - thumb print sign

  • Foreign Body
  • Anaphylaxis
  • Retropharyngeal abscess- deep neck infection secondary to local spread versus penetrating injury
    • Risk: airway compromise, spread to mediastinum, abscess rupture --> asphyxiation/pneumonia
    • Clinical: fever, malaise, dysphagia, trismus, neck stiffness, torticollis, muffled voice, resp distress, stridor, drooling, may be preceeded by URTI, tender unilateral cervical adenopathy, +/- bulge in posterior pharyngeal wall on inspection of oral cavity
    • Investigations: CBC, blood cultures, lateral neck soft tissue Xray, CT (gold standard)
    • Mngt: ABCs, consultation ENT/anesthesia, IV antibiotics, +/- surgical consultation for I+D, close monitored setting
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Retropharyngeal Abscess

  • Heriditary angioedema
  • Subglottic stenosis
  • Caustic injury
  • Peritonsillar abscess
    • Complication of tonsillitis. Often secondary to Group B strep
    • Clinical: may see uvula deviation
    • Management: ABCs, Incision and drainage (definitive mngt), +/- Antibiotics
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Peritonsillar Abscess


  • Droplet precautions
  • ABC's, supplemental oxygen PRN
  • Dexamethasone 0.6mg/kg (max 12mg) PO/IV/IM x 1 dose
    • Reduces rate of intubation, hospitalization, return to ED, symptom duration
  • +/- Racemic Epinephrine 2.25% 0.5mL in 3 mL normal saline by inhalation
    • OR epinephrine 1:1000. Dose: 3mL (3mg) if <10kg or 5mL (5mg) if > 10kg
  • +/- Budesonide 2mg by inhalation x 1 dose
  • +/- acetaminophen/ibuprofen
  • +/- IV fluids
  • Consider transfer/admission if: severe respiratory distress, >2 epinephrine doses with no benefit, history of abnormal airway, prematurity, no improvement 4hours post steroids
  • Supportive management: mist/humidifier (no strong evidence)

Prognosis Edit

  • Self limited. Most resolve in 48 hours.


  • Vaccinations: influenza, diphtheria 


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Images taken from Life in the Fast Lane