Croup versus Epiglottitis
Croup is an acute viral upper-airway illness causing laryngeal and subglottic inflammation that presents with barking cough and inspiratory stridor. [1] Epiglottitis is a medical emergency caused by infection and rapid supraglottic swelling that can progress to complete airway obstruction. [2]
Etiology
Croup is most commonly caused by viral infections, particularly parainfluenza viruses. [4] Epiglottitis is most commonly caused by Haemophilus influenzae infection, with other pathogens possible. [3]
Typical Age of Presentation
Croup typically occurs in children aged 6 months to 3 years. [1] Epiglottitis typically occurs in children aged 3 to 12 years. [1]
Clinical Features
Croup typically presents with acute onset of barking cough, stridor, and hoarseness. [1] Croup usually does not present with prominent drooling or dysphagia. [1] Epiglottitis typically presents with acute onset of dysphagia and odynophagia, drooling, high fever, anxiety, and a muffled voice. [1] Epiglottitis is characterized by distress with air hunger and a toxic appearance with positioning such as tripod posture and difficulty lying flat. [2]
Diagnostic Clues for Bedside Differentiation
Cough is highly sensitive and specific for croup, while drooling is highly sensitive and specific for epiglottitis in pediatric ICU presentations. [1] Drooling in the absence of a barking cough is an important clinical feature suggesting epiglottitis. [2]
Urgent Management Principles
Croup management focuses on corticosteroids for all severities and nebulized epinephrine for moderate to severe disease. [1] Epiglottitis requires priority airway stabilization, with avoidance of sedating medication and avoidance of physical exam maneuvers that could precipitate respiratory collapse. [3] Patients with suspected epiglottitis should be hospitalized. [2] Direct examination of the pharynx and larynx should be avoided or performed only in a controlled setting because it can precipitate complete airway obstruction. [2]
Treatment Initiation Thresholds and Escalation
Croup corticosteroids should be administered for croup of any severity. [1] Croup nebulized epinephrine should be administered for moderate to severe croup. [1] Oxygen should be administered to children with hypoxemia or severe respiratory distress in croup. [1] Epiglottitis should be treated as an emergency with airway management prioritized before diagnostic testing or routine imaging. [3]
Common Pitfalls to Avoid
Croup and epiglottitis can both present with stridor, but treating epiglottitis as routine croup risks potentially rapid deterioration from delayed airway control. [1] Routine throat examination and other potentially provocative maneuvers should be avoided in suspected epiglottitis because they may precipitate airway collapse. [3] A lateral neck radiograph should not delay definitive management in unstable epiglottitis because positioning and transport can precipitate decompensation and airway collapse. [2]
Targets and Goals of Care
The goal in croup is reduction of laryngeal edema and upper-airway obstruction symptoms through anti-inflammatory therapy and bronchodilation/vasoconstriction when indicated by severity. [1] The goal in epiglottitis is preservation of airway patency followed by eradication of the infectious pathogen. [3]