Differentiating croup from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Overview

Croup must be differentiated from other upper respiratory diseases and conditions that cause airway obstruction around the larynx, as well as those that present similar symptoms to influenza.

Differentiating Croup from Other Diseases

Croup must be differentiated from other upper respiratory diseases and conditions that cause airway obstruction around the larynx:[1][2]

The tables below summarize the differences between croup and other upper respiratory conditions with similar symptoms:

Disease Findings
Epiglottitis Typically presents with fever, difficulty swallowing, dysphonia, drooling, and stridor. Can rapidly progress to include cyanosis and asphyxiation and is much more severe than croup; it is often an emergency requiring intubation.[3]
Subglottic stenosis Presents with stridor and difficulty breathing; can be a life-threatening emergency requiring intubation to remove the airway obstruction.[4]
Bacterial tracheitis Presents with barking cough, stridor, fever, chest pain, ear pain, difficulty breathing, headache, dizziness. Symptoms, particularly fever, are more severe than croup. Requires antibiotic treatment.[5]
Retropharyngeal abscess Presents with neck pain, stiff neck, torticollis and may include enlarged cervical lymph nodes, fever, malaise, stridor, and barking cough. Requires tonsillectomy and use of antibiotics.[6]
Angioneurotic edema Presents with swelling of the dermis, subcutaneous, mucosa and submucosal tissues. Can occur in the upper respiratory system and result in stridor and respiratory arrest, requiring emergency treatment. Acquired angioneurotic edema results from an allergic reaction and be treated with epinephrine.[7]



Variable Croup Epiglottitis Pharyngitis Bacterial tracheitis Tonsilitis Retropharyngeal abscess Subglottic stenosis
Presentation Cough Sore throat, pain on swallowing, fever, headache, abdominal pain, nausea and vomiting Barking cough, stridor,

fever, chest pain,

ear pain, difficulty breathing, headache, dizziness.

Sore throat, pain on swallowing, fever, headache, cough Neck pain, stiff neck, torticollis

fever, malaise, stridor, and barking cough

Depends on severity. May have respiratory distress at birth, exercise-induced dyspnea, intermittent wheezing. Inspiratory stridor. [8]
Stridor
Drooling
Others are Hoarseness, Difficulty breathing, symptoms of the common cold, Runny nose, Fever Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice
Causes Parainfluenza virus H. influenza type b, beta-hemolytic streptococci, Staphylococcus aureus, fungi and viruses. Group A beta-hemolytic streptococcus. Staphylococcus aureus Most common cause is viral including adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. Second most common causes are bacterial; Group A streptococcal bacteria,[9]  Polymicrobial infection. Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella, and Veillonella species)[10][11][12][13][14][15] Congenital, trauma
Physical exams findings Suprasternal and intercostal indrawing,[16] Inspiratory stridor[17], expiratory wheezing,[17] Sternal wall retractions[18] Cyanosis, Cervical lymphadenopathy, Inflammed epiglottis Inflammed pharynx with or without exudate Subglottic narrowing with purulent secretions in the trachea[19][20] Fever, especially 100°F or higher.[21][22]Erythema, edema and Exudate of the tonsils.[23] cervical lymphadenopathy, Dysphonia.[24] Child may be unable to open the mouth widely. May have enlarged

cervical lymph nodes and neck mass.

Signs of respiratory distress, intermittent wheezing. Inspiratory stridor. [8]
Age commonly affected Mainly 6 months and 3 years old

rarely, adolescents and adults[25]

Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals[26]

with a mean age of 44.94 years.

Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years.[27]

Mostly during the first six years of life Primarily affects children

between 5 and 15 years old.[28]

Mostly between 2-4 years, but can occur in other age groups.[6][29] May be congenital congenital or acquired. Mean age in acquired is 54.1 years[30]
Imaging finding Steeple sign on neck X-ray Thumbprint sign on neck x-ray Lateral neck xray shows intraluminal membranes and tracheal wall irregularity. Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[31][32][33] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[34][35] Bronchoscopy reveals subglottic stenosis. Computed tomography may reveal a concentric stenotic tracheal segment.[36]
Treatment Dexamethasone and nebulised epinephrine Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[37][38] Antimicrobial therapy mainly penicillin-based and analgesics. Airway maintenance and antibiotics Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases. Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin. Endoscopic balloon dilation for patients with low-grade subglottic stenosis,[39] glucocorticoid injections, and resection.[40]

References

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  2. Cherry JD (2008). "Clinical practice. Croup". N. Engl. J. Med. 358 (4): 384–91. doi:10.1056/NEJMcp072022. PMID 18216359.
  3. de Vries CJ, de Jongh E, Zwart S, van den Akker EH, Opstelten W (2015). "[Epiglottitis in adults in general practice: difficult to recognise and life-threatening]". Ned Tijdschr Geneeskd (in Dutch; Flemish). 159: A9061. PMID 26332815.
  4. "Subglottic Stenosis | Otolaryngology - Head and Neck Surgery | Baylor College of Medicine | Houston, Texas".
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  8. 8.0 8.1 Nussbaumer-Ochsner Y, Thurnheer R (2015). "IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis". N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.
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  18. Johnson D (2009). "Croup". BMJ Clin Evid. 2009. PMC 2907784. PMID 19445760.
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  28. Sharav, Yair; Benoliel, Rafael (2008). Orofacial Pain and Headache. Elsevier. ISBN 0723434123.
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  36. Nussbaumer-Ochsner Y, Thurnheer R (2015). "IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis". N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.
  37. Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
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  40. Nussbaumer-Ochsner Y, Thurnheer R (2015). "IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis". N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.