Introduction

From raspy coughs to silent struggles, the line between croup and epiglottitis isn't always clear. Let's uncover the differences between these respiratory mysteries. While both may sound similar and affect the upper respiratory tract, they are distinct in their causes, symptoms, and treatments. Understanding these differences is crucial for effective management and ensuring the well-being of those affected.

Croup is a common childhood illness characterized by inflammation of the upper airway, often caused by a viral infection. On the other hand, epiglottitis is a more serious condition involving inflammation and swelling of the epiglottis, a small flap of tissue at the base of the tongue that covers the windpipe during swallowing. Both conditions can lead to breathing difficulties, but their underlying causes and management strategies differ significantly.

In this article, we'll delve into the key aspects of croup and epiglottitis, including their symptoms, diagnostic approaches, and treatment options. By the end, you'll have a clearer understanding of how to recognize and respond to croup and epiglottitis, promoting better outcomes for those affected. 

Anatomy and pathophysiology

Pathophysiology of croup

Croup primarily affects the larynx and trachea, causing inflammation and swelling of the airway lining. This inflammation is often triggered by viral infections, such as the parainfluenza virus. As a result, the airway becomes narrowed, leading to characteristic symptoms such as a barking cough, hoarseness, and inspiratory stridor (a high-pitched sound heard during inhalation).¹

Pathophysiology of Epiglottitis

Epiglottitis, on the other hand, involves inflammation and swelling of the epiglottis, a small flap of tissue located at the base of the tongue. Unlike croup, which is typically viral in origin, epiglottitis is commonly caused by bacterial infections, particularly Haemophilus influenzae type B (Hib).² The swelling of the epiglottis can rapidly obstruct the airway, leading to severe respiratory distress and potentially life-threatening complications.

Clinical presentation

While croup and epiglottitis share some similarities in their clinical presentations, they also exhibit distinct features that can help differentiate between the two conditions.³,⁴

Symptoms of Croup

• Characteristic Cough: One of the hallmark features of croup is a barking cough, which sounds similar to the bark of a seal or a dog. This cough is often described as harsh and may worsen at night
• Hoarseness: Children with croup may develop hoarseness or changes in their voice due to inflammation of the vocal cords
• Inspiratory Stridor: Another common symptom of croup is inspiratory stridor, a high-pitched wheezing or crowing sound heard during inhalation. This occurs due to the narrowing of the upper airway
• Fever (in some cases): While fever is not always present in croup, some children may develop a mild fever as a result of the underlying viral infection

Symptoms of epiglottitis

• High Fever: One of the key features of epiglottitis is a high fever, often exceeding 38.5°C (101.3°F). This fever is usually sudden in onset and may be accompanied by chills
• Difficulty Swallowing: Children with epiglottitis may experience difficulty swallowing (dysphagia) due to swelling and inflammation of the epiglottis and surrounding tissues
• Drooling: Another common symptom of epiglottitis is excessive drooling, as swallowing becomes difficult and saliva may pool in the mouth
• Inspiratory Stridor (less common than in croup): While inspiratory stridor can occur in epiglottitis, it is less common than in croup and may indicate more severe airway obstruction.
• Severe Respiratory Distress: In severe cases of epiglottitis, children may exhibit signs of significant respiratory distress, including rapid breathing, retractions (visible sinking of the skin between the ribs and in the neck), and cyanosis (bluish discolouration of the skin or lips) due to inadequate oxygenation

Below is a table showing a comparison between symptoms of croup vs epiglottitis:

Diagnosis

Diagnosing croup and epiglottitis involves a combination of clinical examination findings and, in some cases, imaging studies.⁵ While croup is typically diagnosed based on clinical symptoms and may be confirmed with imaging studies such as a neck X-ray, the diagnosis of epiglottitis requires careful evaluation, including direct visualization of the throat and imaging studies to assess the severity of airway involvement.

Management and treatment

While both croup and epiglottitis require prompt medical attention, their treatment approaches differ significantly. Croup is primarily managed with supportive care, steroids, and, in severe cases, nebulized adrenaline. On the other hand, epiglottitis necessitates immediate medical attention, intravenous antibiotics, and potentially invasive airway management to ensure patient safety and optimal outcomes.

Treatment options for croup

For the management of croup, the focus is on providing supportive care and alleviating symptoms.⁶ Treatment options include:

Supportive care

The cornerstone of croup treatment involves providing supportive care to relieve symptoms and promote recovery. This may include ensuring adequate hydration and providing humidified air to help ease breathing.

Steroids

Oral or intravenous corticosteroids are often prescribed to reduce airway inflammation and swelling in cases of moderate to severe croup. Steroids help alleviate symptoms and improve breathing within a relatively short period.

Nebulized adrenaline (in severe cases) 

In severe cases of croup where there is significant airway obstruction and respiratory distress, nebulized adrenaline may be administered. Adrenaline helps reduce airway swelling and improve breathing, providing rapid relief of symptoms.

Treatment options for epiglottitis

Epiglottitis requires immediate medical attention and often involves more aggressive interventions compared to croup. Treatment options for epiglottitis include:

Immediate medical attention

Epiglottitis is a medical emergency that requires prompt evaluation and treatment in a hospital setting. Upon suspicion of epiglottitis, healthcare professionals will initiate immediate interventions to ensure airway patency and stabilisation.

Antibiotics (Intravenous)

Since bacterial infections commonly cause epiglottitis, intravenous antibiotics are typically administered to target the underlying infection. Antibiotic therapy helps eradicate the bacteria responsible for the inflammation and prevents the progression of the condition.

Airway management (May require intubation)

In severe cases of epiglottitis where there is significant airway obstruction and respiratory compromise, airway management may be necessary. This may involve intubation (placement of a breathing tube) to secure the airway and ensure adequate oxygenation.⁷

Steroids (In some cases)

Similar to croup, corticosteroids may be used in the treatment of epiglottitis to reduce airway inflammation and swelling. However, the use of steroids in epiglottitis is often considered on a case-by-case basis and may be less common compared to croup.

FAQ’s

What is the main difference between epiglottitis and croup?

The main difference lies in their underlying causes and anatomical involvement. Epiglottitis is often bacterial in origin and involves inflammation of the epiglottis, causing rapid airway obstruction. Croup, on the other hand, is typically viral and affects the larynx and trachea, resulting in characteristic symptoms like a barking cough and inspiratory stridor.

What is the best way to differentiate between croup and epiglottitis in the pre-hospital setting?

Differentiating between croup and epiglottitis relies on recognizing key clinical features. In croup, symptoms typically develop gradually and include a barking cough and inspiratory stridor, while epiglottitis presents with a sudden onset of high fever, difficulty swallowing, and drooling, indicating a medical emergency.

What is croup and what are at least 2 signs of croup?

Croup is a viral infection that causes inflammation of the upper airway, leading to symptoms like a barking cough and inspiratory stridor. Two common signs of croup include hoarseness and a harsh, barking cough, often worsening at night.

What are two common signs of acute epiglottitis in children?

Common signs of acute epiglottitis in children include high fever and difficulty swallowing. Additionally, drooling may also be present due to the inability to swallow saliva effectively.

What is the triad of epiglottitis?

The classic triad of epiglottitis consists of high fever, difficulty swallowing, and inspiratory stridor. These three symptoms together suggest significant airway obstruction and require immediate medical attention.

What is croup distinguished by?

Croup is distinguished by its characteristic symptoms, including a barking cough, hoarseness, and inspiratory stridor. These symptoms typically develop gradually and are often worse at night.

What can be mistaken for croup?

Conditions such as laryngotracheitis (viral croup), bacterial tracheitis, and foreign body aspiration can be mistaken for croup due to similar symptoms like coughing and difficulty breathing. However, croup is distinguished by its characteristic barking cough and inspiratory stridor.

Summary

In summary, croup and epiglottitis are two distinct respiratory conditions, most commonly seen in paediatrics, that require different approaches to treatment and management. While both conditions can cause airway obstruction and respiratory distress, they differ in their underlying causes, clinical presentations, and treatment options.

Croup, typically caused by viral infections, is managed with supportive care, steroids, and, in severe cases, nebulized adrenaline. Symptoms of croup include a characteristic barking cough, hoarseness, and inspiratory stridor.

Epiglottitis, on the other hand, is often caused by bacterial infections and requires immediate medical attention. Treatment involves intravenous antibiotics, airway management (including potential intubation), and, in some cases, steroids. Symptoms of epiglottitis include high fever, difficulty swallowing, drooling, and severe respiratory distress.

It is crucial for healthcare professionals to accurately diagnose and differentiate between croup and epiglottitis to ensure appropriate management and prevent complications. While croup can usually be managed on an outpatient basis, epiglottitis requires hospitalisation and close monitoring due to the potential for rapid airway obstruction and respiratory compromise.

By understanding the key differences between croup and epiglottitis, healthcare providers can provide timely and effective care, ultimately improving outcomes for patients affected by these respiratory conditions.