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Patient Story

A 9-month-old infant is brought to the emergency department because of a 1-hour history of a barky cough and difficulty breathing, which followed a 2-day history of rhinorrhea and low-grade fever. He does not appear toxic, but is tachypneic, and has inspiratory stridor and suprasternal retractions. He is not drooling and has no change in voice. A dose of nebulized epinephrine is administered while awaiting the results of his neck x-ray. The frontal view of an x-ray of the soft tissues of the neck shows narrowing of the subglottic space (Steeple sign) (Figure 30-1). A diagnosis of croup is made and the infant is given a dose of dexamethasone orally. Thirty minutes later, his stridor and retractions have resolved.


Subglottic narrowing (“steeple sign”) of croup on frontal x-ray of the neck. (Used with permission from Kshama Daphtary, MBBS, MD.)

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Upper airway obstruction refers to blockage of any portion of the airway above the thoracic inlet or the extrathoracic airway. It is one of the most daunting emergencies faced by a physician and, if not promptly diagnosed and managed, can progress to hypoxia and can lead to cardio-respiratory arrest and irreversible brain damage. Stridor, suprasternal retractions, and change of voice are the sentinel signs of upper airway obstruction.


  • Upper airway obstruction is often referred to as extra-thoracic airway obstruction.

  • Croup is also known as laryngotracheobronchitis.

  • Epiglottitis is used synonymously with supraglottitis.

  • Bacterial tracheitis is also known as bacterial laryngotracheobronchitis or pseudomembranous croup.


  • Upper airway obstruction is one of the most common life-threatening emergencies in children, accounting for up to 15 percent of visits to the emergency department.1

  • Croup is the most common infection that causes acute upper airway obstruction and has an annual incidence of 18 per 1,000 children in the US; children between the ages of 6 months and 4 years are primarily affected, with a peak incidence of 60 per 1,000 among children 1 to 2 years of age. Although sporadic cases occur throughout the year, croup is epidemic in early fall and winter.2

  • The incidence of epiglottitis has decreased dramatically, since the introduction of the conjugated Haemophilus influenzae type b vaccine, from 41 cases per 100,000 children in 1987 to 1.3 per 100,000 in 1997.2,3

  • Bacterial tracheitis has an estimated incidence of approximately 0.1 cases per 100,000 children per year and has a peak incidence in fall and winter. Although it affects all age groups, it occurs more frequently in children between the ages of 6 months and 8 years. Retropharyngeal abscess is more common in young children, with the vast majority of cases occurring in patients younger than 6 years of age.2

  • Peritonsillar abscess is usually a ...

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