Croup vs epiglottitis: barking cough, drooling and why the throat is not examined

Barking cough versus drooling

The most differentiating finding is the combination of cough and drooling. Croup produces a brassy, barking cough with inspiratory stridor and a hoarse voice. Epiglottitis typically produces drooling without a barking cough, which is a highly specific pattern. The child cannot swallow saliva because the swollen epiglottis makes swallowing painful.

Posture and appearance reinforce the difference. A child with epiglottitis often sits upright, leaning forward on the hands with the neck extended to keep the airway open, looks ill and anxious, and may have a muffled voice. A child with croup is usually less toxic and may look relatively well between coughing spells.

Onset, age and cause

Croup usually affects children between six months and three years, follows a viral cold, most often parainfluenza, and develops over a day or two with symptoms worse at night. It typically lasts several days. Mild cases are managed at home, while moderate to severe cases receive steroids and sometimes nebulised epinephrine.

Epiglottitis develops over hours with high fever and severe sore throat. It was classically caused by Haemophilus influenzae type b and is now rare where Hib vaccination is routine. Ask about immunisation history, because an unvaccinated child with sudden severe sore throat and drooling raises concern.

For croup at home, cool or moist air and fever medicine may help comfort, and cough medicines are not useful. Parents should know the escalation signs in advance, because night-time worsening can be frightening and families need to tell a manageable barking cough from true respiratory distress.

Overlap: stridor alone cannot separate them

Both conditions can cause stridor, respiratory distress, retractions and anxiety. Severe croup can also cause stridor at rest, cyanosis and exhaustion, so stridor is a severity signal rather than a diagnostic one. Neck X-rays may show a steeple sign in croup and a thumb sign in epiglottitis, but imaging should never delay airway management in an unstable child.

Drooling or trouble swallowing in a child believed to have croup is a warning that the diagnosis may be wrong or the airway is worsening. The nurse escalates rather than continuing routine croup care.

Stridor at rest or worsening stridor, chest retractions or blue lips in any child with upper airway symptoms need emergency help, whichever diagnosis is suspected.

Why the throat is not examined in suspected epiglottitis

Examining the pharynx with a tongue depressor, or anything that upsets the child, can trigger complete airway obstruction in epiglottitis. Do not attempt to look in the throat, take a throat swab, lie the child flat or separate the child from the parent. Keep the child calm and upright in the position they choose, and call for urgent airway expertise.

Airway assessment and intubation are performed by experienced staff in a controlled setting with resuscitation equipment ready. Intravenous access and blood tests may wait until the airway is secured, because a frightening procedure can precipitate obstruction. Antibiotics are started once epiglottitis is diagnosed, according to prescriber orders.

Worked scenario: what the nurse does first

A hypothetical four-year-old with no recorded immunisations arrives with high fever, drooling, a muffled voice and sits leaning forward on his mother's lap. Options are inspecting the throat with a tongue depressor, inserting an intravenous cannula, or keeping him calm with his mother and summoning airway help. Keeping him calm and escalating is correct.

Contrast a two-year-old who woke at night with a barking cough and mild stridor only when crying. Croup care applies: calm the child, assess work of breathing and give prescribed steroids. Local pathways determine the exact response, but upsetting the child is avoided in both conditions.

Sources and further reading

MSD Manual Professional: Croup. Age, parainfluenza cause, barking cough and stridor, steeple sign, steroids and epinephrine, and contrast with epiglottitis.

MSD Manual Professional: Epiglottitis. Hib and vaccination, drooling without barking cough, tripod position, avoiding throat examination and airway priority.

MedlinePlus: Croup. Seal-like cough worse at night and emergency warning signs including drooling and stridor at rest.