Croup in Adults: A Clinical Rarity Requiring Alternative Diagnosis
Croup is fundamentally a pediatric disease and does not occur in adults with normal anatomy. If an adult presents with symptoms suggestive of croup (barking cough, stridor, hoarseness), you must immediately consider alternative diagnoses including epiglottitis, foreign body aspiration, angioedema, laryngeal tumor, or infectious laryngotracheitis from other causes 1.
Why Croup Doesn't Occur in Adults
- Croup is caused by viral infection (primarily parainfluenza viruses types 1-3) that produces subglottic edema and inflammation 2, 1
- The adult airway anatomy has a significantly larger diameter than pediatric airways, making clinically significant subglottic narrowing from viral infection extremely unlikely 2
- All published guidelines and research on croup specifically address pediatric populations (ages 4 months to 5 years) 3, 1, 4
Critical Differential Diagnoses to Consider
When an adult presents with barking cough and stridor, immediately evaluate for:
- Epiglottitis: Assess for drooling, inability to swallow, toxic appearance, and high fever 1
- Foreign body aspiration: Obtain history of choking episode or sudden onset of symptoms 1
- Angioedema: Check for facial swelling, recent ACE inhibitor use, or allergic triggers 1
- Bacterial tracheitis: Look for high fever, toxic appearance, and purulent secretions 5
- Peritonsillar or retropharyngeal abscess: Examine for unilateral throat swelling, trismus, or neck mass 1
- Laryngeal malignancy: Consider in patients with chronic hoarseness, smoking history, or progressive symptoms 1
Immediate Management Approach
If stridor is present at rest, this represents a medical emergency requiring immediate airway assessment and otolaryngology consultation 3, 1.
Diagnostic Workup
- Perform direct visualization of the upper airway via laryngoscopy to identify the anatomic cause 5
- Obtain lateral neck radiograph if epiglottitis is suspected (but do not delay definitive airway management) 1
- Consider CT imaging of the neck and chest if mass lesion or abscess is suspected 1
Symptomatic Management While Establishing Diagnosis
If the patient has isolated cough without stridor or respiratory distress while you complete your workup:
- Simple home remedies like honey and lemon provide first-line symptomatic relief 6, 7
- Dextromethorphan 60 mg provides maximum cough suppression if pharmacological treatment is needed 6, 7
- First-generation antihistamines can be used for nocturnal cough 6, 7
Common Pitfall to Avoid
Do not treat an adult with "croup-like" symptoms empirically with corticosteroids and nebulized epinephrine without establishing the underlying diagnosis. While these are standard pediatric croup treatments 1, 4, using them in adults without identifying the actual pathology may delay recognition of serious conditions like epiglottitis or laryngeal cancer that require entirely different management 1.