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diagnostic tools for croup Radiographs are not necessary, in the evaluation of routine clinically diagnosed croup However, anteroposterior and lateral neck radiographs should be obtained if the diagnosis of croup is in question or if the child does not respond to therapy as expected If supraglottitis is strongly suspected, a lateral neck radiograph should only be obtained in stable and cooperative patients Otherwise the child should have their airway secured by the most senior or skilled clinician prior to other interventions, in the controlled setting of the operating room whenever possible Airway radiographs must be interpreted with care because they are affected by positioning, crying, swallowing, and the phase of respiration To properly interpret the prevertebral space, the lateral neck radiograph must be taken with the patient’s head extended and during inspiration Normal tracheal buckling, which is seen during expiration in a young child, may be misinterpreted as tracheal mass lesion or deviation from an extrinsic mass ( Fig 75.2 ) Abnormal findings on a lateral neck radiograph include a swollen epiglottis or aryepiglottic folds (supraglottis), irregular tracheal borders or stranding across the trachea (bacterial tracheitis), and increased prevertebral width (retropharyngeal abscess) ( e-Figs 75.1 and 75.2 ) In children, the prevertebral space should be less than the width of the adjacent cervical vertebral body Radiographic findings consistent with croup are a narrowed subglottic area on anteroposterior view (the “steeple sign”) and possibly ballooning of the hypopharynx best appreciated on the lateral view Afebrile Child In the afebrile child with acute onset of stridor, the child’s age, the duration of symptoms, and the likelihood of foreign-body aspiration are all key elements to consider Emergent otolaryngologic or surgical consultation should be obtained in a child with an evidence of airway obstruction if either aspirated foreign body or trauma is a likely cause of stridor Stridor from anaphylaxis follows exposure to an allergen, and may be associated with vomiting, wheezing, facial or oral edema, urticaria, or hypotension Angioneurotic edema, an autosomal-dominant trait, is characterized by rapid onset of swelling without discoloration, urticaria, or pain Symptoms may occur in affected patients as young as years of age but usually are not severe until adolescence Symptoms may be precipitated by trauma, emotional stress, or menses Determination of the C1 -esterase inhibitor level should be considered if angioneurotic edema is suspected (See Chapter 85 Allergic Emergencies )