Recurrent 'Croup' in a Toddler at a District Hospital
A 22-month-old boy (11.5 kg) is brought to a district hospital at 22:00 with noisy breathing at rest that began 4 hours earlier. He has had six episodes labelled 'croup' in the past 14 months; three required nebulised adrenaline and all improved with dexamethasone. He is afebrile, not drooling, and drinking sips. There is biphasic stridor with mild suprasternal recession, respiratory rate 38/min, SpO2 94% on room air, and no barking cough. He received dexamethasone 0.6 mg/kg and one nebulised adrenaline dose with partial improvement. He has grown along the 25th centile, has no witnessed choking episodes, and was never intubated as a neonate. The nearest paediatric ENT unit is 90 minutes away by road and has no overnight operating capacity. An on-call anaesthetist is available, and a second adrenaline dose is being prepared.
1. What are your immediate airway priorities, and which features in this history and examination most strongly suggest a structural rather than recurrent viral aetiology? Justify your reasoning.
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Immediate priorities
- Keep the child calm, upright on the parent's lap; avoid forced intravenous access, throat examination or lying flat, all of which can precipitate complete obstruction.
- Continuous SpO2/HR monitoring, oxygen if tolerated, and a second nebulised adrenaline dose while observing response over 20–30 minutes.
- Alert anaesthesia and prepare a difficult-airway plan: age-appropriate tube 0.5–1.0 mm smaller than predicted, videolaryngoscope, and surgical airway equipment. Do not paralyse or instrument the airway outside theatre unless obstruction is imminent.
Why structural disease is likely
- Six episodes in 14 months is far above expected; recurrent croup usually has a viral prodrome, fever and barking cough, none of which are present now.
- Biphasic (inspiratory and expiratory) stridor at rest suggests a fixed laryngeal/tracheal lesion rather than the variable subglottic oedema of viral croup, which is predominantly inspiratory.
- Only partial response to adrenaline, absent fever and normal swallowing argue against simple croup or epiglottitis.
- The differential includes subglottic stenosis (congenital or post-intubation), subglottic haemangioma (typically 1–6 months, worse with crying), recurrent respiratory papillomatosis (hoarseness, progressive) and occult foreign body.
- Absence of a choking history reduces but does not exclude foreign body; a normal chest radiograph does not exclude it.
2. Which investigations would you arrange before and during definitive assessment, and why is rigid endoscopy reserved for the operating theatre?
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Before transfer
- Flexible nasolaryngoscopy by the most experienced available clinician, without sedation, can identify supraglottic/laryngeal pathology and vocal cord mobility; it is low-risk if the child is stable and cooperative, and it should not delay transfer if the child is deteriorating.
- Do not perform rigid laryngoscopy or blind intubation in the emergency department; manipulation can convert partial obstruction into complete obstruction, and bleeding or oedema may make rescue impossible.
- Plain neck and chest films are of limited value; they may suggest a foreign body or narrowing but cannot exclude either. They should not delay definitive care.
- Blood gases and routine bloods add little and distress the child.
Definitive assessment
- Microlaryngobronchoscopy under general anaesthesia with spontaneous ventilation, in theatre with ENT and anaesthesia present, tracheostomy set open, and the child breathing on a maintained airway. This allows grading of stenosis (Cotton–Myer), biopsy of a mass, and removal of a foreign body.
- If intubation is required before theatre, use a smaller tube and avoid multiple attempts, since each pass worsens subglottic injury.
- Contrast-enhanced MRI is useful if a subglottic haemangioma is suspected but should follow, not precede, airway control.
3. Assuming microlaryngoscopy shows a circumferential firm subglottic narrowing with no mass, how would you manage the child and counsel the family?
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Interpretation A firm circumferential narrowing without a mass is consistent with subglottic stenosis. Grade it by Cotton–Myer (grade I <50%, II 51–70%, III 71–99%, IV no lumen). In a 22-month-old with recurrent presentations and no neonatal intubation, congenital or acquired (occult intubation, reflux-related) stenosis is possible.
Management by grade and symptoms
- Grade I–II with mild symptoms: observe, treat reflux if present, avoid unnecessary intubation, and manage intercurrent viral infections early with steroids and adrenaline.
- Grade II–III with recurrent severe episodes or failure to thrive: endoscopic balloon dilatation with or without radial incisions is first-line; repeat as needed.
- Grade III–IV or failed endoscopic treatment: anterior cricoid split or laryngotracheal reconstruction; tracheostomy may be needed as a bridge or definitive option in severe cases.
Counselling
- Recurrent 'croup' admissions are not benign; each episode carries obstruction risk, and any future respiratory illness needs a low threshold for steroid and early review.
- Explain that definitive treatment is staged, may require more than one procedure, and carries risks of restenosis, voice change and, rarely, tracheostomy.
- Give a written airway emergency plan, ensure the family knows to call emergency services rather than drive, and arrange follow-up at the tertiary unit with an endoscopy plan.