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Recurrent croup presentation, diagnosis, and


management

Article in American Journal of Otolaryngology November 2007


DOI: 10.1016/j.amjoto.2006.11.013 Source: PubMed

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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407
www.elsevier.com/locate/amjoto

Recurrent croup presentation, diagnosis, and managementB


Kelvin Kwong, MHSca, Michael Hoa, MDb, James M. Coticchia, MDb,4
a
Wayne State University School of Medicine, Detroit, MI
b
Department of Otolaryngology, Wayne State University, School of Medicine, Detroit, MI
Received 10 October 2006

Abstract Purpose: The lack of clinical insight into recurrent croup often leads to underdiagnosis of an upper
airway lesion, and subsequently, inadequate treatment. This study examined the underlying etiology,
diagnosis, treatment, and clinical outcome of patients with a history of recurrent croup identified at
initial presentation. The aim was to present common diagnostic features and suggest new diagnostic
and management recommendations.
Materials and methods: A retrospective chart review of 17 children diagnosed with recurrent croup.
Demographic, historical, and intraoperative data as noted in clinic charts were collected. Specific
collected data included age, sex, chief complaint, presenting symptoms, past medical history,
previous medication history, number of emergency room visits and inpatient admissions, tests/
procedures performed and corresponding findings, current treatment given, and posttreatment
clinical outcome.
Results: Six (35.3%) patients presented initially with a past medical history of gastroesophageal
reflux disease. Fourteen (82.3%) patients had positive endoscopic evidence of gastroesophageal
reflux. For these 14 patients, 44 laryngopharyngeal reflux lesions were noted, with 32 (72.7%)
occurring in the subglottis. All 14 patients demonstrated various degrees of subglottic stenosis
ranging from 30% to 70% (Cotton-Myer grade I-II). All 17 patients (100%) demonstrated subglottic
stenosis ranging from 15% to 70% airway narrowing.
Conclusions: History suggestive of recurrent croup requires close monitoring and expedient direct
laryngoscopy/bronchoscopy for diagnosis. Long-term follow-up and antireflux treatment are
necessary as well as endoscopic documentation of significant reflux resolution.
D 2007 Published by Elsevier Inc.

1. Introduction population followed up for the first 4 years of life [1]. Despite
the relatively common nature of this problem, this clinical
Recurrent croup is a clinical entity characterized by
entity is not well described and is distinct from viral croup or
repeated bouts of croup-like cough that occur in a relapsing
laryngotracheobronchitis in terms of etiology and differential
and remitting nature that worsen with the onset of upper
diagnoses. Viral croup, typically preceded by a prodrome of
respiratory tract infection s (URIs), that persist for weeks in a
URI, is an acute infection characterized by hoarseness,
relapsing and remitting nature, and that reflect an exacerba-
barking cough, various degrees of inspiratory and/or expira-
tion of a localized airway process. That being said, recurrent
tory stridor, and expiratory rhonchi. These symptoms suggest
croup is a relatively common problem in the pediatric
involvement of the larynx, subglottis, and lower respiratory
population, with a reported incidence of 6.4% in the infant
tract, respectively. Viral croup is the most common cause of
upper airway obstruction among children aged between
B
Financial support: Medical research grant from the Department of 6 months to 6 years [2]. The incidence of the infection
Otolaryngology, Wayne State University. exhibits a seasonal pattern, peaking when parainfluenza type
4 Corresponding author. Department of Otolaryngology, Wayne State
University, 4201 St. Antoine, 5E-UHC, Detroit, MI 48201, USA. Tel.: +1
1, respiratory syncytial virus, and influenza activities are
313 577 0804. highest. Despite its mild and self-limited nature, this infection
E-mail address: jcoticch@med.wayne.edu (J.M. Coticchia). occasionally results in severe airway obstruction with a
0196-0709/$ see front matter D 2007 Published by Elsevier Inc.
doi:10.1016/j.amjoto.2006.11.013

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402 K. Kwong et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407

reported hospitalization rate ranging from 1.3% to 2.6% [3]. Table 2


Certain patients have multiple bouts of croup-like symptoms Endoscopic findings by location
similar to viral croup, except that antecedent or concurrent Supraglottic Glottic Subglottic
URI may or may not be associated. Although recurrent croup Arytenoid edema 7
has been characterized by a constellation of signs and Interarytenoid edema 3
Granular changes to epiglottis 1
symptoms, it is not a specific diagnosis in itself [4]. Indeed,
Granular changes to 1
recurrent croup may represent a manifestation of different true vocal cords
underlying airway narrowing processes. Initial studies in the SGS 17
1970s and 1980s suggested a correlation between recurrent Carinal blunting 8
croup and reactive airway disease (RAD) together with other Mucosal cobblestoning 4
Subglottic shelf 3
allergic diseases [5-9]. More recent studies have shifted the
Total findings 11 1 32
focus to examining the etiologic association between
recurrent croup and upper airway disease processes, such as
gastroesophageal reflux (GER), subglottic stenosis (SGS), All patients underwent diagnostic direct laryngoscopy/
and other airway narrowing diseases [4,10-12]. The lack of bronchoscopy (DLB) with rigid equipment as part of a
insight into the underlying etiology of recurrent croup often diagnostic workup of recurrent croup. Endoscopic findings
leads to misdiagnosis or underdiagnosis of an upper airway of any anatomic abnormalities and pathologic changes in the
lesion and therefore results in improper or inadequate airway were noted at the time of DLB. Some patients
treatment. The objective of this retrospective study was to underwent follow-up DLB for clinical reassessment. In
review the underlying etiology, diagnosis, treatment, and addition, 2 patients underwent esophagoscopy with biopsy.
clinical outcome of patients with a history of recurrent croup All endoscopic evaluations and grading of stenosis were
identified at initial presentation. performed by the senior author, who has performed over a
thousand DLBs, at a university-affiliated tertiary care hospital.
Endoscopic findings, considered to be suggestive of patho-
2. Methods genic GER, included erythema and edema of the arytenoids
After approval from institutional review board was and posterior glottis, SGS, edematous and erythematous
obtained, medical records of 17 infants and children who tracheal mucosa, blunting of the tracheal carina, esophageal
were referred to the otolaryngology outpatient clinic with a strictures and signs of esophagitis, and visualized active reflux
history of recurrent croup between January 2005 and May during esophagoscopy. In patients with SGS, DLB was used to
2006 were reviewed. Recurrent croup was defined as 2 or assess the degree of stenosis in percentage obstruction and
more episodes of croup-like symptoms including barking Cotton-Myer classification (C-M grade) by comparing the
cough, hoarseness, inspiratory stridor, with or without individuals endoscope size with the age-appropriate size.
dyspnea, either confirmed medically or reported by parent. Although C-M classification is the most widely used grading
In this retrospective case series, the collected data included system of SGS, we think that the ability to grade smaller
age, sex, chief complaint, presenting symptoms, past changes in SGS with percentage stenosis allows judgements
medical history (PMH), previous medication history, num- on clinical improvement in a more detailed fashion.
ber of emergency room visits and inpatient admissions, Current treatment given for each patient was recorded,
tests/procedures performed and corresponding findings, and the treatment outcome represented by resolution or
current treatment given, and posttreatment clinical outcome. improvement of recurrent croup symptoms was followed up
prospectively in historical time. To reduce the confounding
Table 1 effect of multiple treatments, the clinical outcome following
Study findings a single type of treatment was studied. Specifically, cure was
Average age at first visit 3.9 (2.5 mo-11 y) defined as patients with gastroesophageal reflux disease
Male-to-female ratio 13/17 (3.25:1) (GERD) who achieved symptom-free status while on
% Patients having PMH of RAD 13/17 (76.5%) antireflux treatment in the absence of other medical treat-
% Patients having allergy 5/17 (29.4%) ments (eg, antibiotics). Detailed case descriptions of
% Patients having PMH of GERD 6/17 (35.3%)
2 selected patients were also included in this study.
% Patients with endoscopic 14/17 (82.4%)
evidence of GERD
% Patients with endoscopic GER changes 15/15 (100.0%)
having positive endoscopic SGS finding
3. Results
% Patients with endoscopic 17/17 (100.0%) The medical records of 17 children with a history of
confirmed dx of SGS
% Patients with endoscopically confirmed 15/17 (88.2%)
recurrent croup-like symptoms were reviewed. The summa-
SGS having confirmed dx of GERD ry of findings is shown in Table 1. The studied patients
% Patients with sx improvement after 13/17 (76.5%) consisted of 13 males and 4 females (male-to-female ratio,
starting antireflux medications 3.25:1). The mean age at initial visit was 3.9 years, with a
dx, diagnosis; sx, symptomatic. range between 2.5 months and 11 years. Of the 17 studied

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K. Kwong et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407 403

Fig. 1. Pathogenesis of viral croup versus recurrent croup. Fig. 3. Posttreatment DLB findings.

eal changes seen in DLB, and 1 had an esophagogastroduo-


patients, 13 (76.5%) had a PMH of RAD. Among them, denoscopy done by an outside physician demonstrating
5 (29.4%) had a prior history of allergy or atopic disease. Of reflux esophagitis. The remaining 3 patients, despite the
the 17 patients, 6 (35.3%) presented initially with a PMH of absence of endoscopic evidence of GER, were found to have
GERD. All patients underwent endoscopic evaluation. SGS between 15% and 70% (C-M grade I-II), meaning
Of 17 patients, 14 (82.3%) had positive endoscopic 100% of our studied patients with recurrent croup demon-
evidence of GER. All 14 patients demonstrated various strated a localized narrowing in the airway. No elliptically
degrees of SGS ranging from 30% to 70% (C-M grade I-II). shaped cricoid cartilage was noted in any these patients.
Among these patients, 13 had GER-related laryngopharyng- Of the endoscopic findings of GER-related changes, 32
(72.7%) of 44 lesions were noted at the level of the

Fig. 2. Pretreatment DLB findings. Fig. 4. Diagnostic and management algorithm.

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404 K. Kwong et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407

subglottis in the form of either mucosal cobblestoning, barking cough. The age at first visit of our studied
SGS, a subglottic shelf, or carinal blunting (Table 2). All population ranged from 2.5 months to 11 years, with an
17 patients were started on antireflux medications. Thirteen average of 3.9 years. There was a strong male preponder-
(76.5%) patients demonstrated clinical improvement as ance in our patients, which was also observed in other
noted by shortened duration of croup-like episodes, de- studies [1,5,13]. Besides the croup-like symptoms, our
creased symptom severity, or the patient becoming asymp- patients also presented with other symptoms including nasal
tomatic. These 13 patients all had positive endoscopic congestion, rhinorrhea, apneic pauses, and/or intercostal
evidence of laryngopharyngeal reflux-related changes. retractions. Although the data suggest that recurrent croup
episodes were commonly preceded by a URI challenge,
3.1. Case 1
some patients experienced recurrent episodes in absence of a
TM was a 3-month-old male who presented with a URI prodrome or symptoms. Typically, a recurrent croup
2-month history of recurrent croup-like cough and inspira- episode could last from several days to weeks. There was a
tory stridor. The patients mother noted that episodes of seasonal variation in these patients coinciding with the peak
intermittent croup-like cough would last for 1 to 2 weeks at of respiratory tract infection in the fall and winter months.
a time and would be exacerbated by upper respiratory tract Our patients were referred by primary care physicians,
infections. The patient had no known drug allergies and had general pediatricians, and pediatric subspecialists for
no significant PMH. On examination, the patient was noted a history of bcroupy cough,Q bstridor,Q or bairway evalua-
to have croup-like cough with inspiratory stridor. In tion.Q Most of our patients (76.5%) had a PMH of RAD.
addition, costal and subcostal retractions were noted. Nevertheless, none of the patients presented with wheezing,
Remainder of physical examination was normal. Endoscop- rhonchi, or other symptoms or signs of lower respiratory
ic findings at the first DLB included 50% SGS (C-M grade tract involvement. Atopic symptoms were only found in 5
I), arytenoid and interarytenoid edema, carinal blunting, and (29.4%) of the 17 patients. Many of them were treated with
mucosal cobblestoning. In the subsequent DLB after maximized doses of RAD medications in an attempt to
antireflux treatment, SGS was reduced to 15% to 20% control the aforementioned symptoms. Despite aggressive
(C-M grade I) with minimal GER-related mucosal changes. medical therapy for RAD, there was no documented
improvement in clinical symptoms.
3.2. Case 2
Although having not been well defined, spasmodic croup
JB was a 7-year-old boy who presented with a history of a is often referred as a type of afebrile croup with a sudden
persistently intermittent croup-like cough that worsened in onset, almost always at night or during sleep, significantly
the presence of upper respiratory tract infections. Parents associated with inspiratory stridor and respiratory distress,
related frequent upper respiratory tract infections distributed and usually responds well to humidification [12]. The
throughout fall, winter, and spring, with 8 of 10 episodes proposed pathophysiologic mechanism is spasm of the
associated with a croup-like paroxysmal cough. The patient larynx related to allergy, psychological causes, URI, and/or
noted the presence of an intermittent cough at least 1 to 2 times GERD. The disease can be recurrent and usually subsides
per day. Multiple visits to the emergency department spontaneously [12]. Sharing some common characteristics
averaging 1 to 2 times per month along with multiple steroid with recurrent croup, spasmodic croup may indeed represent
treatments were noted by the patients mother. The patient a clinical entity that fits into the pathophysiologic model
had no known drug allergies. Past medical history was proposed later in this section.
notable for IgG immunodeficiency. Physical examination The comparison between recurrent croup and viral croup
of the patient was essentially unremarkable. Endoscopic reveals that the 2 conditions indeed represent 2 different
findings at the initial DLB included 40% SGS (C-M grade II), clinical entities. First, the recurring nature distinguishes
subglottic shelf, and mild arytenoid erythema and edema. recurrent croup from viral croup, which tends not to recur
Repeat examination of the patient revealed an improvement within the same year unless the patient is immunocompro-
to 15% SGS (C-M grade I) on DLB in addition to mised or infected by a different strain of pathogen. Second,
symptomatic improvement as noted on clinical examination. viral croup first starts as an acute infection of the nasal and
pharyngeal mucosa and then extends downward along the
respiratory tract to the larynx, subglottic region, trachea, and
4. Discussion even bronchi in severe cases. The involvement of the lower
4.1. Characterization of recurrent croup respiratory tract, especially the intrathoracic segment,
manifests as expiratory stridor, rhonchi, or wheezing. In
Despite being a relatively common condition in infant contrast, recurrent croup involves mainly the upper airway
and pediatric populations, recurrent croup has not been well and spares the lower respiratory tract in most cases,
described in previous literature in terms of its epidemiology, as suggested by the lack of rhonchi and wheezing in its
natural history, and etiology. Recurrent croup is commonly clinical manifestation.
defined as recurring episodes (more than 2) of croup-like The 2 differences between recurrent croup and viral
symptoms, such as hoarseness, inspiratory stridor, and croup suggest that the pathogenesis of the 2 conditions is

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fundamentally distinct. The recurrent nature and the lack of ingly, in our patients with recurrent croup, GERD may have
lower respiratory tract involvement (ie, less severe infec- been largely undiagnosed, as suggested by the observation
tion) indicate that recurrent croup has a lower threshold to that only 35% of our studied patients had a past diagnosis of
clinically significant airway obstruction. This is reinforced GERD. Several other studies document the prevalence of
by the fact that a recurrent croup episode is not always GERD in patients with recurrent croup. In an inpatient study
preceded by URI challenge or prodrome, meaning that of children admitted for recurrent croup (2 or more episodes),
minimal insult or irritation to the subglottic mucosa can GERD, which was documented by scintiscan, esophago-
make patients with recurrent croup become symptomatic. scopy, pH probe, and barium swallow study, was found in 15
All of these observations point toward a plausible explana- (47%) of 32 subjects [13]. Among 16 children with 3 or more
tion that all patients with recurrent croup have a baseline episodes, 10 (65%) had a diagnosis of GERD. In an
airway narrowing caused by various etiologies. When esophageal biopsy study, 12 (75%) of 16 children with a
challenged with URI or other airway irritating processes, recurrent croup history had positive esophageal biopsy
the additional edematous mucosal changes further constrict results [12]. Using a double pH probe, Contencin and Narcy
the already narrowed airway, therefore causing clinically [16] observed pharyngeal and esophageal reflux in 8 (100%)
significant obstruction (Fig. 1). To adequately control and of 8 children with recurrent croup.
treat recurrent croup, it is essential to find the true under- In addition to the high prevalence of GERD, the outcomes
lying cause of the existing baseline airway narrowing in of antireflux treatment in our patients give us further insight
the patients. into the relationship between GERD and recurrent croup.
Among 14 patients with positive endoscopic finding of
4.2. Etiologies of the baseline airway narrowing GER, 12 of them showed either improvement or resolution
of recurrent croup symptoms after starting the antireflux
4.2.1. Recurrent airway disease as an etiology versus medications. Gastroesophageal reflux diseaserelated mu-
comorbidity of recurrent croup cosal changes were also improved in the patients who had
The association between recurrent croup and RAD was posttreatment follow-up endoscopic evaluation (Fig. 2 vs 3).
frequently reported in various earlier studies [5-7,14-16]. In This observation provides suggestive evidence that GERD is
these studies, the reported percentages of recurrent croup either a cause or a significant contributing factor to recurrent
patients with RAD range from 40.4% to 82%, which is in episodes of croup.
good agreement with our finding of 76.5%. Despite the
significant association, prior studies have been unable to 4.2.3. Subglottic stenosis
conclusively demonstrate a cause-and-effect relationship. Another striking finding in our study is that 17 (100%) of
Neither temporality nor positive dose-response relationships the 17 studied patients had positive endoscopic findings of
between RAD and recurrent croup have been demonstrated. various degree of SGS ranging from 30% to 70% (C-M
In addition, no plausible biological mechanism can fully grade I-II). Compared to other recurrent croup studies, SGS
explain the proposed hypothesis. Finally, inconsistency in was much more common in our studied patients. Waki et al
the association of recurrent croup and atopic diseases further [13] noted that 8 (25%) of their 32 patients with recurrent
undermines the proposed causal link between RAD and croup demonstrated anatomical airway abnormalities in-
recurrent croup [7-9]. cluding SGS and laryngomalacia. Farmer and Wohl [4]
Certain findings in our study argue against the causative reported that 24 (45%) of their 53 pediatric patients with
role of RAD in reproducing recurrent croup episodes. First, recurrent intermittent airway obstruction had airway nar-
most patients remained symptomatic and continued to have rowing such as acquired laryngotracheal stenosis, congenital
recurrent croup episodes despite medically maximized cricotracheal abnormality, and subglottic hemangioma. In
therapy for RAD. Furthermore, none of the patients particular, our findings support the hypothesized pathophys-
presented with wheezing, rhonchi, or other symptoms/signs iologic mechanism that all recurrent croup patients have
suggestive of lower respiratory tract involvement. Finally, a a certain degree of baseline subglottic narrowing, which
high percentage of the patients (82.4%) demonstrated lowers their threshold to clinically significant airway
endoscopic findings of laryngopharyngeal reflux. Together obstruction and makes the patient more prone to recurrent
with its documented association with RAD, GERD is likely croup episodes.
an inducing or exacerbating factor for asthmatic symptoms, Subglottic stenosis can either be congenital or acquired.
hence plausibly explaining the high incidence of RAD The former is less common and is usually seen in patients
among recurrent croup patients. born with small elliptically shaped cricoid cartilage [17].
The causes of acquired SGS include traumatic intubation,
4.2.2. Gastroesophageal reflux disease as a common finding infection [18-33], and GERD [21-23]. Various animal
in our studied patients models have been used to demonstrate these etiologic
In this study, GER changes in the laryngotracheal portion causes of SGS. Using a canine model, Klainer et al [24]
of the airway were very common endoscopic findings, found complete ciliary denudation after 2 hours of
observed in 82.3% of our recurrent croup patients. Interest- intubation with a minimally occlusive low-pressure cuff.

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406 K. Kwong et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407

Squire et al [19] demonstrated that rabbits with intratracheal (Fig. 4). First, a thorough history and physical should be
bacterial inoculation using Staphylococcus aureus had obtained to establish the recurrent croup status. The relevant
narrower stenoses than those that remained noninfected. symptoms include hoarseness, barking cough, and various
Gaynor [21] observed severe mucosal ulceration and degrees of inspiratory and/or expiratory stridor that recur
necrosis in rabbit tracheas irrigated with synthetic gastric more than 2 times. Second, presence of URI symptoms, such
juice of pH 1.4 and pepsin, as compared with controls with as fever, nasal discharge, congestion, and sore throat, should
saline, which demonstrated no significant mucosal changes. be assessed. If the patient has persistent URI symptoms more
Koufman [25] reported a similar finding as well as healing than a few days, antibiotic treatment is administered to treat
delay of subglottic submucosal injuries in a canine model. the superimposed bacterial infection. The next step is assess-
Although the relative contribution of various etiologies to ment of potential baseline airway narrowing using DLB,
SGS in patients with recurrent croup remains unclear, which provides direct visualization of any potential narrow-
several findings in our study may provide further insight ing and bsilentQ laryngopharyngeal manifestations of GER.
into this particular issue. Direct laryngoscopy/bronchoscopy should be performed
In this study, positive endoscopic findings of laryngo- when the patient is free of respiratory tract infections, which
pharyngeal manifestation of GER were found in 14 (82.4%) may cause airway edema that hinders the ability to detect
of 17 patients with endoscopically confirmed SGS. This baseline airway changes. If DLB is positive for SGS and/or
prevalence of laryngopharyngeal GER finding among SGS laryngopharyngeal reflux findings such as erythema and
patients was in good agreement with previous studies. In a edema of arytenoids and posterior glottis, edematous and
study of 19 patients with SGS undergoing 24-hour erythematous tracheal mucosa, and blunting of the carina,
ambulatory pH probe testing with 3- or 4-port probes, antireflux medication together with dietary and lifestyle
Maronian et al [26] reported that a pH of less than 4 was modifications should be started immediately to control the
recorded at the level of larynx in 12 (86%) of the 14 tested GER. Initial conservative management includes avoidance
patients. Yellon et al [27] also demonstrated in a series of 36 of food containing high amounts of fat, chocolate, pepper-
children with SGS who underwent laryngotracheal recon- mint, caffeine, and citrus ingredients; frequent small meals
struction, that 21 (81%) of the 26 tested patients had at least taken well before bedtime; elevation of the head of the bed;
1 positive test for GERD. Although the prevalence of and weight loss for obese children. Initial pharmacologic
pathologic GERD is estimated to be only 20% and 8% in treatment includes H2 blockers, such as ranitidine or
infants and children after 12 months of age, respectively, the cimetidine, in combination with prokinetic agents (eg,
elevated GERD prevalence in patients with SGS supports metoclopramide). We routinely prefer the use of ranitidine
the hypothesis that GERD may play an important role in the over cimetidine because of its higher potency, longer
etiology of SGS [28]. duration, and less frequency of adverse effects and drug
The outcome of antireflux treatment could provide further interaction [31,32]. Cases refractory to the above initial
evidence on the association between GERD and SGS. Four pharmacologic treatment may require a proton-pump inhib-
of our studied patients underwent a second DLB follow-up itor (PPI), such as omeprazole or lansoprazole. Proton-pump
after antireflux treatment. Of the 4 patients, 4 (100%) demon- inhibitors are generally safe and well-tolerated medications
strated an improvement or reduction in stenosis by a in both adults and children [33,34]. Given the limited data
magnitude ranging from 10% to 30%. Pretreatment/Post- and evidence, multicenter studies are needed to investigate
treatment endoscopic findings of a patient demonstrating the safety profile of the long-term use of PPIs, particularly in
30% stenosis reduction are shown in Fig. 2 (70% stenosis) pediatric populations.
and Fig. 3 (40% stenosis), respectively. Similarly, Jindal et al Although 24-hour pH probe monitoring remains the gold
[29] reported that 7 of 7 women with idiopathic SGS who standard of diagnosing GERD, endoscopic studies have
initially failed to respond to all conservative measures and been shown to demonstrate good correlation with histolog-
radical surgical intervention required GERD medical treat- ical studies. In an esophageal biopsy study done by Yellon
ment for symptom resolution. In her study of 25 pediatric et al [12], if an erythematous or edematous posterior glottis
SGS patients, Halstead [23] reported that the failure rate of was noted, the esophageal was positive 83% and 81% of the
endoscopic repair dropped dramatically after aggressive time, respectively. Patients should then be followed up a
preoperative GER treatment when compared with the month after starting the antireflux medications. In patients
historical controls and additionally noted that 35% avoided with SGS higher than 50% to 60%, DLB should be done in
surgical intervention. Gray et al [30] also described the
3 months to follow the progression of the condition. In cases
improvement in laryngotracheoplasty outcomes with aggres-
refractory to antireflux treatment, esophagogastroduodeno-
sive antireflux treatment.
scopy is recommended. Referral to gastrointestinal sub-
specialty and pediatric surgery for potential surgical inter-
4.3. Management of recurrent croup
vention for GERD may be necessary. Patients with negative
We are proposing a diagnostic and management algorithm DLB findings should be observed closely for any future
for patients presenting with recurrent croup-like symptoms recurrent episodes and condition progression.

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K. Kwong et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 28 (2007) 401 407 407

5. Conclusion [12] Yellon RF, Coticchia J, Dixit S. Esophageal biopsy for the diagnosis
of gastroesophageal reflux-associated otolaryngologic problems in
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