21/36. Spasmodic croup in the adult. Recurrent inspiratory stridor, for which there appears to be no organic basis, can present a serious medical problem. We measured the changes in cross-sectional area of the glottic aperture during the respiratory cycle in a patient with recurrent inspiratory stridor when she was well, during a spontaneous attack, and during one induced with histamine aerosol. The glottis was visualized using a fiberoptic bronchoscope passed transnasally and attached to a video camera and tape recorder. During stridor there was marked constriction of the glottis on inspiration and phase reversal of the normal movements of the vocal cords with respect to respiration. Intermittent positive pressure ventilation (IPPV) and continuous positive airway pressure (CPAP) applied during stridor, in the absence of inspiratory effort, reversed the glottic narrowing. Pulmonary resistance (RL) on inspiration was elevated during stridor and returned to normal during IPPV and CPAP. Expiratory RL was normal throughout. Our results show that stridor in this patient was due to dynamic inspiratory constriction of the vocal cords. Glottic constriction could be induced by histamine aerosol and reversed when lung inflation was unaccompanied by inspiratory effort during IPPV and CPAP. Recognition and appropriate management of this condition may avoid potentially dangerous therapeutic interventions. ( info) |
22/36. Radiolucent intratracheal foreign body mistaken for croup in a 9-year-old boy. Stridor was present for at least three months in a 9-year-old boy whose cervical trachea contained granulation tissue in association with a chronically enlodged plastic wheel, 1.8 cm in diameter. Roentgenograms revealed irregularly lobulated narrowing of the cervical trachea. Our clinical impression was croup until bronchoscopic examination led to removal of the toy. We could elicit no history of aspiration. Chronic stridor in association with a radiolucent intratracheal foreign body is unusual in the absence of a history of aspiration. ( info) |
23/36. Pseudomembranous croup. During a 2-year period, 7 children were seen with a severe form of laryngotracheobronchitis associated with sloughing of the respiratory epithelium and profuse mucopurulent secretions. We have called this condition pseudomembranous croup. The children had severe upper airways obstruction, appeared toxic with high fever, and were older than the typical age group for viral laryngotracheobronchitis. Lateral x-ray films of the airways showed subglottic narrowing and often these suggested the presence of radio-opaque foreign material in the tracheal lumen. At endoscopy, in addition to pseudomembrane in the subglottic region and trachea, there was thick mucopus and debris, and in some cases these changes extended into the bronchi. An artificial airway was required in all except one, and even after intubation it proved difficult to maintain the airway. staphylococcus aureus was the most common pathogen isolated from tracheal cultures but other organisms were grown. ( info) |
24/36. Telling patients about medical negligence. A 7-year-old boy, diagnosed as having croup, develops an upper airway obstruction due to epiglottitis during the therapy, resulting in cerebral anoxia. Pediatricians to whom the boy is referred feel that failure to consider epiglottitis in the original diagnosis constitutes negligence. The parents suspect nothing. What should the pediatricians say or do? ( info) |
25/36. Foreign-body aspiration. Potential misdiagnosis. Clandestine aspiration of foreign bodies lodged high in tracheal airway can mimic subglottic croup. Although this relationship is emphasized in textbooks of otolaryngology, documentation in the recent literature is lacking. This report underscores our awareness of a potentially lethal diagnosis masquerading as a more benign viral infection of the laryngotracheal airway. ( info) |
26/36. Secondary airway support in the management of croup. Over a four year period of 2,567 croup admissions, 65 required secondary airway support, 45 were intubated, and 30 underwent tracheotomy. The median duration of nasotracheal intubation was six days and of tracheotomy 11 days. The overall morbidity was less for nasotracheal intubation but tubal obstruction resulted in the death of one patient in this group. ( info) |
| The incidence of gastroesophageal reflux in recurrent croup was evaluated by a retrospective analysis of patients at the Children's Hospital of michigan from 1986 to 1991. Sixty-six patients required hospitalization for recurrent croup during this 6-year period. Of the patients evaluated, 47% with recurrent croup had an additional diagnosis established of gastroesophageal reflux. In patients with three or more hospitalizations for croup, there was a 63% association with gastroesophageal reflux. Compared to all patients with recurrent croup, the patients with gastroesophageal reflux tended to be younger and had a shorter interval between episodes of croup. A prospective series of six cases of recurrent croup was seen in consultation. The diagnostic procedures involving lipid-laden macrophage quantitation, endoscopy, and gastroesophageal reflux scintiscans were utilized to establish the diagnosis of gastroesophageal reflux with tracheal aspiration. The results of these studies and the follow-up is discussed. ( info) |
| Pediatric acute subglottic croup is generally of limited duration (usually 2 to 7 days) and caused by influenza or parainfluenza viruses. Prolonged infections may involve other pathogens. To date and to our knowledge, there has been but a single case report of herpes simplex virus type 1 (HSV-1) infection prolonging croup attributed to prolonged use of corticosteroids. Other authors have reported a wide range of HSV-1 infections of the upper and lower respiratory tracts in all age groups that are usually associated with immunocompromise. Two immunocompetent toddlers with prolonged croup associated with HSV-1-positive subglottic lesions are described herein. In one case the culture was obtained 11 days after just three doses of dexamethasone treatment. In the second case the culture was obtained after 10 days of prednisone therapy; the infection cleared quickly following treatment with acyclovir and rapid taper of the prednisone dose. These cases suggest that prolonged croup-like symptoms warrant thorough airway evaluation. herpes simplex virus type 1 should be a suspected pathogen in cases of prolonged or atypical croup. herpes simplex virus type 1 croup is not necessarily associated with immunocompromise or prolonged corticosteroid therapy. acyclovir seems to be effective in treating other airway HSV infections, and by analogy it is the treatment of choice in recalcitrant herpetic croup. It is unknown whether HSV-1 represents a primary or secondary pathogen in prolonged croup. ( info) |
| Two children, ages 9 and 2 1/2 years, with clinical diagnoses of laryngotracheitis (croup) and epiglottis, respectively, developed florid pulmonary edema without evidence of cardiac enlargement. Both children responded to vigorous therapy, which included endotracheal intubation, mechanical ventilation with high oxygen concentrations and positive end expiratory pressure, diuretics, and support of the intravascular volume with colloid infusions. Swan-Ganz catheterization was performed in the child with epiglottitis to elucidate any hemodynamic malfunction. pulmonary artery occluded pressure was found to be normal. We postulate that pulmonary edema may be the result of any of three major physiologic alterations: alveolar hypoxia, increased alveolar-capillary transmural pressure gradient, and a catechol-mediated shift of blood volume from the systemic to the pulmonary circulation. These alterations acting in concert would increase the volume of blood presented to the pulmonary capillaries, the pore size in those capillaries, and the hydrostatic pressure gradient promoting transduation. Failure of pulmonary lymphatics to effectively clear this fluid would result in pulmonary edema. Although pulmonary edema associated with acute upper airway obstruction is unusual, physicians should be altered to its possible appearance and the need for early and vigorous therapeutic measures. ( info) |
30/36. steroids for intubated croup masking airway haemangioma. Recently, the beneficial role of steroids for acute laryngotracheobronchitis has been more clearly defined for both intubated and unintubated patients. However, corticosteroids also improve the clinical signs of airway haemangiomata. Two patients are described who illustrate how this can be a source of diagnostic confusion. ( info) |