Re: Croup in the paediatric emergency department

To the Editors; As a paediatric otolaryngologist, I enjoyed reading the Bjornson and Johnson (1) article “Croup in the paediatric emergency department”, published in the July/August 2007 issue of Paediatrics & Child Health. I would like to share a few comments and questions with you and Drs Bjornson and Johnson. Regarding the differential diagnosis “occult foreign object” in Table 1: The most common location for a foreign body that causes a croupy cough and biphasic stridor is the glottic and subglottic larynx. At BC Children's Hospital (Vancouver, British Columbia), we have removed from the larynx numerous thin, rigid, radiolucent objects, such as metallic stickers, a pencil shaving and the corner of a ketchup wrapper, that were lodged between the vocal cords for days to weeks and had caused formation of granulation tissue (while the toddlers had been treated with medications for croup). The presense of dysphonia was the historical clue to diagnosis, and awake flexible laryngoscopy confirmed the need for rigid laryngoscopy in the operating room to remove these laryngeal foreign bodies. Very rarely, a large spherical esophageal foreign body (such as a marble) can cause biphasic stridor from anterior compression of the posterior, membraneous tracheal wall. A coin, oriented in the sagittal plane of the esophagus, can also cause biphasic stridor, but approximately 99% of esophageal coins are oriented in the coronal plane and cause no respiratory symptoms (only pain and drooling). The most common and dangerous esophageal foreign bodies that cause biphasic stridor are disc batteries, which leak lye and electrical current, and within hours cause mucosal edema of the tracheoesophageal membrane and then esophageal perforation. Radiographic differentiation between coins and disc batteries is essential and has been the subject of previous reports in the medical literature. The differential diagnosis of croup also includes subglottic hemangioma (usually in children younger than one year of age, with or without a cutaneous hemangioma; an x-ray of the subglottis usually shows asymmetrical soft tissue swelling) and subglottic submucosal cysts (usually in infants who were born prematurely and were intubated at birth). We have seen several infants with subglottic hemiangiomas or cysts who were asymptomatic until they additionally acquired viral croup. Therefore, any child with a croupy cough and biphasic stridor who is younger than one year of age should have an x-ray of the subglottis and/or an otolaryngology consultation. Surgical management of these lesions should be considered before intubation. Could you please clarify the sections on corticosteroids and racemic adrenaline? Did the authors mean to write ‘dexamethasone is equally effective when given orally... as when given parenterally’? In the algorithm, under “SEVERE”, should ‘intramuscular or intravenous dexamethasone’ be mentioned? Is the minimum safe period of observation after nebulized adrenaline now 2 h or 3 h? (the text states “2 h to 3 h” but the algorithm states “2 h”). With sincere thanks,

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.