What is recurrent or atypical croup?

Many babies and toddlers will have a bout of croup, also known as laryngotracheitis, when an infection causes a narrowing in their throat that leads to a high-pitched noise heard when a child breathes in (called stridor) and a barking cough. It usually lasts a few days and almost always less than a week. Note: If children are having a difficult time breathing, they need medical attention.

If a child has repeated bouts of croup, more than two episodes a year, they are said to have recurrent croup. If a child has signs and symptoms of croup outside of the normal preschool age group or the symptoms do not improve in a timely manner with the typical medications, they may have atypical croup.

Recurrent and atypical croup are not diagnoses in and of themselves. They are a signal that there may be another underlying disease or condition. These children may benefit from being seen in the aerodigestive clinic by a pediatric gastroenterologist, otolaryngologist and pulmonologist to help determine if further evaluation and treatment are needed.

Signs and symptoms of recurrent or atypical croup

Signs and symptoms that may warrant further evaluation:

• more than two episodes of croup per year
• illness that seems to be nearly gone, only to come back with symptoms lasting several weeks
• little or no response to standard croup therapies
• occurring outside of the usual age range of 6 months to 3 years

Here are some of the conditions that could be masquerading as croup:

• Foreign bodies: an object lodged in the throat or airway
• Vascular rings: a blood vessel encircles the trachea and/or esophagus
• Gastroesophageal reflux disease (GERD): when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of the esophagus, causing swelling which can cause the sounds of croup.
• Eosinophilic esophagitis (EoE): a chronic allergic inflammatory disease of the esophagus
• Asthma: a chronic lung disease in which the lungs overreact to various materials in the air and some respiratory infections, causing inflammation in the airways
• Food or environmental allergies

Sometimes recurrent croup signals an abnormality in the throat or airway, either that the child was born with (congenital) or due to an injury. Potential anatomic abnormalities include:

• Subglottic stenosis: a narrowing of the airway below the vocal cords and above the trachea
• Subglottic cysts: a growth or growths in the airway below the vocal cords
• Subglottic hemangioma: large mass of immature blood vessels growing in the airway below the vocal cords
• Recurrent respiratory papillomatosis: rare type of warts that grow on the vocal cords and in the airway
• Vocal cord paralysis
• Tracheoesophageal fistula: an abnormal connection (fistula) in one or more places between the esophagus and the trachea
• Tracheomalacia: when the cartilage that keeps the airway open partly collapses, blocking the flow of air
• Laryngotracheal cleft: a rare malformation when there is an opening connecting the larynx, trachea and the esophagus
• Laryngomalacia: a congenital floppiness of the structures of the larynx (voice box)

To check for these types of abnormalities, a child might undergo a “triple scope procedure” which consists of a flexible bronchoscopy, a rigid bronchoscopy and an esophagogastroduodenoscopy. These procedures closely examine the upper and lower airways, as well as the esophagus, stomach and duodenum (very top of the small intestine), to try to identify any abnormalities that might contribute to recurrent or atypical croup.