Children with known congenital anomalies of their upper airway may present with more-severe symptoms of croup. These children should be observed in the hospital setting, as they are at risk for rapid progression of airway obstruction and respiratory failure. These anomalies may include, but are not limited to, laryngomalacia, acquired or congenital subglottic stenosis, vocal fold paralysis, juvenile laryngeal papillomatosis, and subglottic hemangioma.76 Special attention should also be given to patients with craniofacial anomalies (eg, Pierre Robin sequence, Treacher Collins syndrome, Goldenhar syndrome, or Crouzon syndrome) if they present with severe symptoms that may require airway management.77-78 Urgent consultation with an otolaryngologist or anesthesiologist for potential difficult intubation should be made in these cases.
Recurrent episodes of croup in the same year (more than 2), especially if not accompanied by the classic prodrome of upper respiratory tract symptoms, should prompt a referral to an otorhinolaryngologist for assessment of the airway by direct laryngoscopy/bronchoscopy.79 Retrospective studies have shown that these children are often found to have various degrees of acquired or congenital subglottic stenosis. Gastroesophageal reflux is emerging as a possible cause of these recurrent episodes. Patients with laryngoscopic findings of gastroesophageal reflux should be adequately treated with antireflux medications to reduce the progression of airway narrowing secondary to inflammatory mucosal edema.80 There is some suggestion that there may be a correlation between recurrent croup and family history of atopy.81,82 Children with recurrent croup should be monitored for development of symptoms of airway hyperreactivity. A chest radiograph may be considered to rule out the possibility of occult foreign body.