CRP12 THE RETURN OF THE CROUP - MORE THAN MEETS THE AIRWAY: A CASE STUDY IN RECURRENT UPPER AIRWAY OBSTRUCTION

Anita Suppiah1, Yee Yen Tan2, Ranveer Singh3, Ruwaida Isa4
Hospital Sg Buloh1, Hospital Tengku Ampuan Rahimah2,3,4

Introduction
Croup, a common respiratory illness in children is typically viral in origin and is self-limiting. However, recurrent croup is a different entity that warrant further investigation to exclude other conditions like airway abnormalities, functional or infectious causes.

Case Presentation
We report a case of a boy with history of prematurity and suspected Russell Silver Syndrome. He has prominent forehead, small triangular facies, faltering growth, and speaks in soft, high-pitched voice. He presented with multiple episodes of croup beginning at 7 months of age. Over a span of two years, he experienced six hospital admissions for croup, with varying intervals in between episodes. Most episodes were preceded by mild upper respiratory symptoms and responded to standard therapy with systemic and nebulised corticosteroids though some episodes required nebulised adrenaline. Highest oxygen support was high-flow oxygen therapy for two of the episodes. Apart from the acute episodes, he remained asymptomatic. Flexible laryngoscopy during early admissions showed no abnormalities. However, due to increasing frequency and severity of symptoms, a direct laryngoscopy and bronchoscopy done revealed mild adenoid hypertrophy, laryngomalacia, Grade 1 subglottic stenosis, and mild tracheomalacia. A supraglottoplasty was perfomed and subsequently there were no more recurrence of croup.

Conclusion
We postulate that his recurrent croup is due to a combination of subglottic stenosis, laryngomalacia and small laryngeal size. This case highlights the importance of considering anatomical causes in children with recurrent croup, especially when episodes are severe, frequent, or deviate from the typical clinical course. Early referral to pediatric respiratory and otolaryngology team can be essential in guiding management and improving outcomes.