Krzysztof Ślączka1, Marcin Dziekiewicz2, Monika Jabłońska-Jesionowska1, *Lidia Zawadzka-Głos1
Gastroesophageal reflux disease in children with recurrent croup
1Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
2Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
Head of Department: Piotr Albrecht, MD, PhD
Summary
Introduction. Episodic croup occurs most often in children between 0.5 and 3 years of age. Recurrent croup presents most often in older children. It shows an association with gastroesophageal reflux disease, allergy and laryngeal abnormalities.
Aim. The aim of this study was to explore the relationship between recurrent croup and gastroesophageal reflux disease in children with the history of at least one episode of severe croup.
Material and methods. The study included 22 children with recurrent croup admitted to the Department of Pediatric Otolaryngology of the Medical University of Warsaw between the years 2013 and 2016. Information concerning leading symptoms and medical history was obtained from the medical documentation of the patients. All the patients underwent rigid laryngoscopy and were diagnosed using 24-hours, single probe esophageal pH monitoring.
Results. 22 children aged between 1.5 year to 7.5 years were examined and their medical records were analyzed. An acid reflux was diagnosed in fourteen patients (63.6%) and the mean Reflux Index was 11.6. On endoscopic examination of the larynx, 15 patients (61.8%) had normal findings, 7 patients (31.8%) were diagnosed with an airway abnormality including: 3 cases of laryngeal cleft (type I), 2 cases of laryngomalacia, 1 case of subglottic stenosis, 1 case of vocal fold nodules. In 5 cases (22.7%), GERD coexisted with larynx abnormalities.
Conclusions. All the children with recurrent croup should be diagnosed for both gastroesophageal reflux disease and laryngeal abnormalities. Therefore, ENT specialists, as well as gastroenterologists, should take part in diagnostic procedures to reveal primary conditions responsible for recurrent croup.
INTRODUCTION
Croup is a common respiratory tract disease in children. It presents with an acute onset, hoarseness, inspiratory stridor, barking cough and respiratory distress (1). These symptoms are caused by the inflammation and narrowing of the subglottic area of the larynx, which is the narrowest part of the respiratory tract in children (2, 3). Infectious croup is typically caused by viruses, especially during fall and winter (4). It primarily affects children between 6 months and 3 years of age, with the peak incidence at two years of age (5). It is unusual for healthy children to have more than one episode of croup per year (6). However, when the croup-like episodes occur more than two times in a year, it is referred to as recurrent croup and its presence should alert clinician to investigate underlying reasons for it (tab. 1) (7).
Tab. 1. Risk factors for recurrent croup in children (11)
| Congenital | Congenital subglottic stenosis
Congenital cardiovascular abnormality
Tracheo-oesophageal fistula
Laryngotracheal cleft
Tracheobronchomalacia
Vocal cord paralysis
Congenital tracheal stenosis
Congenital goitre |
| Traumatic | Acquired subglottic stenosis
Subglottic cyst
Airway foreign body |
| Inflammatory | Gastroesophageal reflux disease
Asthma
Allergy |
| Infectious | Viral
Bacterial |
| Tumor | Subglottic haemangioma
Lymphangioma
Thyroid neoplasm
Recurrent respiratory papillomatosis
Thymoma
Lymphoma
Mediastinal mass |
Frequent croup episodes can be caused by a disease that narrows respiratory tract (6). Several recent studies have shown an association between recurrent croup and gastroesophageal reflux disease (GERD), laryngeal abnormalities, allergy, atopy, airway hyperreactivity and asthma (tab. 2) (8-10).
Tab. 2. Diseases and symptoms related to GERD in children (16)
| Upper respiratory tract | Lower respiratory tract | Digestive tract |
– subglottic
– stenosis
– laryngomalacia
– vocal cord
– nodules
– recurrent croup
– recurrent otitis media
– chronic rhinitis | – asthma
– recurrent
– papillomatosis
– wheezing | – eosinophilic esophagitis
– swallowing
– dysfunction
– vomiting
– burping |
Moreover, antireflux therapy in GERD-positive cases can successfully reduce the number and duration of croup-like episodes (11).
AIM
The aim of this study was to explore the relationship between recurrent croup and gastroesophageal reflux disease in children with the history of at least one episode of severe croup.
MATERIAL AND METHODS
The study was conducted on a group of pediatric patients with recurrent croup admitted to the Department of Pediatric Otolaryngology of Medical University of Warsaw between January 2013 and February 2016. Recurrent croup was defined as more than 2 episodes of croup-like syndrome per year. All children were admitted to the hospital due to an episode of severe croup (more than 6 points in Westley Croup Score) at least once in their lifetime. In most cases, the leading symptoms of croup episodes included inspiratory stridor, barking cough and inspiratory dyspnea. In the Department, each patient was treated using the same scheme, including i.v. steroids combined with nebulized steroids and adrenaline. The collected medical data included age, sex, symptoms, medical history, the number of croup episodes and hospitalizations for croup, as well as the number of emergency visits. All patients undergone rigid endoscopic laryngoscopy to inspect the airways from epiglottis to trachea. Reflux finding score (RFS) was then given based on the endoscopic examination. All the patients were investigated for GERD using 24-hour, single probe esophageal pH monitoring, which was placed at the level of the 2nd vertebra above the diaphragm (based on the X-ray scan). Based on the results of the examination, Reflux Index (RI) was calculated and acid gastroesophageal reflux disease was diagnosed or excluded. Children with diagnosed GERD were enlisted for the outpatient reflux treatment. They all subsequently achieved symptom-free status.
RESULTS
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Piśmiennictwo
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