Dear Dr. Faust,

Please help us figure out what is wrong with our son. He is 5 years old, and continues to have recurrent croup. Our doctor told us that he would outgrow it by age 3, but he keeps having problems. He requires steroids so often that they are making him fat. What should we do?

Real Croup

True “Croup” is a respiratory illness that is characterized by a “barky cough” that sounds like a seal bark. It is usually (but not always) accompanied by some mild difficulty breathing, and often hoarseness.

When it is severe, these children can have severe difficulty breathing, and the sounds that they make are scary – it can sound like they won’t be able to get enough air. Difficulty inhaling during croup will commonly be accompanied by a high-pitched noise, called “stridor”. There are many causes of stridor, but it is always associated with a narrowing of the airway.

Causes

Croup results from a virus that causes swelling of the trachea and voice box (larynx). The “seal bark” cough is caused during forced-exhalation (cough), that causes the swollen tracheal walls to contact each other – that is what makes that terrible bark sound.

Moist air (a humidifier or sitting in the bathroom with a steamy shower running) and keeping the child calm (meaning: parents remaining calm) are usually all that are needed for mile croup.

Severe croup, especially when associated with any breathing difficulties, should be evaluated in urgent care or the emergency department of your local hospital (children’s if possible). Most commonly, inhalers and steroids are used to reduce the swelling and improve the airway, reduce the croup.

Natural History – What You Can Expect

As your child grows older, their airway – their trachea and larynx – also grow larger. At about the age of three, more or less, the trachea is usually a large enough diameter that the usually amount of swelling that results from viral inflammation will no longer cause the “seal bark” cough. That is also around the age that the larynx is large enough that most common viral infections will no longer result in stridor.

When to Worry

Dial “911” or go directly to the emergency department of your nearest hospital if your child is:

• struggling to get enough air
• stops breathing
• turning blue

When to Consider Other Diagnoses

(time to see your pediatrician)

If your child has any of the following features to their “croup,” their cough or noisy breathing may not be simply from viral infection.

When you should think about other causes of “recurrent croup” – that it might NOT BE CROUP :

• stridor lasts for hours
• stridor that lasts for longer than the infection
• severe stridor that requires multiple ER visits
• severe stridor that requires hospitalization
• any respiratory distress that requires intubation
• stridor in child older than 3 or 4 years of age
• progressive stridor that worsens over time
• worsening or frequent episodes of croup
• progressive weakening of the voice over weeks
• choking or gagging before onset of stridor

Red Flags

It is time for further medical attention for ANY of these signs listed above!

Maybe not right this minute. But soon.

Premies

Children who had previously been intubated and on the ventilator (breathing machine) as newborns are at greater risk of anatomic narrowing of their airways. Intubation is common for babies that are  very premature.

Referral to Specialist

Your child may be referred to an Otolaryngologist (Ear, Nose & Throat Specialist) by your Pediatrician.

Depending on their history, signs and symptoms, the ENT doc may recommend looking at your child’s upper airway using a tiny flexible fiberoptic “laryngoscope” – essentially a way to look at the larynx and upper airway using a spaghetti-like instrument, placed into the nose.

It does not hurt. On the other hand, nobody enjoys the feeling – it is just so strange.

We won’t review all of the many, many, rare (and some scary) possible causes of “recurrent croup” in children here.

But to answer the mother’s question above:

This youngster meets a couple criteria for further evaluation: He has had multiple ER visits and is frequently treated with steroids, and he continues to have “recurrent croup” beyond the usual age of 3 or 4 years.

My recommendation is therefore further medical evaluation. Depending on the history, signs, symptoms, and exam, possibilities may include laryngoscopy in clinic, evaluation by Speech Pathologist, pH probe or other assessment of gastro-esophageal reflux, and even endoscopy under general anesthetic.

Thanks for visiting!

Visit again sometime soon for a review of the causes of airway narrowing, including some photos taken during endoscopic surgeries.

________

Resources

Image Credit: LifeART (and/or) MediClip images, copyright 2010 Lippincott Williams & Wilkins. All rights reserved.

(I just love this pic!)

1. Faust RA: An 18-month-old with progressive hoarseness. Pediatric Rounds. Hospital Physician, 39: 38-45, 2003.
2. Faust RA: Childhood voice disorders: Ambulatory evaluation and operative diagnosis. Clinical Pediatrics, 42: 1-9, 2003.

________

I appreciate your comments and questions.  Keep ‘em coming.  Please, “be excellent to one another.”

I invite you to subscribe (it’s FREE) to this blog for weekly updates – you won’t be swamped by updates, I simply cannot write for the blog everyday.

Click here to receive free weekly updates: (http://eepurl.com/FGnP)

Type in your best email address (the one you actually use).

Your email is safe - will never be shared or sold. Ever.

Click here to read our Privacy Policy: http://wp.me/PR4iB-r

When the confirmation email from boogor doctor arrives, click on the link to give your okay to receive free weekly updates, occasional book reviews or product reviews, occasional discount-coupons for products that I use (not affiliates), all without needing to visit the website.

It’s free, it’s convenient. No ads. No spam. You can un-subscribe at any time. How cool is that?

Stay Informed.

Stay Healthy.

Best of health and success to you and your families.

Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

Simply stated, reflux – or Gastro-esophageal reflux (GER) – is the regurgitation of gastric contents into the esophagus, or even higher, into the mouth or nose (lovely image, no?).

You see babies with reflux all the time. You know, babies “spitting up”. Gastro-esophageal reflux (GER) is common among infants, but it usually resolves on its own – it is estimated that 50% of 2-month-old infants have reflux of gastric contents (regurgitate, or “urp up”) at least twice per day, but only 1% of them still do it at 12 months old.

Most infants simply out-grow it. As they spend more time upright, they reflux less. For nearly all babies with reflux, it goes away without intervention. Most of these infants who are “spitty babies” do not seem bothered by this; most they don’t have symptoms.

So – for most babies with reflux – they don’t have symptoms, and it goes away by itself.

Groovy.

A small minority of babies will have symptoms from GER, and some do not outgrow it. When GER is abnormal, it gains the designation GERD: gastro-esophageal reflux disease.

One of the ways that reflux can show itself in babies, infants, and children is asthma. “Reactive airway disease.”

How Does Reflux Cause Asthma?

There are probably 2 mechanisms involved.

(1)  The first involves inflammation from the reflux. Reflux causes inflammation of the esophagus – esophagitis.

Various biochemicals from that inflammation cause a reaction in other parts of the aero-digestive system. See my article on the Unified Airway Model for more.

(2)  The second mechanism involves nerve reflexes that are triggered by the irritated esophagus – the esophagitis.

These reflexes cause bronchospasm – commonly known as asthma. There is evidence that both of these mechanisms contribute to reactive airway disease.

[Aside: although we are focused on asthma here, reflux can be a factor in rhinitis, sinusitis, otitis, and almost any "itis" of the upper airway - see future posts.]

Of course, what you want to know is:

Does MY Child Have Reflux ?

Two Common Tests:

Esophagoscopy

There are several ways to look for reflux, or to look for evidence of reflux.  One of the ways that we can tell that reflux is causing inflammation is to look at the esophagus – if there are inflammatory changes (esophagitis) then we consider the reflux to be a significant problem.

Back in one of the earlier studies looking for a link between respiratory symptoms and reflux, we asked, “what is the prevalence of reflux among infants and children with difficulty breathing?”

When we looked at the esophagus of infants and children who were taken to the operating room for airway evaluation (a group of children who had breathing difficulties, like severe asthma, stridor (squeaky breath sounds), apnea, recurrent pneumonias, so that endoscopy in the operating room was indicated), we found that 71% had reflux esophagitis!

That doesn’t prove that their reflux was the cause, but suggests a strong link between reflux esophagitis and breathing difficulties in babies and children.

pH Probe

Another way to look for reflux is to measure pH (acidity) of the esophagus over time using a pH probe – a long catheter placed through the nose into the esophagus, left in place at least 24 hours to record the pH (no, not a lot of fun).  When this has been done with infants and children, multiple studies have found that episodic stridor and apnea are correlated to gastric acid refluxing into the esophagus.

One limitation of using a pH probe to diagnose reflux is that some people (especially babies and children) have non-acid reflux.

That means that the pH probe will not detect the reflux (it isn’t acidic), even though they are refluxing, and even though the reflux is causing symptoms. A newer probe that can detect even non-acid reflux is the combination pH / impedance probe. Its use is similar to the usual pH probe, just as uncomfortable.

So, if your child has asthma, is there an easy way to tell whether reflux is a factor?

Treatment as a Diagnosis

Other studies have shown that episodes of reactive airway, asthma, and wheezing all correlate with reflux by pH probe;  ALL of these symptoms improved significantly after medical or surgical treatment of the reflux.

Treating children who have these breathing difficulties (for example, asthma, stridor, or apnea) for reflux can relieve their breathing symptoms.

One study found that 82% of asthmatics have reflux;  70% asthma improved by treating them for reflux.

Sounds promising, yes?

To conclude, perhaps the simplest way of finding out whether reflux is the cause of your child’s symptoms is this:  treat them as if they have reflux, see whether their symptoms improve.

Next week we will review the treatments for reflux – conventional and alternative approaches.

.

I appreciate your comments and questions.  Keep ‘em coming.  Please, “be excellent to one another.”

I invite you to subscribe (it’s FREE) to this blog for weekly updates – you won’t be swamped by updates, I simply cannot write for the blog everyday.

Click here to subscribe for free weekly updates: (http://eepurl.com/FGnP)

Type in your best email address (the one you actually use).  When the confirmation email from boogor doctor arrives, click on the link to give your okay to receive free weekly updates, without needing to visit the website.

It’s free, it’s convenient. No ads, no spam. You can un-subscribe at any time.

Stay Informed.

Stay Healthy.

Best of health and success to you and your families.

Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

Resources (this blog):

Things You Should Know About Reflux: http://wp.me/pR4iB-7k

Things You Should Know About Asthma: http://wp.me/pR4iB-7b

What is the Unified Airway? http://wp.me/pR4iB-gS

Use Plants to Purify Your Air: http://wp.me/pR4iB-bs

Reflux and Otitis: Does GER Cause Ear Infections? http://wp.me/pR4iB-fZ

Stop Breathing: Your Air is Killing You (and what to do about it): http://wp.me/pR4iB-5E

How The Beattles Helped Fund the Invention of the CT Scanner

Back in the late 1960’s, Sir Godfrey Hounsfield was working for a multi-conglomerate corporation, EMI Group. He was an engineer who was trying to figure out how to use x-rays to make 3-D images of the inside of the body. He was working away in a warehouse-type laboratory near Heathrow Airport outside London.

The technology was primitive, and the computers were under-powered for the task. The best computer at the time was less capable than today’s typical smart phone.

For most of his calculations, he was using a slide-rule. Think about that for a bit. (For those of you too young to know what a slide-rule is, it was an “analog mechanical computer”. See resources below)

The work was expensive, and would have been closed down except for the Beattles.

You read that right – it was the commercial success of the Beattles’ recordings that enabled EMI Group to continue funding Sir Hounsfield’s work. At the time, the Beattles had sold 200 Million records! That commercial success allowed EMI Group, their recording publisher, to keep Hounsfield’s research going.

Sir Hounsfield worked on his invention for 4 years, and succeeded in bringing the CT scanner to market in the early 1970’s.

CT Scan Axial Plane Head

CT scanners have helped save millions of lives since then. Obviously, the CT and computer technology have continued to evolve, providing high-resolution and 3-Dimensional images that are invaluable in their ability to give us a view inside the body.

Sir Hounsfield shared the Nobel Prize in Medicine in 1979 for this work.

Thanks to the success of the Beattles.

.

This is simply the introduction to a multi-part series on TESTING in Pediatric ENT.

In these articles we will review:

• sinus imaging
• hearing tests
• allergy testing
• pulmonary function testing
• reflux testing
• immunological testing
• cilia function testing
• rhinometry
• manometry
• and perhaps some others.

(I don’t think that the Beattles played a role in any of these other tests).

These articles will be randomly sprinkled in over the next several months so that you don’t get sick of articles on testing. I don’t want to lose loyal readers.

On the other hand, I do receive many questions about testing – How old does a child need to be for allergy testing? What does a CT scan show? How do you test a baby’s hearing? – things like that, and I want to provide accurate information.

Because you can make better decisions about your child’s health when you are informed.

What tests do YOU want to know about?

Leave a reply and let me know, or send me an email.

.

I invite you to subscribe (it’s FREE) to this blog for weekly updates – you won’t be swamped by updates, I simply cannot write for the blog everyday.

Click here to subscribe for free weekly updates: (http://eepurl.com/FGnP)

Type in your best email address (the one you actually use).  When the confirmation email from boogor doctor arrives, click on the link to give your okay to receive free weekly updates, without needing to visit the website.

It’s free, it’s convenient. No ads, no spam. You can un-subscribe at any time.

Stay Informed.

Stay Healthy.

Best of health and success to you and your families.

Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

Resources

Image Credits: image of the Beattles from Wikipedia.com, public domain.

Role of Beattles in funding Sir Houndsfield’s research: http://www.whittington.nhs.uk/default.asp?c=2804&t=1

Slide rule: http://en.wikipedia.org/wiki/Slide_rule

“Nasal and Sinus Anatomy”: http://wp.me/pR4iB-1g

How to “Read” a CT Scan:

Some brief instructions on reading sinus CT scans: black is air; white is bone; gray is “soft tissue,” or everything else – brain, eyeball, cheek tissue, thickened sinus lining, or snot, or even pus.

[These instructions, along with some CT scans, are from previous post,“3 Year Old Boy Hospitalized for Severe Sinusitis”:  http://wp.me/pR4iB-2k]

Danger Will Robinson Danger

Warning … Danger, Will Robinson …

Complications of sinusitis are rare, but they can have horrible outcomes if not treated promptly, aggressively, and with skill.  The following review describes what can go wrong, what some of the signs and symptoms are, and when you need to seek medical help, like right now.

For those of you who are too young to know, the robot at the right (“B9″) was a regular feature on “Lost in Space” from the mid-1960′s.  You can buy a full-sized replica for only $25,000.  Seriously, people buy them.  There are now several websites devoted to the B9 robot and the Lost in Space series. I just can’t imagine being so nostalgic for a TV series that I would spend $25 grand for one of these.  It’s not like it will vacuum the floor or fetch you a beer.

Intracranial Complications:

The ethmoid, frontal, and sphenoid sinuses are separated from the brain by only a thin layer of bone.  If infection – sinusitis – passes through these bones it can infect the fluid and tissues that surround the brain, resulting in meningitis (1).  If the infection enters the brain tissue it can cause an abscess (2), or walled-off infection.  Inflammation of the intracranial blood vessels can result in abnormal clotting (thrombosis) of blood vessels inside the skull (3).  This, in turn, can cause blindness, brain swelling, stroke, and death. Stress-point: intracranial complications can be fatal.

Forehead Abscess ("Pott's Puffy Tumor") Complicating Sinusitis

Case #1

This teenage boy had 2 rare complications of sinusitis: extension of the infection to form an abscess in his forehead (“Pott’s Puffy Tumor”), and intracranial extension to form a brain abscess:

You can see from the photo on the right that his forehead looks like he is hiding a golf ball.  This abscess is very tender.  He rapidly developed “mental status changes” (he was irritable and lethargic), and an emergency MRI revealed that the infection in the forehead had eroded through the bone of the anterior skull to form a brain abscess:

Forehead Abscess That Extends Through Skull to Form Brain Abscess

This young man required emergency surgery to drain both his forehead abscess and his brain abscess, as well as to remove all of the infected tissue (mostly polyps) within his sinuses that caused the problem in the first place.  He recovered fully.

Summary:

Any of these infections – meningitis, brain abscess, thrombosis (blood clot)– can be life threatening.  They require urgent and aggressive treatment.  When these complications are suspected, an MRI is usually obtained, sometimes in addition to a CT scan.

These patients require hospitalization, with possible consultation of multiple specialists including neurosurgeon, ophthalmologist, otolaryngologist (ENT), and infectious disease experts.  Many will require urgent surgery.

Anyone with sinusitis who exhibits changing mood or mental abilities, sudden and severe irritability, lethargy, or difficulty speaking, walking, or managing fine motor skills, must be evaluated by a physician.  Right Now.

Orbital Complications:

The ethmoid sinuses fill the space between the eye sockets (“orbits”), and the maxillary sinuses in the bones of the cheeks form the floors of the orbits.  Again, these sinuses are separated from the orbits by only a thin layer of bone.  If infection from sinusitis in these sinuses passes through these bones, orbital abscess (4) or infection (orbital cellulitis, 5) in the orbit can result in blindness.

Case #2

The photo below shows a 6-year old boy with a recent history of a “cold” – a viral URI.  Over the past 24 hours his right eye is drooping, he complains of double vision. On exam, his eye does not move easily, seems to be looking down, as you might detect in this photo.

Abscess next to boy's right eye socket (orbit)

A CT scan of his sinuses reveals a small abscess just inside his right eye socket (orange arrow).  This causes inflammation and compression of one of the eye muscles (medial rectus) that moves the eye (dashed orange line).  This often requires surgery to cure.

Axial CT Scan Showing Sub-periosteal Orbital Abscess

Case #3

The photo below is from a 6-year  old girl with an identical story.  Her eye actually looks worse, with redness and swelling so that she cannot easily open her left eye.

Sinusitis Complication: Girl's Left Eye with Peri-orbital Cellulitis

A CT scan of her sinuses shows “stuff” in the ethmoid sinuses next to her left eye, but there is no abscess. She has “peri-orbital cellulitis,” or infection of the tissues around the eye.  This  improved with intravenous antibiotics, no surgery.

Girl's Left Ethmoid Sinuses, and Peri-Orbital Cellulitis

Thrombosis of Ophthalmic Vein, and Cavernous Sinus Thrombosis

Case #4

Different patient:  The MRI shown on the right shows a life-threatening complication of sinusitis.  This complication is also a risk for blindness.  It shows an MRI from a teenage girl with severe sinusitis.  The complication is clotting of the veins of her left eye, and clotting of a large venous area inside the skull – the cavernous sinus (orange arrows).

She was hospitalized for intravenous antibiotics for severe sinusitis, and otitis.  When she began to complain of vision changes this MRI was obtained.  Visual testing revealed that she was losing the sight in her left eye.

She was taken to emergency surgery for sinus surgery, mostly to decompress her left orbit to relieve pressure on her eye and optic nerve.

Although she had a very difficult hospitalization and required several surgeries and long-term antibiotics, and anti-clotting medications, she recovered fully.  Her vision is perfect, and unchanged.  [Aside: after leaving the hospital, she brought me huckleberry turnovers that she had baked herself every time she saw me in clinic, for years!] Her story is described in the first journal paper listed in Resources, below.

Summary:

These patients usually require hospitalization, with consultation of ophthalmologist, otolaryngologist, neurosurgeon, and infectious disease experts.  Many will require urgent surgery.

Anyone with sinusitis who experiences ANY change in vision (double vision, blurring of vision, difficulty seeing in any way), or bulging of one or both eyes, must be evaluated by a physician.  Right Now.

Local Complications:

Sinus Polyps, Complication of Sinusitis, Chronic Rhinitis

Polyps (6):

Chronic inflammation from sinusitis can be associated with sinus and nasal polyps.  These are abnormal swellings of the lining.  Polyps can cause nasal obstruction, making nasal breathing difficult or impossible.  Polyps can also block the sinus openings, causing worsening of sinusitis.  Chronic growth of polyps can push bone out of place and cause distortion of the nasal profile – how the nose looks from the outside.  Obstruction from polyps can also cause loss of smell.  Finally, recurrent and chronic sinusitis can cause permanent loss of smell due to injury of the olfactory nerves.  Children with cystic fibrosis are at increased risk for sino-nasal polyps.

Mucoceles (7):

Obstruction of the sinus opening from chronic inflammation can result in formation of a sinus mucocele.  As mucus continues to be produced by the lining of the sinus, the mucocele gradually enlarges.  This can result in erosion and remodeling of surrounding bone.  Mucoceles are benign, but can cause significant problems, especially if they spread into the orbits or skull.  Most mucoceles are not a problem, but if they become infected they can cause severe bacteremia – bacteria in the bloodstream.  That can be life-threatening.

Osteomyelitis (8): Infection of the Bone

Recurrent and chronic sinusitis can cause infection of the surrounding bone.  This may be how the intracranial or intra-orbital infections of sinusitis travel.  Bone infections can be extremely difficult to cure.  They often require long-term intravenous antibiotic therapy, and possibly surgery to remove the infection.

Summary:

Any of these complications of sinusitis can become true emergencies.  Some of these complications require immediate surgery in order to save a life, or to prevent permanent brain injury or blindness.  These complications are not limited to children – they can threaten your life too.

These complications are most common during the worst of the cold-and-flu season, but CAN happen ANY time of the year.  If your child has recurrent and chronic rhinosinusitis, be alert.

This short list of sinusitis complications is not complete, but touches on the most dangerous complications, and some of the common complications.  If you suspect that you or your child has any of these complications of sinusitis, get medical attention.  Sinusitis is nothing to sneeze at (sorry, couldn’t help myself).

Thanks for visiting, and see you here again.  I appreciate your comments and questions.  Keep ‘em coming.  Continue to “be excellent to one another.”

Best of health and success to you and your families.

Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

Resources:

Zapanta PE, Chi DH, Faust RA: A unique case of Bezold’s abscess associated with multiple dural sinus thromboses. Laryngoscope, 111: 1944-1948, 2001

Caylaki F, Yaviz H, Cagici AC, Ozluoglu LN.  Endoscopic sinus surgery for maxillary sinus mucoceles. Head & Face Medicine, Vol. 2: http://www.head-face-med.com/content/2/1/29