Acute Laryngitis in Children — Symptoms and Treatment

What is acute laryngitis in children?

Acute laryngitis (acute laryngotracheitis, viral croup) is a viral infection of the upper respiratory tract that causes inflammation and edema of the larynx, particularly in the subglottic area. In young children, this area is the narrowest part of the airway, so even slight edema can cause significant obstruction.

It is a common condition, with peak incidence between 6 months and 3 years of age, predominantly during the cold season (autumn and winter). Most cases are mild and resolve at home, but severe forms require emergency evaluation and treatment.

Symptoms

Onset is usually sudden, often nocturnal, preceded by 1-2 days of cold symptoms:

• Barking cough ("seal-like" cough) — the characteristic symptom, metallic and harsh
• Hoarse voice (dysphonia) — due to vocal cord inflammation
• Inspiratory stridor — harsh sound during inspiration, a sign of laryngeal obstruction
• Dyspnea — breathing difficulty, in moderate-to-severe forms
• Fever — usually mild to moderate (37.5-39°C)
• Agitation and anxiety — the child becomes restless
• Intercostal and suprasternal retractions — retraction of accessory respiratory muscles, a sign of respiratory effort

Symptoms are usually more intense at night and improve in the morning.

Causes

• Parainfluenza viruses (types 1 and 3) — the main cause (75% of cases)
• Respiratory syncytial virus (RSV)
• Adenoviruses
• Influenza virus — more severe forms
• Rhinoviruses and enteroviruses

Differential diagnosis includes:

• Acute epiglottitis — extreme emergency (rare since Hib vaccination)
• Laryngeal foreign body
• Bacterial tracheitis — more severe form, with purulent secretions
• Allergic laryngospasm — sudden onset, without fever

Diagnosis

• Diagnosis is clinical — the classic triad of barking cough + hoarse voice + stridor is sufficient
• Pulse oximetry — oxygen saturation monitoring
• Lateral neck radiograph — rarely needed, may show the "steeple sign" (subglottic narrowing)
• Flexible laryngoscopy — indicated only in atypical or recurrent cases, to exclude structural causes

Oropharyngeal examination with a tongue depressor is not recommended in a child with severe stridor and suspected epiglottitis, as it may precipitate complete airway obstruction.

Treatment

Mild forms (no stridor at rest)

• Calming the child — crying worsens stridor
• Cool, moist air — exposure to cool night air improves symptoms
• Adequate hydration
• Antipyretics — paracetamol or ibuprofen if fever is present
• Oral dexamethasone — single dose of 0.15-0.6 mg/kg, reduces edema and shortens symptom duration

Moderate-to-severe forms (stridor at rest)

• Nebulized epinephrine — rapid onset of action (10-30 minutes), reduces subglottic edema
• Dexamethasone — oral, intramuscular, or nebulized (budesonide 2 mg)
• Oxygen therapy — if saturation drops below 92%
• Monitoring — at least 3-4 hours after epinephrine (possible rebound effect)

Severe forms (respiratory failure)

• Orotracheal intubation — in case of failure of medical treatment
• Admission to the pediatric intensive care unit

When to see a doctor

Go to the emergency department immediately if:

• Stridor at rest — persistent, not only during coughing or agitation
• Visible intercostal or suprasternal retractions
• Breathing difficulty — rapid, shallow breathing
• Cyanosis — bluish discoloration of the lips
• Extreme agitation or, conversely, lethargy
• Difficulty swallowing saliva (suspicion of epiglottitis)
• The child assumes a preferred position — leaning forward, with mouth open

Complications

• Severe airway obstruction — can be life-threatening if not promptly treated
• Bacterial superinfection (bacterial tracheitis) — high fever, purulent secretions, clinical deterioration
• Pneumonia — through extension of infection to the lower airways
• Post-obstructive pulmonary edema — rare, following severe obstruction
• Recurrent laryngitis (recurrent croup) — some children are predisposed to repeated episodes; evaluation is needed to exclude an allergic component or laryngeal anomalies