A puzzling airway problem

A fit and well 11 month old girl who was living with her single mother and 3 year old brother presented to the emergency department with acute shortness of breath and cough. Her mother had not witnessed any episodes of foreign body inhalation. A diagnosis of bronchiolitis was made and the child was discharged after oxygen therapy and observation. One week later she presented with the same symptoms and signs. Chest radiography was performed and was reported as normal. Again she was diagnosed and treated for bronchiolitis and made a complete recovery.

Six weeks after the initial presentation she re-presented with a two day history of increasing shortness of breath, cough, and stridor. Signs of respiratory distress were noted, and chest auscultation identified bilateral wheeze and transmitted upper airway noises. Her symptoms improved with salbutamol and adrenaline nebulisers, but an apparent stridor remained. A repeat chest radiograph during this time was also normal.

She was admitted and treated with nebulisers, oxygen, and steroids. Her symptoms improved but did not resolve completely. An ear, nose, and throat nasoendoscopic examination showed a normal epiglottis, but no clear laryngeal views were obtained. Again the mother denied any witnessed aspiration of a foreign body but reported that her two children sometimes played together unsupervised.