An unusual presentation of stridor in an infant.

A 9-month-old boy presented with a 1-day history of fever and croupy cough. He had been diagnosed with laryngomalacia at 4 months of age and treated for recurrent croup and bronchiolitis. He was <0.4th centile for weight. He had marked biphasic stridor in all positions along with tachypnoea. He showed some initial improvement with bronchodilators, steroids and antibiotics for suspected pneumonia, but his stridor persisted. He decompensated after 2 days of treatment. Emergency intubation was performed in theatre followed by microlaryngoscopy. Figure 1 shows the findings of extensive laryngeal papillomatosis around the endotracheal tube. The child was transferred to a tertiary ear, nose and throat unit where he had microlaryngobronchoscopy and removal of papillomas, with intralesional cidofovir injections. He is now doing well. This case highlights the importance of defining the quality of stridor and using this to formulate differential diagnoses. Laryngeal papillomatosis is a benign growth of the epithelium of the larynx, trachea and bronchi caused by human papilloma virus types 6 and 11. The Gardasil vaccine may be used preventatively in mothers and potentially curatively in children. 5 Laryngeal papillomatosis is rare (incidence of 1–4 cases per 100 000 population), but due to its morbidity it must always be included in the differential diagnosis of recurrent paediatric stridor with the following red flags: 7 8 ▸ stridor at rest ▸ progressively worsening stridor over time ▸ abnormal cry ▸ severe respiratory distress (cyanosis with laryngomalacia is rare) ▸ biphasic/expiratory stridor ▸ failure to thrive ▸ hoarse voice/dysphonia/aphonia.