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Barking up the wrong bronchial tree
  1. Christine Sloan1,
  2. Rachel Philpott1,
  3. Carol McCarthy1,
  4. Kathryn Mullan2,
  5. Suzanne Lawther3,
  6. Jonathan McGuinness4,
  7. Andrew Thompson1,
  8. Peter Mallett1,5
  1. 1 Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
  2. 2 Royal Belfast Hospital for Sick Children, Belfast, UK
  3. 3 Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, UK
  4. 4 Cardiothoracic Surgery, Children's Health Ireland at Crumlin, Crumlin, Dublin, Ireland
  5. 5 Centre for Medical Education, Queen's University Belfast, Belfast, UK
  1. Correspondence to Dr Christine Sloan, Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, Belfast, UK; csloan1{at}

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A 1-year-old girl presented to the emergency department with a 3-week history of barking cough and inspiratory stridor at rest. She was afebrile and tachypnoeic with normal oxygen saturations. She had presented 3 weeks prior, having choked on watermelon and was subsequently discharged following a reassuring clinical assessment. She had no significant medical history. During the current admission, oral dexamethasone and nebulised epinephrine were trialled with minimal improvement.

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  1. What is the most likely diagnosis?

    1. Acute laryngotracheobronchitis.

    2. Bacterial tracheitis.

    3. Congenital malformation.

    4. Foreign body.

    5. Laryngomalacia.

Given the chronicity and persistence of symptoms, an X-ray of the chest (CXR) was obtained (figure 1).

Figure 1

Anteroposterior chest radiograph demonstrating a reduction in the transverse diameter of the trachea, which is deviated to the right side.

  1. What is the most appropriate next step in management?

    1. Administer a further dose of oral dexamethasone.

    2. Prescribe a course of oral antibiotics.

    3. Refer to the respiratory team for consideration of bronchoscopy.

    4. Request ear, nose and throat (ENT) review.

    5. Request a CT scan of the chest.

The …

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  • X @katemullan8, @No twitter, @SimEdRBHSC

  • Contributors CS, RP, CM, SL, JM, AT and PM were involved in patient care.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.