BackgroundOperative endoscopy and flexible fiber-optic in-office tissue biopsy are common techniques to assess suspicious laryngopharyngeal lesions.MethodsThe primary outcome was the delay to the initiation of treatment. Secondary outcomes were delay to biopsy, histopathological diagnosis, and assessment at a multidisciplinary oncology clinic. A retrospective analysis was performed to assess the relative delays between these approaches to biopsy of laryngopharyngeal lesions.ResultsThere were 114 patients in the study cohort; 44 in-office and 70 operative endoscopic biopsies). The mean delay from consultation to biopsy was 17.4 days for the operative endoscopy group and 1.3 days for the in-office group. The mean delay from initial otolaryngology consultation to initiation of treatment was 51.7 days and 44.6 days for the operative endoscopy and in-office groups, respectively.ConclusionIn-office biopsy reduced the time from initial consultation to biopsy. The temporal gains via in-office biopsy did not translate into faster access to treatment. This outcome highlights the opportunity to improve access to treatment for patients with early diagnosis.

A B S T R A C TBackground: Croup is a common respiratory illness in children. It presents with a barky cough, stridor and hoarseness occurring secondary to inflammation of the subglottis and larynx. The clinical course of croup is welldescribed, however atypical presentations pose a diagnostic and management challenge. Objectives: This case report and systematic review aims to synthesize the published literature on the definition, diagnosis and treatment of atypical croup. Study selection: Peer-reviewed journal publications in Ovid MEDLINE® and EMBASE from inception to January 1, 2019 in English, focusing on pediatric patients (< 18 years of age) with diagnoses of atypical croup. Data extraction: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Twelve studies involving 670 patients ranging from 6 months to 11 years of age presenting with atypical croup were selected. A variety of definitions of atypical croup were identified based on recurrence, duration of symptoms, severity, and etiology. Data on the incidence of atypical croup, the overall rates of intubation and tracheostomy, and patient characteristics leading to definitive airway management were not clearly characterized. Limitations: All studies were case series, case reports or retrospective chart reviews. Conclusions: Atypical croup is a poorly defined clinical entity that is used to describe recurrent, refractory, or croup-like illness that follows an uncharacteristic natural history. Our case presentation and accompanying literature review highlights the variable, but limited, information available on the diagnosis of atypical croup. Given the commonality of its use in clinical practice, we propose some guidelines around the use of the term 'atypical croup' as well as a management algorithm.