Extern conference

28 June 2007

What is the abnormal finding ?

Stridor

musical, monophonic, audible breath sounds (noisy breathing)

caused by oscillations of narrowed large extrathoracic airways

indicates a partial obstruction of the upper airways, glottis, or trachea

History

CC : inspiratory stridor 1 day after birth

PI : Maternal Hx. : 24 yr. G1P0A0

Antenartal Hx : Adequate ANC

GA 40 wks by date

C/S due to CPD

Term AGA female infant

BW 3630 g (P75), HC 34 cm (P50), Lt 51 cm (P 50)

Apgar 7 (color 2, RR1), 9 (RR1)

O2 tubing 5 LPM and tactile stimulation

After birth RR 48/min

30 min after birth developed tachypnea and grunting

Transfer to nursery

At nursery: physical examination

V/S : T 37.6 C, P 163/min, BP 61/36 mmHg, RR 52/min

Sp O2 65% (RA)

GA : Active, central and peripheral cyanosis, no jaundice, no hemangioma at beard and neck region

HEENT : no midline defect, poor nasal air

flow Rt. > Lt.

RS : Dyspnea, subcostal retraction, no flaring of alar nasi, no grunting, normal breath sounds, no adventitious sound, no stridor

CVS : Normal S1,S2, no murmur Abdomen : WNL NS : Normotonia, symmetrical movement,

grasping reflex +ve, rooting reflex +ve, Moro reflex +ve

At nursery: physical examination

At nursery

O2 tubing 10 LPM and Syringe ball suction with

NSS Nasal drop : improved

Then continue O2 hood 5 LPM :

SpO2 99 %, FiO2 0.45 then wean off O2 in 6 hrs

later SpO2 98%

Cyanosis developed when she received spoon feeding and spontaneously recovered, then she was retained OG tube.

Cyanosis and inspiratory stridor related with hoarse crying can be improved by prone position.

Problem list

Problem list

1. C/S due to CPD

2. Term AGA female infant

3. Perinatal depression (Apgar 7,9)

4. Cyanosis and inspiratory stridor related to feeding and crying

5. Hoarseness of voice

Approach to congenital stridor

Approach to congenital stridor

Stridor = upper airway obstruction

Anatomical Supralaryngeal Laryngeal Tracheal

Approach to congenital stridor

•Laryngeal : oLaryngomalacia

oVocal cord paralysis

oSubglottic stenosis

oLaryngeal abnormalities (hemangiomas, webs, cysts, cleft)

Approach to congenital stridor

oSupralaryngealoVallecular cysts

oThyroglossal cysts

oTongue teratoma

Differential diagnosis

1. Laryngomalacia2. Unilateral vocal cord paralysis3. Laryngeal abnormalities4. Supralaryngeal causes

Initial Investigation

Initial Investigation

CXRFilm lateral neck

Further Investigation

Bronchoscopy

Diagnosis

Left Unilateral Vocal cord paralysis

Congenital Vocal cord paralysis

Unilateral- stridor and retraction are not marked weak & hoarse cry, aggravated by agitation Feeding difficulties

Congenital Unilateral Vocal cord paralysis

Etiologyousually idiopathic osecondary to peripheral n. esp. recurrent laryngeal n.

-Lt.sided : common perhaps from birth trauma

-Rt. Sided : complication of thoracic & neck surgery oMay be lesions in the mediastinum (tumors and vascular malformations)

Prognosis – uncertain due to etiologies

Congenital Vocal cord paralysis

Bilateral -much more serious condition stridor at rest near-normal phonation progressive airway obstruction poor prognosis due to underlying and

associated problems

Management in this patient

Specific No specific treatment for vocal cord paralysis Ix for underlying etiology

Supportive Observe respiratory: apnea, SpO2 Retain OG tube Correct position

Position picture.

Lies on paralyzed side

Take home message

Upper airway obstruction can be cured as conservative but when the patient develop - cyanosis when feeding

- weak cry

- hoarseness of voice

- abnormal lat. neck film

- biphasic stridor

REFER

Members Ext. Assawin

Ruangmongkolleot Ext. Panrudee Watanaprakornkul Ext. Nisarath

Soontrapa Ext. Prapa

Pattrapornpisut Ext. Patcharaporn

Chandraparnik