Extern conference

1. Extern conference 28 June 2007

2. What is the abnormal finding ?

3. 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

4. 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

5. 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

6. 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 peripheralcyanosis, no jaundice, no hemangioma at beard and neck region • HEENT : no midline defect, poor nasal air flow Rt. > Lt.

7. At nursery: physical examination • 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

8. 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%

9. 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.

10. Problem list

11. Problem list • C/S due to CPD • Term AGA female infant • Perinatal depression (Apgar 7,9) • Cyanosis and inspiratory stridor related to feeding and crying • Hoarseness of voice

12. Approach to congenital stridor

13. Approach to congenital stridor Stridor = upper airway obstruction • Anatomical • Supralaryngeal • Laryngeal • Tracheal

14. Approach to congenital stridor • Laryngeal : • Laryngomalacia • Vocal cord paralysis • Subglottic stenosis • Laryngeal abnormalities (hemangiomas, webs, cysts, cleft)

15. Approach to congenital stridor • Supralaryngeal • Vallecular cysts • Thyroglossal cysts • Tongue teratoma

16. Differential diagnosis • 1. Laryngomalacia • 2. Unilateral vocal cord paralysis • 3. Laryngeal abnormalities • 4. Supralaryngeal causes

17. Initial Investigation

18. Initial Investigation • CXR • Film lateral neck

21. Further Investigation • Bronchoscopy

22. Diagnosis • Left Unilateral Vocal cord paralysis

23. Congenital Vocal cord paralysis • Unilateral- • stridor and retraction are not marked • weak & hoarse cry, aggravated by agitation • Feeding difficulties

24. Congenital Unilateral Vocal cord paralysis Etiology • usually idiopathic • secondary to peripheral n. esp. recurrent laryngeal n. -Lt.sided : common perhaps from birth trauma -Rt. Sided : complication of thoracic & neck surgery • May be lesions in the mediastinum (tumors and vascular malformations) Prognosis – uncertain due to etiologies

25. 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

26. 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

27. Position picture. • Lies on paralyzed side

28. 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

29. Members • Ext. Assawin Ruangmongkolleot • Ext. Panrudee Watanaprakornkul • Ext. Nisarath Soontrapa • Ext. Prapa Pattrapornpisut • Ext. Patcharaporn Chandraparnik