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.

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

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 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

Approach to congenital stridor

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

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

Approach to congenital stridor Supralaryngeal Vallecular cysts Thyroglossal cysts Tongue teratoma

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

Initial Investigation

Initial Investigation CXR Film 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 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

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