Dr.Himabindhu,(PG)

Dr.s.Balasubramanian

HOD pediatrics

Dr.Thirunavukkarasu

Consultant pediatric ENT & airway surgeon

chief complaints:38 days old Female infant

Noisy breathing since birth.

poor weight gain (b.wt:2.9kg,admission wt:2.8 kg) since birth

EXAMINATION: Alert,audible stridor +

Respiratory distress+,

no hypoxia

Muffled voice

Anthrapometry:

Wt : 2.8 kg (<3rd )

Length: 51 cm (3rd-15th )

HC :37 cm(50th )

Initial workup: Chest x ray -N

2 D echo –N

TRANSNASAL FLEXIBLE LARYNGOSCOPY(TNFL)

Diffuse mass lesion in the posterior 1/3 rd of tongue & vallecula pushing the epiglottis posteriorly.

Laryngomalacia

Further work up: USG neck :no thyroid gland in the usual location and

no other cystic lesions.

TFT: TSH : 328 increased(0.8-8.2)

Free T4- 0.48 (0.78-1.79)

Tc 99 uptake scan: increased uptake in ectopic thyroid and no technetium uptake in the thyroid bed.

TC 99 thyroid uptake scan:

Treatment and hospital course:Treatment:

thyroxine 15 mcg/kg.

anti-reflux measures.

NG feeds + oral feeds

D 6 of hospitalisation -had sudden onset of respiratory distress following aspiration of feeds associated with hypoxia & lethargy

shifted to PICU and was commenced on mechanical ventilation & inotropic support for 3 days after which child gradually improved.

Chest x-ray- massive bilateral pulmonary infiltrates

blood counts were normal.

Baby was initially started on Meropenam&Vancomycin but as the cultures were sterile antibiotics were stopped

surgery

Endoscopic lingual thyroidectomy with Supraglottoplasty & Gastrostomy.

She was successfully extubated after 24 hours & later started on Gastrostomy feeds .

Tolerated feeds well, respiratory distress & noisy breathing gradually improved with normal activity and weight gain(Wt : 3.2kg),hence discharged.

Follow up: activity and wt.gain 4.1

kg good.

repeat TFT was normal.

Approach to stridor in infants and children: Stridor: high pitched sound due to turbulence of

airflow in narrowed airways.

Most common Causes :

laryngomalacia(60%)

subglottic stenosis,hemangiomas

vocal cord palsy,

tracheomalacia,

vascular malformaltions,

Craniofacial abnormalities,

History :

1.nature(inspiratory,biphasic ,expiratory)

2.aggrevating factors,postural variation

3.feeding difficulties,choking/aspirations,growth

4.quality of cry

5.perinatal& intubation history

Examination:

craniofacial abnormalities,facialdysmorphism,hemangiomas ,severity of respiratory distress.

When to investigate:Signs of severity(10%-20%) of laryngomalacia

Poor weight gain with failure to thrive

progressive Stridor

Tachypnea with severe respiratory distress

Feeding difficulties associated with episodes of apnea /cyanosis.

Weak cry.

Pathophysiology and diagnostic approach to laryngomalacia in infants european annals of otorhinolaryngology. October 2012,update

In infants with persistent stridor, but no significant increase in the work of breathing, no cough, normal cry, no apnea or cyanotic episodes, and thriving, then laryngomalacia is the most likely cause. No further investigation is warranted apart from follow-up review. Quality of evidence: High. Large observational studies with consistent findings.

If stridor is persistent and associated with any of the above features, then consider significant upper airway pathology, and probable larangoscopy and bronchoscopy. Quality of evidence: Moderate. Mostly from small cohorts and case series.

Respiratory Noises: How Useful are They Clinically? Pediatric Clinics of North

America, 2009-02-01, Volume 56,

Lingual thyroid

Lingual thyroid is rare,but most common type of ectopic thyroid(90%),F:M ratio (5:1)

Clinical presentation: Feeding difficulties,dysphonia, stridor and upper airway obstruction .

Diagnosis: TNFL,USG neck,Tc99 scan,TFT.

Management:

1. thyroid replacement therapy-correct the hypothyroidism &suppress the size of the ectopic thyroid

2.surgery- considered if adequate thyroid replacement therapy fails to resolve obstructive symptoms.

3. The general conditions of the patient, the size of the lesion, and presence of local symptoms or complications, such as hemorrhage, cystic degeneration, or malignancies determine the mode of treatment.

Case reports: A 6-day-old female,presented with stridor and poor

feeding, initially thought to be laryngomalacia, nasendoscopy revealed a lingual thyroid. The baby had deranged thyroid function, despite being symptomatic, the patient was managed medically,babyimproved with thyroxine.

journal of laryngology and otology 2015 Apr;129(4):403-5. doi:

A case of lingual thyroid causing airway obstruction in a 3-month-old infant is reported. Endoscopic examination showed 4 X 3 cm base of tongue lesion. Nuclear isotope scanning confirmed this to be the only thyroid tissue,& transoral excision done.

Int J Pediatr Otorhinolaryngology 1988 Oct;16(1):77-82PMID: 3203989

A 3.5 months female infant presented with stridor and respiratory distress. TFT showed elevated TSH: 67.6 mIU/dl.scintigraphic examination no activity in usual gland site but in hypo pharyngeal site at midline . treatment L-thyroxine 50 mcg/day was given and the symptoms improved.

Turkish Journal of Endocrinology and Metabolism, (2003) Three Cases of Lingual Thyroid and Review of

the Literature Haluk Sargın* Gökhan

Take home message Common cause of Stridor in infants –

laryngomalacia(60%)

Although majority of cases are self limiting severe persistant stridor with respiratory distress deserves careful assessment,investigations & interventions .

Lingual thyroid should be included in the differential diagnosis of midline swelling in the base of tongue and thyroid function tests should always be done .

Surgery is not always indicated in lingual thyroid except in severe obstruction or complications.