extern conference 28 june 2007. what is the abnormal finding ?
TRANSCRIPT
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