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Extern conference 28 June 2007. What is the abnormal finding ?

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Presentation on theme: "Extern conference 28 June 2007. What is the abnormal finding ?"— Presentation transcript:

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) O 2 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 O 2 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.

7 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

8 At nursery O 2 tubing 10 LPM and Syringe ball suction with NSS Nasal drop : improved Then continue O 2 hood 5 LPM : SpO 2 99 %, FiO 2 0.45 then wean off O 2 in 6 hrs later SpO 2 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 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

12 Approach to congenital stridor

13 Stridor = upper airway obstruction Anatomical  Supralaryngeal  Laryngeal  Tracheal

14 Approach to congenital stridor Laryngeal : oLaryngomalacia oVocal cord paralysis oSubglottic stenosis oLaryngeal abnormalities (hemangiomas, webs, cysts, cleft)

15 Approach to congenital stridor oSupralaryngeal oVallecular cysts oThyroglossal cysts oTongue teratoma

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

17 Initial Investigation

18 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 ousually 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

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, SpO 2  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

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