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 peripheral cyanosis, 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 %, FiO 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