1. An Interesting Case of Neonatal Respiratory Distress Mary Callahan, MS4 June 2013

2. History  Infant male born at 38 4/7 weeks via uncomplicated spontaneous vaginal delivery  Mother 38 year old G4P1, history of gestational diabetes  Apgars: 8, 3, 7  Cried at delivery with spontaneous respirations  At 5 minutes of life retractions, apnea and cyanosis noted

3. Initial Physical Exam  HR: 80-100  General: Cyanotic, color improved with O2  Resp: Poor respiratory effort, unable to auscultate breath sounds or air entry  Stridor noted during bagging  CV: Regular rhythm, normal S1 and S2, no murmurs  HEENT: Nares appear patent, copious nasal secretions, unable to pass suction tubing down either nare

4. Differential Diagnoses  Transient tachypnea of the newborn  Upper airway obstruction (choanal atresia)  Meconium aspiration syndrome  Hyaline membrane disease  Infection  Pneumothorax

5. Imaging Options  Chest radiography Common causes of neonatal respiratory distress have characteristic findings No clear ACR Appropriateness Criteria

6. Accession: 5285724

7. Evaluation for Choanal Atresia  Nasal Endoscopy  CT of Paranasal Sinuses Confirms diagnosis Noninvasive Able to characterize nature and severity of deformity Anatomic visualization helpful for surgical planning Suction mucous out of nares prior to scan

8. Our PatientNormal Accession: 5285706Accession: 5088681

9. Our PatientNormal Accession: 5285706Accession: 5088681

10. CT Findings of Choanal Atresia  Common findings: narrowing of posterior nasal cavity, medialization of lateral nasal wall, thickening of vomer  Diagnosed if posterior choanal oriface measures less than 0.34 cm unilaterally or posterior vomer measures greater than 0.55 cm  Our Patient: Max choanal diameter: 0.22 cm right, 0.24 cm on left  Both bony and membranous components Accession: 5285706

11. Choanal Atresia  Congenital obstruction of posterior nasal apertures, nasal cavity fails to communicate with nasopharynx  Occurs in 1 of every 5000-7000 live births, but most common congenital nasal anomaly  Unilateral atresia more common  Bony, membranous, or mixed membranous (70% mixed)  Associated with other congenital anomalies in 50% of cases (CHARGE syndrome)

12. Choanal Atresia  Neonates obligate nasal breathers  Bilateral atresia presents with neonatal respiratory distress or cyclical cyanosis that improves with crying and worsens with feeding  Unilateral may present later in life with nasal obstruction, persistent nasal discharge, noisy breathing

13. Treatment & Outcome  Definitive treatment is surgical repair  Patient went to OR on day 10 of life for repair and placement of bilateral nasal stents  CHARGE syndrome work-up (ophtho eval, ECHO, retroperitoneal ultrasound) negative

14. References  Suurna M. Chapter 11: Congenital Nasal Anomalies. Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery. 3rd ed. New York: McGraw-Hill; 2012.  Adil E, Huntley C, Choudhary A, Carr M. Congenital nasal obstruction: clinical and radiologic review. Eur J Pediatr. 2012. 171: 641-650.  Manson, D. Congenital Anomalies of the Neonatal Upper Airway. Radiological Imaging of the Neonatal Chest. 2008. 163- 175.

15. Questions?