An Interesting Case of Neonatal

Respiratory DistressMary Callahan, MS4

June 2013

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

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

Differential Diagnoses

Transient tachypnea of the newborn

Upper airway obstruction (choanal atresia)

Meconium aspiration syndrome

Hyaline membrane disease

Infection

Pneumothorax

Imaging Options

Chest radiography• Common causes of neonatal respiratory distress have

characteristic findings• No clear ACR Appropriateness Criteria

Accession:5285724

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

Our Patient Normal

Accession: 5285706 Accession: 5088681

Our Patient Normal

Accession: 5285706 Accession: 5088681

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

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)

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

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

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.

Hermansen, C, Lorah, K. Respiratory Distress in the Newborn. 2007. Am Fam Physician. 76: 987-994.

Questions?