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An Interesting Case of Neonatal
Respiratory DistressMary Callahan, MS4
June 2013
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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
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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
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Differential Diagnoses
Transient tachypnea of the newborn
Upper airway obstruction (choanal atresia)
Meconium aspiration syndrome
Hyaline membrane disease
Infection
Pneumothorax
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Imaging Options
Chest radiography• Common causes of neonatal respiratory distress have
characteristic findings• No clear ACR Appropriateness Criteria
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Accession:5285724
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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
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Our Patient Normal
Accession: 5285706 Accession: 5088681
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Our Patient Normal
Accession: 5285706 Accession: 5088681
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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
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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)
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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
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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
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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.
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Questions?