Pediatric emergency medicine trisk 631

degrees of distress Physicians must determine how much the obstruction is affecting the baby and if emergency airway management is needed CLINICAL PEARLS AND PITFALLS Neonates are obligate nasal breathers until weeks of life Any nasal obstruction can cause respiratory distress during this period The ability to successfully pass a nasogastric tube bilaterally rules out choanal atresia Natal teeth can be an aspiration risk If loose, they should be extracted Cysts or masses in the neck should be immediately assessed for acute airway obstruction Nasal Obstruction Neonates are obligate nasal breathers up to to weeks of age Any nasal obstruction causing bilateral mucosal swelling will cause significant symptoms of obstruction and respiratory distress This is commonly seen in infants with upper respiratory tract infections Simple nasal obstruction should be differentiated from unilateral and bilateral choanal atresia Bilateral choanal atresia occurs in in 7,000 live births Associated anomalies such as CHARGE syndrome (C oloboma, H eart disease, choanal A tresia, R etarded development, G enital hypoplasia, E ar anomalies with hearing loss) occur in 20% to 50% of neonates with bilateral choanal atresia Unilateral atresia is more common than bilateral involvement Symptoms of bilateral choanal atresia vary from mild cyanosis during feeds to severe hypoxia and respiratory distress The onset is shortly after birth Cyanosis occurs when the mouth is completely occluded during feeds and improves with crying Inability to pass a 6F catheter bilaterally through the nares is suspicious Smaller soft catheters may coil in the nares and give a false impression of patency Visualizing or palpating the nasogastric tube in the mouth will also confirm passage and patency Clinicians should also avoid unnecessary mucosal swelling by repeated forceful trials since this will also make it difficult to rule out obstruction Unilateral choanal atresia presents with intermittent nasal obstruction which may pass unnoticed at birth Bedside endoscopic nasal examination can be performed by trained personnel or otolaryngologist A CT or MRI scan will confirm presence of choanal atresia, differentiate unilateral from bilateral, differentiate between choanal stenosis and atresia, and determine whether the lesion is boney or membranous ( Fig 96.30 ) MRI minimizes radiation exposure and can determine the presence of nasal masses Simple nasal obstruction due to edema is managed conservatively with humidification, saline drops, and gentle suctioning Vigorous suction can worsen mucosal edema Intranasal steroid drops should be used with caution as prolonged use may lead to paradoxical worsening Neonates with bilateral choanal atresia should have an oral airway placed to maintain mouth patency and relieve the obstruction Endotracheal intubation is warranted if there is severe respiratory distress or if there is continued obstruction due to failure to maintain patency of the airway Otorhinolaryngology consultation and hospital admission are necessary A genetic workup is warranted for diagnosis of associated conditions FIGURE 96.30 Choanal atresia in a newborn with difficulty breathing Axial CT scan shows a widely patent right nasal passage The left nasal passage is occluded by a thin, ossified septum (arrow ) (Reprinted with permission from Siegel MJ, Coley B Core Curriculum: Pediatric Imaging Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Normal Neonatal Mouth Findings Common normal findings in the oropharynx include natal teeth and benign gingival cysts The incidence of natal teeth (teeth present at birth) is about in every 3,000 live births The mandibular central incisors are the most commonly affected teeth One single tooth usually erupts; eruption of two is rare ( Fig 96.31 ) Because most natal teeth are primary teeth that have erupted early, they should be extracted only if they are loose and pose a danger of aspiration, cause discomfort to the mother or child during nursing, or are confirmed to be supernumerary by focused radiographic examination Consultation with a pediatric dentist is strongly recommended Benign gingival cysts are found in 75% of newborns Epstein pearls are usually single, small, white, keratin-filled cysts found along the midline of the palate ( Fig 96.32 ) Bohn nodules are mucous gland cysts that appear as multiple, firm, grayish white lesions along the gums and occasionally on the palate ( Fig 96.33 ) Dental lamina cysts are formed by remnants of dental lamina epithelium and appear as small, cystic lesions along the crests of the mandibular and maxillary mucosa They are usually larger and more lucent than both Epstein pearls and Bohn nodules These cysts generally disappear by weeks of age Cleft Lip and Palate Defects in the formation of the lip (cleft lip) are obvious on even casual visualization They occur in 0.8% of live born infants Cleft lip is usually lateral in position and may be isolated or accompanied by a cleft palate Isolated cleft palate may be more difficult to detect without focused inspection of the mouth, but should be considered in any neonate with feeding difficulties Median cleft lip and palate is suspicious for other associated midline defects such as holoprosencephaly Cleft lip and palate can occur in many diverse syndromes Physical examination will delineate the extent of the defect and should also determine presence of associated anomalies Presence of pits in the lower lip is suggestive of Van der Woude syndrome (an autosomal recessive disorder) These infants should be referred for eventual surgical repair and for monitoring of feeding techniques Genetics referral is also recommended if other accompanying features are suggestive of other syndromes FIGURE 96.31 Natal teeth Bilateral lower central incisors in a neonate (Courtesy of Denise A, Salerno, MD, FAAP In: Chung EK, Atkinson-McEvoy LR, Boom JA, et al., eds Visual Diagnosis and Treatment in Pediatrics 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010 With permission.) Neck Cysts Congenital neck lesions may present during infancy or sometimes later in childhood The most common lesions include thyroglossal duct cysts (midline in the neck and inferior to the hyoid bone), dermoid cysts (midline tongue lesions), branchial cleft cysts (along the lateral neck), and cystic hygromas (usually located behind the sternocleidomastoid muscle in the supraclavicular fossa; two-thirds of cystic hygromas are present at birth) Obstruction of the airway may occur as a result of mass effect when cysts increase in size This can be insidious in onset, occurring months after birth Infection in any of these cysts can cause rapid increase in size Differential diagnosis of neck masses in a neonate includes reactive lymphadenitis, thyroid cysts, lymphatic or vascular malformations, and tumors (see also Chapter 48 Neck Mass ) US is a rapid tool for evaluation of neck cysts in an afebrile child US will confirm presence of a thyroglossal cyst and can also rule out ectopic thyroid tissue and visualize a normal thyroid CT scan with contrast gives a better delineation of extent of cystic lesions such as cystic hygroma but should be used judiciously because of the high dose of radiation MRI is helpful in determining extent of vascular lesions Assessment of ... thin, ossified septum (arrow ) (Reprinted with permission from Siegel MJ, Coley B Core Curriculum: Pediatric Imaging Philadelphia, PA: Lippincott Williams & Wilkins; 2005.) Normal Neonatal Mouth... nursing, or are confirmed to be supernumerary by focused radiographic examination Consultation with a pediatric dentist is strongly recommended Benign gingival cysts are found in 75% of newborns Epstein... MD, FAAP In: Chung EK, Atkinson-McEvoy LR, Boom JA, et al., eds Visual Diagnosis and Treatment in Pediatrics 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010 With permission.) Neck