Neonatal respiratory distress

Abstract

Case A 38 week male baby was born from a 36 year old mother after a problem free pregnancy by voluntary cesarean section After birth low APGAR score and respiratory distress was found The patient was tried to be intubated but the trial was unsuccessful and ventilation was provided by performing intubation by oral route Choanal atresia was excluded by inserting a nasogastric tube through the nasal passage Other physical examination and laboratory findings were found to be normal No pathology was found on chest graphy After intubation respiratory distress improved and the patient was referred to the neonatal intensive care unit of our hospital During otolarygofarengeal examination the patient was extubated but reintubated since respiratory distress and cyanosis developed Endoscopy was performed Picture 1 Diagnosis: Nasal hairy polyp A large polipoidal mass was found in the oral cavity during otolaryngeal examination Respiratory distress and cyanosis developed during examination The patient was urgently taken to operation under general anesthesia A mouth opener was placed and a 4x2x3 cm polipoidal mass which prolapsed downward from the oropharynx was visiualized with the help of an endoscope The mass was extending from the nasopharynx to the oropharynx and occupying the oral cavity to a large extent Picture 1 Severe respiratory distress developed again during examination Therefore the patient was intubated and the mass was extirpated under endoscopic imaging Magnetic resonance imaging was not performed before the operation because of the urgency of the case After the operation all complaints of the patient improved and the patient was discharged on the second day The extirpated mass was a polipoidal mass with a dimension of 4x2x3 cm macroscopically with a smooth surface Since histopathological examination revealed squamous epithelium skin extensions pilosebaceous glands and fibroadipose tissue the mass was evaluated to be hairy polyp Picture 2 In the follow up after the operation the patient was not seen again for 5 months Discussion Hairy polyps HP are benign tumors which can be observed in any part of the body wrap the fibroadipose tissue and are composed of skin appendages and extensions 1 They occur in the early embriogenesis period and are originated only from the ectoderm and mesoderm 2 Despite abundant discussions in the literature the actual embriogenesis and nature of HP are not fully elucidated yet and continue to be a subject of discussion These tumors are usually localized in the nasopharynx oropharynx soft palate hard palate tonsillae tounge eustachy tube and middle ear The most common localizations include the nasopharynx and oropharynx When they develop in the oropharynx they typically occur as pedunclated masses The clinical status and urgency of the patient depends on the size and localization of the polyp Rarely it may not be recognized until advanced ages if it stays complaint free Although HP occurs rarely it is the most common congenital tumor of the oropharynx and nasopharynx 3 Kelly et al 3 compiled 135 cases which were published until 1996 in the literature written in English In addition there are approximately 35 cases reported between 1996 and 2011 4 Hairy polyp usually occurs as a single disorder However it may rarely be associated with anomalies including cleft palate uvula and external ear agenesis and facial hemihypertropy 5 Malign transformation of these tumors have not been reported Alhtough it nearly always occurs in newborns and infants it has also very rarely been reported at advanced ages 6 The clinical picture depends on the size and localization of the polyp The dimensions may range between 0 5 cm and 6 cm Small lesions can lead to intermittent cyanosis or may stay asymptomatic If the polyp is large enough to close the larynx respiratory distress develops Although radiologic imaging is beneficial it can not differentiate diseases However computarized tomography and magnetic resonance imaging are absolutely necessary to assess if there is intracranial involvement In differential diagnosis choanal atresia which leads to a similar clinical picture should be excluded by inserting a nasogastric tube through the nose In addition hamartoma teratoma hemangioma neuroblastoma meningoencephalocele rabdomyosarcoma thyroglossal cyst and lingual cyst should be included in the differential diagnosis 7 Since it may extend into the brain it is fairly significant to diffeentiate HP from meningoencephalocele The primary goal of treatment is to secure the airway After the airway is secured treatment consists of extirpating the mass fully as in our case In summary all newborns with airway obstruction should be evaluated in terms of pharyngeal tumor In all patients endoscopic examination should be performed before surgery and radiological imaging should be performed to determine if the mass extends into the cranium We could not perform any imaging method because of the urgency of our case We were lucky because the mass was not extending into the cranium Address for Correspondence: Vefa Kınış MD Dicle University Medical Faculty Division of Otolaryngology Diyarbakır Turkey E mail: vefakinis@hotmail com Received: 09 06 2011 Accepted: 10 05 2011 References

Keywords

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Solunum sıkıntısı olan bir yenidoğan

Öz

Otuz sekiz haftalık erkek bebek, 36 yaşındaki anneden sorunsuz bir hamilelik sonrasında isteğe bağlı olarak sezaryenle doğurtulmuş. Doğum sonrası olguda düşük APGAR skoru ve solunum sıkıntısı saptanmış. Hasta entübe edilmek istenmiş, başarılamamış ve ancak orofarengeal ‘airway’ takılarak solunum sağlanmış. Hasta dış merkezden gönderilmiş ve hastanemiz yenidoğan ünitesinde entübe edilmiştir. Koanal atrezi burun boşluğundan nazogastrik tüp geçirilerek dışlanmış. Diğer fizik muayene ve laboratuvar bulguları normalmiş. Akciğer grafisinde sorun saptanmamış. Entübasyon edildikten sonra solunum sıkıntısı düzelmiş olan hasta hastanemiz yenidoğan yoğun bakım birimine gönderildi. Kulak, burun, boğaz muayenesi sırasında ‘ekstübe’ edildi, ancak solunum sıkıntısı ve siyanoz gelişmesi nedeniyle hemen geri takıldı ve hasta endoskopiye alındı

Anahtar Kelimeler

• Solunum
• sıkıntısı
• yenidoğan