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The Noisy Breather

The Noisy Breather. 7 th Annual Pediatric Otolaryngology Symposium October 4, 2012 Melissa M. Dziedzic APRN, CORLN. Meet Solaris. History. Presented at 4 mos with a h/o noisy breathing since birth Parents describe a “stridorous sound” on inspiration and expiration

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The Noisy Breather

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  1. The Noisy Breather 7th Annual Pediatric Otolaryngology Symposium October 4, 2012 Melissa M. Dziedzic APRN, CORLN

  2. Meet Solaris

  3. History • Presented at 4 mos with a h/o noisy breathing since birth • Parents describe a “stridorous sound” on inspiration and expiration • +Retractions; color pink; gaining weight; feeds vigorously; occasional vomiting (on Prevacid) • On Budesonide and Albuterol via nebulizer without an improvement • Several office and ER visits for her noisy breathing

  4. Past Medical History • Normal pregnancy without complications • Born at 30 wks gestation requiring 2 mos in the NICU for ventilatory support and then CPAP • Heart Murmur at birth resolved without further intervention

  5. Physical Examination • Mild inspiratory and expiratory stridor • Mild intercostal retractions • No nasal flaring • Color is pink and extremities are warm with brisk capillary refill • Chest is clear with transmitted inspiratory and expiratory upper airway sounds

  6. Diagnostic Laryngoscopy

  7. Right Subglottic Cyst

  8. Right Subglottic Cyst

  9. Subglottic Cyst • Ductal Cysts arise from the blockage of submucosal glands which can occur in the vallecula, subglottis, or vocal cords • Subglottic cysts are common after prolonged intubation d/t irritation and blockage of the submucosal glands

  10. Treatment Plan • Allow Solaris to feed and grow and have her return in 3 months • Follow-up visit 3 months later>doing well • 2 months later>admitted for pneumonia with increased stridor and respiratory distress • Plan to expedite surgical excision of the right subglottic cyst with a diagnostic laryngoscopy and bronchoscopy to further evaluate the airway • Developed respiratory distress and increased stridor-surgery planned for that evening

  11. Diagnostic Laryngoscopy and Bronchoscopy • Using a rigid telescope the oral cavity, oropharynx, hypopharynx, and supraglottic and glottic larynx was evaluated • Diagnosed with a large cystic mass on the right posterior half of the vocal cord that extended below the level of the glottis • Rigid bronchoscopy – no abnormalities below the level of the glottis

  12. Excision of Right Subglottic Cyst

  13. Excision Right Subglottic Cyst

  14. Excision of Right Subglottic Cyst

  15. Postoperative Care • Post operative observation in the PICU • Placed on Steroids • Kept intubated overnight • Extubated the next day but kept on O2 • O2 d/c’d the next day, but increased WOB>received racemic epi • Improved overnight>to regular pedi floor • Discharged the next day

  16. Postoperative Follow-Up • 1 month later-remarkable improvement *no further stridor *no nebulizer treatments *feeding and growing well • Pathology Report *fibrous tissue partially lined with respiratory type mucosa • 3 months later-Diagnostic Laryngoscopy Clear

  17. Easy Breathing!

  18. Questions?

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