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Clinical Challenge
February 2016

Respiratory Distress in a Neonate

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland
  • 2Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
JAMA Otolaryngol Head Neck Surg. 2016;142(2):191-192. doi:10.1001/jamaoto.2015.3118

A full-term 4260-g infant was transferred to a neonatal intensive care unit on day 1 of life after he had respiratory distress in the delivery suite requiring endotracheal intubation. He was delivered by cesarean delivery following a maternal history of cesarean delivery. Prenatal ultrasonography showed polyhydramnios and a fetus that was large for gestational age. In the neonatal intensive care unit, 6F catheters would not pass through either side of the nose, and fiberoptic nasal endoscopy demonstrated a firm, mucosal-covered posterior wall of the bilateral nasal cavities without opening into the nasopharynx. The infant also had zygomatic hypoplasia, micrognathia, and bilateral grade III microtia with atresia of the external auditory canals. Echocardiogram demonstrated large left patent ductus arteriosus and patent foramen ovale with left to right shunt, mild decrease in RV systolic function, and elevated pulmonary artery pressures. Results from head and abdominal ultrasonograph and an ophthalmologic evaluation were unremarkable. Computed tomographic (CT) imaging was performed to plan transnasal repair of clinically suspected choanal atresia. This scan showed bony posterior nasal obstruction, with the hard palate extending directly to the sphenoid bone, with irregular shape and inferior position of the basisphenoid (Figure). The infant remained intubated until, at 11 days of age, he underwent tracheotomy and examination of the nose and nasopharynx under general anesthesia.

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