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 6 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 4 to 6 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 1 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 1 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 4
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