LUNG
Early Management of Respiratory Obstruction in Micrognathia by Use of a Nasogastric Tube A Case D.
Report
Gary Benfield,
M.D.*
~Y ! IGRC~GN ~THIA
associated with posof the tongue is a well-
terior displacement known cause of airway obstruction in the immediate newborn period. When nipple feeding is attempted, the infant may regurgitate and frequently aspirate as he struggles to suck, swallow, and breathe simul-
taneously, During the 1940s and 1950s, cases of micrognathia associated with severe airway obstruction were treated with tongue-lip later on, with elective tracherecently, in 1973, ~IcEvitt ostomy.3 successfully managed 13 cases with severe symptoms by simply passing a #8 or larger size nasogastric tube. The patient reported here was born in October, 1973, at which time McEvitt’s novel approach came to our attention.
adhesion,1,2
Morse
Case A
old,
Description 3.4 kg white boy was born to gravida 2, para 1 mother at 39
Director, The Children’s
a
24-year-
weeks’ ges-
of Akron, Regional Neonatal Intensive Care Unit; Department of Pediatric Medicine, Division of Neonatology, Buchtel Avenue at Bowery Street, Akron, O. 44308. *
Hospital
tation. The infant was transferred to the Regional Neonatal Intensive Care Unit at The Children’s Hospital of Akron at six hours of age because of multiple congenital anomalies, respiratory distress, and cyanosis. The admission examination showed ruclimentary external ears, apparently absent auditory canals, malar hypoplasia, antimongoloid slanting of the palpebral fissures, cleft palate, and micrognathia-changes compatible with Treacher-Collins’ syndrome. The initial attempts to feed by nipple induced episodes of cyanosis, sternal retraction, bradycardia, and apnea. Limited success was achieved by frequent small volume feeding through a #5 nasogastric tube, but periodic episodes of cyanosis, sternal retraction, bradycardia, and apnea reoccurred despite prone positioning and careful nursing care. The pathogenesis was lifethreatening airway obstruction caused by the posteriorly displaced tongue. To remedy this, tracheostomy was seriously considered. However, insertion of a larger #8 nasogastric tube produced dramatic complete relief. Relief of the airway obstruction enabled the infant to suck, swallow, and breathe without distress. With the larger tube in place, adequate nutrition was achieved by use of Lamb’s nipple feeding ~
(Fig. 1).
.
The infant was discharged at two weeks of age, with the #8 nasogastric tube in place. The author then made weekly home visits to supervise nasogastric tube removal and positioning of a clean tube through the opposite
630
Downloaded from cpj.sagepub.com at Bobst Library, New York University on May 10, 2015
Fuc. la,b. ~’1icrognathic with nasogastric tube in place illustratin~ relief of airway obstruction and ability to nipple feed.
patient
nt~stril. The at
nasogastric
tube
was
finally
removed
2Y2 months of age and Lamb’s nipple
feeding
continued without incident.
Discussion The treatment of airway obstruction associated with micrognathia should be individualized to meet particular patient needs,5 In our infant, the nasogastric tube apparently created a vertical column of air around the tube sufficient to relieve obstruction (Fig. 2). Weekly repositioning of a clean tube in the opposite nostril avoided chronic nasal trauma. Sufficient mandibular growth was achieved by 2!/2 months of age to the point where obstruction was no longer a problem. References 1.
2.
3. 4.
FIG. 2. Position of nasogastric tube in relation to the posteriorly displaced tongue, creating a vertical air colmnn around the tube sufficient to relieve airway obstruction.
B.: The treatment of micrognathia associated with obstruction by a plastic procedure. Plast. Reconstr. Surg. 1: 300, 1946. —: A further report on the treatment of micrognathia with obstruction by a plastic procedure: results based on reports from 21 cities. Plast. Reconstr. Surg. 5: 113, 1950. McEvitt, W. G.: Micrognathia and its management. Plast. Reconstr. Surg. 41: 450, 1968. —: Treatment of respiratory obstruction in micrognathia by use of a nasogastric tube. Plast. Reconstr. 138, 1973. Lindsay, W. K., Randall, P., and McDowell, F.: The voice of polite dissent. Plast. Reconstr. Surg. 52: 306, 1973.
Douglas,
52: Surg.
5.
631
Downloaded from cpj.sagepub.com at Bobst Library, New York University on May 10, 2015
Early Management of Respiratory Obstruction in Micrognathia by Use of a Nasogastric Tube A Case D.
Report
Gary Benfield,
M.D.*
~Y ! IGRC~GN ~THIA
associated with posof the tongue is a well-
terior displacement known cause of airway obstruction in the immediate newborn period. When nipple feeding is attempted, the infant may regurgitate and frequently aspirate as he struggles to suck, swallow, and breathe simul-
taneously, During the 1940s and 1950s, cases of micrognathia associated with severe airway obstruction were treated with tongue-lip later on, with elective tracherecently, in 1973, ~IcEvitt ostomy.3 successfully managed 13 cases with severe symptoms by simply passing a #8 or larger size nasogastric tube. The patient reported here was born in October, 1973, at which time McEvitt’s novel approach came to our attention.
adhesion,1,2
Morse
Case A
old,
Description 3.4 kg white boy was born to gravida 2, para 1 mother at 39
Director, The Children’s
a
24-year-
weeks’ ges-
of Akron, Regional Neonatal Intensive Care Unit; Department of Pediatric Medicine, Division of Neonatology, Buchtel Avenue at Bowery Street, Akron, O. 44308. *
Hospital
tation. The infant was transferred to the Regional Neonatal Intensive Care Unit at The Children’s Hospital of Akron at six hours of age because of multiple congenital anomalies, respiratory distress, and cyanosis. The admission examination showed ruclimentary external ears, apparently absent auditory canals, malar hypoplasia, antimongoloid slanting of the palpebral fissures, cleft palate, and micrognathia-changes compatible with Treacher-Collins’ syndrome. The initial attempts to feed by nipple induced episodes of cyanosis, sternal retraction, bradycardia, and apnea. Limited success was achieved by frequent small volume feeding through a #5 nasogastric tube, but periodic episodes of cyanosis, sternal retraction, bradycardia, and apnea reoccurred despite prone positioning and careful nursing care. The pathogenesis was lifethreatening airway obstruction caused by the posteriorly displaced tongue. To remedy this, tracheostomy was seriously considered. However, insertion of a larger #8 nasogastric tube produced dramatic complete relief. Relief of the airway obstruction enabled the infant to suck, swallow, and breathe without distress. With the larger tube in place, adequate nutrition was achieved by use of Lamb’s nipple feeding ~
(Fig. 1).
.
The infant was discharged at two weeks of age, with the #8 nasogastric tube in place. The author then made weekly home visits to supervise nasogastric tube removal and positioning of a clean tube through the opposite
630
Downloaded from cpj.sagepub.com at Bobst Library, New York University on May 10, 2015
Fuc. la,b. ~’1icrognathic with nasogastric tube in place illustratin~ relief of airway obstruction and ability to nipple feed.
patient
nt~stril. The at
nasogastric
tube
was
finally
removed
2Y2 months of age and Lamb’s nipple
feeding
continued without incident.
Discussion The treatment of airway obstruction associated with micrognathia should be individualized to meet particular patient needs,5 In our infant, the nasogastric tube apparently created a vertical column of air around the tube sufficient to relieve obstruction (Fig. 2). Weekly repositioning of a clean tube in the opposite nostril avoided chronic nasal trauma. Sufficient mandibular growth was achieved by 2!/2 months of age to the point where obstruction was no longer a problem. References 1.
2.
3. 4.
FIG. 2. Position of nasogastric tube in relation to the posteriorly displaced tongue, creating a vertical air colmnn around the tube sufficient to relieve airway obstruction.
B.: The treatment of micrognathia associated with obstruction by a plastic procedure. Plast. Reconstr. Surg. 1: 300, 1946. —: A further report on the treatment of micrognathia with obstruction by a plastic procedure: results based on reports from 21 cities. Plast. Reconstr. Surg. 5: 113, 1950. McEvitt, W. G.: Micrognathia and its management. Plast. Reconstr. Surg. 41: 450, 1968. —: Treatment of respiratory obstruction in micrognathia by use of a nasogastric tube. Plast. Reconstr. 138, 1973. Lindsay, W. K., Randall, P., and McDowell, F.: The voice of polite dissent. Plast. Reconstr. Surg. 52: 306, 1973.
Douglas,
52: Surg.
5.
631
Downloaded from cpj.sagepub.com at Bobst Library, New York University on May 10, 2015
