984
Letters to the Editor
Vocal cordparalysis in cystic fibrosis To the Editor." Many conditions have been reported to cause vocal cord paralysis. 1 To our knowledge cystic fibrosis has not been described as one of these conditions. CASE REPORT A 15-year-old white male with cystic fibrosis, who has been treated at our hospital, reported hoarseness of two week's duration on a routine clinic visit in March, 1973. There was no history of recent trauma and no other significant change in chronic symptoms. The initial impression was laryngitis, and no specific therapy was begun. In October, 1973, the size of the pulmonary artery as seen on a roentgenogram of the chest had increased significantly when compared to examinations prior to the onset of hoarseness. On subsequent clinic visits the patient reported that the hoarseness was gradually improving; however, the voice never returned to normal. In March, 1974, mirror laryngoscopy revealed a paralysis of the left vocal cord in the paramedian position, consistent with paralysis of the left recurrent laryngeal nerve. The remainder of the physical examination demonstrated many signs of advanced cystic fibrosis, but there was essentially n o change from previous examinations. The neurologic examination was normal except for the vocal cord paralysis.
From the Departments of Pediatrics, Otorhinolaryngology and Human Communication, University of Pennsylvania Medical Center, and The Children's Hospital of Philadelphia.
The Journal of Pediatrics June 1975
In addition to diffuse chronic changes in both lung fields, an enlarged pulmonary artery and an elevated left mainstem bronchus were seen on the chest roentgenogram. A bariumswallow e s o p h a g r a m was n o r m a l . T o m o g r a m s of t h e mediastinum revealed an enlarged pulmonary artery with no other abnormal structure seen. Tomograms of the larynx (Fig. 1) demonstrated an immobile left vocal cord in the paramedian position, and hypertrophy of the right vocal cord. An electrocardiogram was consistent with right axis deviation, right ventricular hypertrophy, and right atrial hypertrophy. Pulmonary function tests revealed marked abnormalities in the lung volumes with significant air trapping and signs of severe airway obstruction. All measurements of pulmonary function were more abnormal than they had been one year earlier. Serum thyroxine was 5.6 p~g/dl and serum glucose (random) was 58 mg/dl. Laboratory values of arterial blood obtained while the patient was breathing room air included: pH 7.38; oxygen tension, 45 mm Hg; and carbon dioxide tension, 50 m m Hg. DISCUSSION It is felt that the vocal cord paralysis in this patient with cystic fibrosis is due to compression of the left recurrent laryngeal nerve by an enlarged pulmonary artery. Because of the patient's advanced pulmonary disease and chronic hypoxia, there is little hope of permanently reducing the increased pulmonary vascular pressure which is probably responsible for the enlargement of his pulmonary artery. The tomograms demonstrated that the right vocal cord is hypertrophied and extends across the midline. Although the compensatory hypertrophy of the right vocal cord has resulted in an improvement in the patient's ability to phonate, there is concern that the incomplete closure of the glottis prevents the patient from
Fig. 1. Tomograms of the larynx demonstrating the immobile left vocal cord and the hypertrophy of the right vocal cord during, a, quiet breathing, b, phonation, and c, valsalva maneuver.
Volume 86 Number 6
Letters to the Editor
985
producing an effective cough. Since the production of an effective cough following chest physiotherapy is an essential part of the t r e a t m e n t of cystic fibrosis, an intracordal injection of Teflon (Teflon paste, Ethicon, Inc., Somerville, N. J.) is being considered as a therapeutic procedure. 2 Thomas F. Scanlin, M.D. Robert S. Shapiro, M.D. M. L. Rosenlund, M.D. University of Pennsylvania Medical Center The Children's Hospital of Philadelphia 34th & Civic Center Blvd. Philadelphia, Pa. 19104
REFERENCES 1. Dedo HH: The paralyzed larynx: An electromyographic study in dogs and humans, Laryngoscope 80:1455, 1970. 2. Dedo HH, Urrea RD, and Lawson L: Intracordal injection of Teflon in the treatment of 135 patients with dysphonia, Ann of Otol Rhinol Laryngol 82:661, 1973. Fig. 1. Peritoneal dialysis catheters, adult (top), pediatric (middle), and infant (bottom).
Peritoneal dialysis catheter for small infants To the Editor: For several years peritoneal dialysis has been successfully utilized in the treatment of children and adults with acute and chronic renal failure as well as for accidental ingestion of poisons. There are only a few reports describing the use of peritoneal dialysis in premature and term newborn infants. 14 In most of the newborn infants the dialysis catheter was placed surgically, t, ~ or a continuous flow peritoneal dialysis was attempted with inflow and outflow catheters. 3 In a few newborn infants the standard percutaneous catheter insertion technique has been described. 2, 4 The drainage holes in the standard adult and pediatric peritoneal dialysis catheter are limited to distal8.4 and 4.2 cm, respectively (Fig. 1) and must be placed well into the peritoneal cavity in order to maintain satisfactorily the dialysis. We have found that the intraperitoneal space in some newborn infants is too small to accommodate all of the drainage holes of the standard pediatric catheter. Thus we have experienced extraperitoneal leakage of the dialysis fluid, when the peritoneal cavity is being filled, as well as poor outflow, owing to intraperitoneal suction of air during the emptying phase of the dialysis cycle. Recently a peritoneal dialysis catheter for infants* has been designed to help overcome the difficulties mentioned above. The catheter has the same internal diameter as the standard adult and pediatric dialysis catheter, but the drainage holes are limited to the distal 2.1 cm (Fig. 1). Following distention of the *Trocath (infant size) McGaw Laboratories, Los Angeles, Calif.
peritoneal cavity with dialysis fluid the infant catheter was inserted percutaneously in the midline one-third of the distance from umbilicus to symphysis pubis. Successful peritoneal dialysis has been accomplished with this catheter in 4 infants with renal failure and/or overexpansion of vascular and extraceUular fluid volume. Two of the patients were boys and the other 2 girls; their weights varied between 2.6 and 6.5 kg. With the use of this catheter no leakage of fluid was observed through the drainage holes or around the catheter. The infant peritoneal dialysis catheter may be used fd'r peritoneal dialysis in newborn and small infants with greater success than other pediatric dialysis catheters with which we are familiar. Sudhir K. Anand, M.B.B.S. James D. Northway, M.D. Edwin L. Gresham, M.D. Indiana University School of Medicine I100 W. Michigan St. Indianapolis, Ind. 46202
REFERENCES 1. Segar WE, Gibson RK, and Rhamy R: Peritoneal dialysis in infants and small children, Pediatrics 27:603, 1961, 2. Lloyd-Still JD, and Atwelt JD: Renal failure in infant with special reference to the use of peritoneal dialysis, J Pediatr Surg 1:466, 1966. 3. Boda D, Muryani L, Altorjay I, and Veress I: Peritoneal dialysis in the treatment of hyaline membrane disease of the newborn premature infants, Acta Pediatr Scand 60:90, 1971. 4. Manley GL, and Collipp PD: Renal failure in the newborn: Treatment with peritoneal dialysis, Am J Dis -'~Child i15:107, 1968.
Letters to the Editor
Vocal cordparalysis in cystic fibrosis To the Editor." Many conditions have been reported to cause vocal cord paralysis. 1 To our knowledge cystic fibrosis has not been described as one of these conditions. CASE REPORT A 15-year-old white male with cystic fibrosis, who has been treated at our hospital, reported hoarseness of two week's duration on a routine clinic visit in March, 1973. There was no history of recent trauma and no other significant change in chronic symptoms. The initial impression was laryngitis, and no specific therapy was begun. In October, 1973, the size of the pulmonary artery as seen on a roentgenogram of the chest had increased significantly when compared to examinations prior to the onset of hoarseness. On subsequent clinic visits the patient reported that the hoarseness was gradually improving; however, the voice never returned to normal. In March, 1974, mirror laryngoscopy revealed a paralysis of the left vocal cord in the paramedian position, consistent with paralysis of the left recurrent laryngeal nerve. The remainder of the physical examination demonstrated many signs of advanced cystic fibrosis, but there was essentially n o change from previous examinations. The neurologic examination was normal except for the vocal cord paralysis.
From the Departments of Pediatrics, Otorhinolaryngology and Human Communication, University of Pennsylvania Medical Center, and The Children's Hospital of Philadelphia.
The Journal of Pediatrics June 1975
In addition to diffuse chronic changes in both lung fields, an enlarged pulmonary artery and an elevated left mainstem bronchus were seen on the chest roentgenogram. A bariumswallow e s o p h a g r a m was n o r m a l . T o m o g r a m s of t h e mediastinum revealed an enlarged pulmonary artery with no other abnormal structure seen. Tomograms of the larynx (Fig. 1) demonstrated an immobile left vocal cord in the paramedian position, and hypertrophy of the right vocal cord. An electrocardiogram was consistent with right axis deviation, right ventricular hypertrophy, and right atrial hypertrophy. Pulmonary function tests revealed marked abnormalities in the lung volumes with significant air trapping and signs of severe airway obstruction. All measurements of pulmonary function were more abnormal than they had been one year earlier. Serum thyroxine was 5.6 p~g/dl and serum glucose (random) was 58 mg/dl. Laboratory values of arterial blood obtained while the patient was breathing room air included: pH 7.38; oxygen tension, 45 mm Hg; and carbon dioxide tension, 50 m m Hg. DISCUSSION It is felt that the vocal cord paralysis in this patient with cystic fibrosis is due to compression of the left recurrent laryngeal nerve by an enlarged pulmonary artery. Because of the patient's advanced pulmonary disease and chronic hypoxia, there is little hope of permanently reducing the increased pulmonary vascular pressure which is probably responsible for the enlargement of his pulmonary artery. The tomograms demonstrated that the right vocal cord is hypertrophied and extends across the midline. Although the compensatory hypertrophy of the right vocal cord has resulted in an improvement in the patient's ability to phonate, there is concern that the incomplete closure of the glottis prevents the patient from
Fig. 1. Tomograms of the larynx demonstrating the immobile left vocal cord and the hypertrophy of the right vocal cord during, a, quiet breathing, b, phonation, and c, valsalva maneuver.
Volume 86 Number 6
Letters to the Editor
985
producing an effective cough. Since the production of an effective cough following chest physiotherapy is an essential part of the t r e a t m e n t of cystic fibrosis, an intracordal injection of Teflon (Teflon paste, Ethicon, Inc., Somerville, N. J.) is being considered as a therapeutic procedure. 2 Thomas F. Scanlin, M.D. Robert S. Shapiro, M.D. M. L. Rosenlund, M.D. University of Pennsylvania Medical Center The Children's Hospital of Philadelphia 34th & Civic Center Blvd. Philadelphia, Pa. 19104
REFERENCES 1. Dedo HH: The paralyzed larynx: An electromyographic study in dogs and humans, Laryngoscope 80:1455, 1970. 2. Dedo HH, Urrea RD, and Lawson L: Intracordal injection of Teflon in the treatment of 135 patients with dysphonia, Ann of Otol Rhinol Laryngol 82:661, 1973. Fig. 1. Peritoneal dialysis catheters, adult (top), pediatric (middle), and infant (bottom).
Peritoneal dialysis catheter for small infants To the Editor: For several years peritoneal dialysis has been successfully utilized in the treatment of children and adults with acute and chronic renal failure as well as for accidental ingestion of poisons. There are only a few reports describing the use of peritoneal dialysis in premature and term newborn infants. 14 In most of the newborn infants the dialysis catheter was placed surgically, t, ~ or a continuous flow peritoneal dialysis was attempted with inflow and outflow catheters. 3 In a few newborn infants the standard percutaneous catheter insertion technique has been described. 2, 4 The drainage holes in the standard adult and pediatric peritoneal dialysis catheter are limited to distal8.4 and 4.2 cm, respectively (Fig. 1) and must be placed well into the peritoneal cavity in order to maintain satisfactorily the dialysis. We have found that the intraperitoneal space in some newborn infants is too small to accommodate all of the drainage holes of the standard pediatric catheter. Thus we have experienced extraperitoneal leakage of the dialysis fluid, when the peritoneal cavity is being filled, as well as poor outflow, owing to intraperitoneal suction of air during the emptying phase of the dialysis cycle. Recently a peritoneal dialysis catheter for infants* has been designed to help overcome the difficulties mentioned above. The catheter has the same internal diameter as the standard adult and pediatric dialysis catheter, but the drainage holes are limited to the distal 2.1 cm (Fig. 1). Following distention of the *Trocath (infant size) McGaw Laboratories, Los Angeles, Calif.
peritoneal cavity with dialysis fluid the infant catheter was inserted percutaneously in the midline one-third of the distance from umbilicus to symphysis pubis. Successful peritoneal dialysis has been accomplished with this catheter in 4 infants with renal failure and/or overexpansion of vascular and extraceUular fluid volume. Two of the patients were boys and the other 2 girls; their weights varied between 2.6 and 6.5 kg. With the use of this catheter no leakage of fluid was observed through the drainage holes or around the catheter. The infant peritoneal dialysis catheter may be used fd'r peritoneal dialysis in newborn and small infants with greater success than other pediatric dialysis catheters with which we are familiar. Sudhir K. Anand, M.B.B.S. James D. Northway, M.D. Edwin L. Gresham, M.D. Indiana University School of Medicine I100 W. Michigan St. Indianapolis, Ind. 46202
REFERENCES 1. Segar WE, Gibson RK, and Rhamy R: Peritoneal dialysis in infants and small children, Pediatrics 27:603, 1961, 2. Lloyd-Still JD, and Atwelt JD: Renal failure in infant with special reference to the use of peritoneal dialysis, J Pediatr Surg 1:466, 1966. 3. Boda D, Muryani L, Altorjay I, and Veress I: Peritoneal dialysis in the treatment of hyaline membrane disease of the newborn premature infants, Acta Pediatr Scand 60:90, 1971. 4. Manley GL, and Collipp PD: Renal failure in the newborn: Treatment with peritoneal dialysis, Am J Dis -'~Child i15:107, 1968.
