An Unusual Case of Noisy Breathing in an Infant

A Missed Diagnosis of Laryngotracheal Injury Secondary to Emergency Intubation: Lessons Learned

Iatrogenic laryngotracheal trauma is a potentially fatal complication of endotracheal intubation, especially in an emergency setting. Symptoms are almost always related to speech, breathing, and swallowing. Hoarseness being the commonest symptom, while shortness of breath and stridor always signify more devastating injury. We present a case of iatrogenic subglottic and tracheal stenosis, which was misdiagnosed in the emergency department during the first visit. This case report highlights the importance of salient history and thorough examination with a high index of suspicion in a stridorous case with a recent history of intubation. Early detection and management are vital to avoid a life-threatening event.

Congenital Ewing Sarcoma Presenting as a Rapidly Growing Neck Mass in a Newborn

BACKGROUND

Ewing sarcoma (EWS) is an aggressive soft-tissue and bone malignancy. Congenital EWS is extremely rare, and its presenting features can be unique from that of EWS occurring in older children.

CLINICAL FINDINGS

A full-term female infant with a neck mass present at birth was admitted to a level I nursery with an otherwise well appearance and normal vital signs. After consultation with a neonatologist, she was transferred to a neonatal intensive care unit where she developed sudden respiratory collapse from rapid growth of the mass causing airway obstruction, leading to emergent intubation. Ultrasound and MRI scans of the neck mass demonstrated cystic and vascular components, and a timely biopsy revealed small round blue cells with diffuse CD99 expression and chromosomal translocation 11;22.

PRIMARY DIAGNOSIS

Ewing sarcoma.

INTERVENTIONS

An accelerated workup for EWS was done due to the patient's critical status. On day of life (DOL) 8, she was started on treatment of EWS as per the current standard-of-care AEWS0031. On DOL 24, she underwent tracheostomy placement.

OUTCOMES

The patient completed 14 total cycles of chemotherapy and is more than 12 months old. Her tracheostomy was decannulated at 6 months of age.

PRACTICE RECOMMENDATIONS

The rarity of EWS in neonates and its presentation as a neck mass make this disease difficult to recognize unless clinicians have a high index of suspicion. The aims of this case report are to increase awareness of malignancy as a potential cause of neck masses in neonates and to prompt nurses and physicians to prepare for airway stabilization at appropriate levels of care if a neck mass is present at birth.

Scoping review of head and neck neoplasms presenting with obstructive sleep apnoea: the importance of flexible nasendoscopy

BACKGROUND

Obstructive sleep apnoea (OSA) can be caused by neoplasms involving the upper aerodigestive tract. Currently, many of these patients have this diagnosis missed, as most adults diagnosed with OSA do not undergo adequate head and neck examination including flexible nasendoscopy. We performed a review of the literature to shed light on this phenomenon and outline the pathologies and issues surrounding this sub-population of patients diagnosed with OSA.

METHODS

A scoping review of the literature was conducted on head and neck neoplasms presenting with OSA. Data were extracted on demographics, clinical presentation, histopathology, treatment and patient outcomes.

RESULTS

Sixty-seven articles were included, describing 79 patients. Mean age was 45.8 years, and 77.2% were male. Symptoms of OSA were present for an average of 29.2 months before a diagnosis of causative neoplasm was made. Forty-two different benign and malignant histopathological entities were reported. At diagnosis, the causative pathology of 100% of patients was visible on head and neck examination including flexible nasendoscopy, while only 53.2% were visible on trans-oral examination. One-third of patients had commenced inappropriate treatment for OSA, including three who had undergone sleep surgical procedures. The majority of patients were treated with surgery alone (72.2%).

CONCLUSION

Although rare, neoplasms of the upper aerodigestive tract should be considered as a cause of OSA, especially in patients experiencing other symptoms in addition to the typical symptoms of OSA. They should particularly be considered in patients with comparatively lower body mass index or those with worsening OSA without an apparent cause identified.