วันจันทร์ที่ 6 เมษายน พ.ศ. 2569

Thyroglossal Duct Cyst (TGDC)

Thyroglossal Duct Cyst (TGDC)

🔎 Overview

  • TGDC = congenital midline neck cyst ที่พบบ่อยที่สุด (~7%)
  • เกิดจาก remnant ของ thyroglossal duct tract
  • Malignancy ~1–2% (ส่วนใหญ่ papillary thyroid carcinoma)

🧠 Embryology (high-yield)

  • Thyroid เริ่มที่ foramen cecum (tongue base)
  • เคลื่อนลงมาตาม thyroglossal tract → anterior neck
  • ปกติ tract หายไปใน week ~10
  • ถ้ายังเหลือ → cyst / sinus / fistula

📍 Anatomy & Location

  • พบได้ตลอดทาง:
    👉 tongue base → suprasternal notch
  • ตำแหน่งพบบ่อยที่สุด: ใกล้ hyoid bone (thyrohyoid membrane)

🧾 Clinical Features

🔑 Classic presentation

  • Midline neck mass
  • soft, cystic, painless
  • move with:
    • swallowing
    • tongue protrusion ← key diagnostic clue

🧒 vs 👨 Adult

  • เด็ก → infection บ่อย
  • ผู้ใหญ่ → อาจมี
    • pain
    • dysphagia
    • hoarseness
    • fistula

⚠️ Complications

  • recurrent infection (common)
  • abscess
  • fistula formation
  • rare: airway compression

🧪 Diagnosis

🔍 Clinical suspicion

  • midline cystic mass + move with tongue

🖥️ Imaging

First-line

  • US → cystic lesion + evaluate thyroid

Preferred in adult

  • CT neck with contrast
    → define relation to hyoid + extent

MRI

  • ใช้ใน recurrent / complex case

🧠 Important: rule out ectopic thyroid

  • ถ้าไม่มี thyroid ปกติ → ห้ามผ่าตัดทันที
  • ใช้:
    • thyroid scan
    • US / CT

🔬 FNA

  • แนะนำใน adult (especially suspicious features)
  • ช่วย exclude malignancy

🧪 Labs

  • ตรวจ thyroid function ทุกเคสก่อนผ่าตัด

🧾 Differential Diagnosis (midline neck mass)

  • Dermoid cyst
  • Branchial cleft cyst (usually lateral)
  • Thyroid nodule
  • Lymphadenopathy
  • Lymphatic malformation
  • Laryngocele

🚨 TGDC Infection (important clinical scenario)

📌 Presentation

  • painful swelling
  • erythema
  • fever

🩹 Management

  • Antibiotics (oral flora coverage)
    • amoxicillin-clavulanate
    • cephalexin
    • clindamycin
  • Severe → IV antibiotics

⚠️ Avoid surgery during acute infection (↑ recurrence)

  • I&D → only if abscess refractory

🔪 Definitive Management

⭐ Gold standard = Sistrunk procedure

  • excise:
    • cyst
    • middle hyoid bone
    • tract up to foramen cecum

👉 ลด recurrence เหลือ ~5%

❗ Why not simple excision?

  • recurrence สูงมาก (up to 40% ใน infected cases)

🧠 Timing

  • ทำหลัง infection resolve แล้ว

🧬 TGDC Carcinoma

🔑 Key facts

  • ~<1–2%
  • ส่วนใหญ่ = papillary carcinoma (~85–90%)

🧪 Suspicious features

  • solid component
  • microcalcification
  • irregular wall
  • lymphadenopathy

🩹 Treatment

Low-risk

  • Sistrunk alone (curative ~95%)

High-risk

  • thyroidectomy ± neck dissection

🧠 Ectopic Thyroid (important pitfall)

  • อาจเป็น functional thyroid tissue เพียงที่เดียว
  • พบร่วม TGDC ได้

👉 ถ้าผ่าตัดโดยไม่รู้ → hypothyroidism รุนแรง

🧠 Clinical Pearls (ใช้จริง)

  • Midline + move with tongue = TGDC until proven otherwise
  • ต้อง rule out ectopic thyroid ก่อน surgery
  • ห้ามผ่าตัดช่วงติดเชื้อ
  • Sistrunk = standard of care
  • malignancy rare แต่ต้องคิดใน adult

🎯 Take-home

  • TGDC = most common congenital neck mass
  • Diagnosis = clinical + imaging
  • Treatment = Sistrunk procedure
  • Always:
    👉 check thyroid
    👉 control infection first
ที่ ไม่มีความคิดเห็น:
ป้ายกำกับ: ,

Congenital Laryngeal Anomalies / Laryngomalasia

Congenital Laryngeal Anomalies

🔎 Overview

  • เป็นความผิดปกติจาก embryogenesis error / intrauterine disruption
  • มัก present ด้วย
    👉 stridor + respiratory distress ตั้งแต่ neonatal period
  • ยิ่งโครงสร้างซับซ้อน → risk malformation สูง

🧠 Embryology (high-yield)

  • เริ่ม ~ day 25 → tracheobronchial groove
  • แยก trachea vs esophagus โดย tracheoesophageal septum
  • week 5–7 → larynx formed
  • Error → cleft, atresia, stenosis

📚 Common Congenital Laryngeal Disorders

1. Laryngomalacia (MOST COMMON)

🔑 Key points

  • ~ 2/3 ของ congenital laryngeal anomalies
  • Inspiratory stridor
  • Worse:
    • supine
    • feeding / crying
  • ดีขึ้นเมื่อ upright
  • onset: neonatal → peak infancy
  • หายเอง: 12–24 เดือน

🧪 Dx

  • Awake flexible laryngoscopy
    → supraglottic collapse

🩹 Tx

  • Mild → observe
  • Severe → supraglottoplasty

2. Vocal Cord Paralysis (2nd most common)

🔑 Presentation

  • Unilateral
    • weak cry
    • aspiration
  • Bilateral
    • biphasic stridor
    • respiratory distress (แต่ cry ปกติได้)

⚠️ Etiology

  • congenital / idiopathic
  • iatrogenic (cardiac surgery)
  • neurologic

🧪 Workup

  • Laryngoscopy + bronchoscopy
  • ± MRI brain / swallow study

3. Laryngeal Cysts

🟢 Vallecular cyst

  • location: base of tongue / epiglottis
  • sx:
    • stridor
    • feeding difficulty
    • FTT
  • severe → apnea / airway obstruction

🧪 Dx

  • flexible laryngoscopy ± CT

🩹 Tx

  • symptomatic → endoscopic excision / marsupialization

🟢 Saccular cyst / Laryngocele

Feature

Laryngocele

Saccular cyst

Content

Air

Fluid

Communication

Yes

No

Symptom

intermittent

constant
  • Tx → surgical excision

4. Laryngeal Webs & Atresia

🔑 Pathophysiology

  • failure of laryngeal recanalization

🧾 Presentation

  • stridor
  • abnormal cry / aphonia
  • severity ∝ % obstruction

🧪 Classification (glottic involvement)

  • Type 1: <35%
  • Type 2: 35–50%
  • Type 3: 50–75%
  • Type 4: >75%

⚠️ Associated

  • 22q11 deletion (DiGeorge)

🩹 Tx

  • mild → division
  • severe → reconstruction / tracheostomy

🚨 Laryngeal atresia (RARE, FATAL)

  • complete obstruction at birth
  • Dx prenatal: CHAOS syndrome
  • Tx:
    • EXIT procedure
    • emergent tracheostomy

5. Laryngeal Cleft

🔑 Pathophysiology

  • failure of fusion → communication larynx ↔ esophagus

🧾 Presentation

  • aspiration
  • dysphagia
  • recurrent pneumonia
  • ± stridor

🧪 Dx

  • VFSS (videofluoroscopic swallow study) / FEES (functional endoscopic evaluation of swallowing)
  • definitive: bronchoscopy

🧾 Classification (Benjamin)

  • Type I → mild
  • Type IV → severe (ถึง carina)

🩹 Tx

  • mild → conservative + GER control
  • severe → surgical repair

6. Congenital Subglottic Stenosis

🔑 Presentation

  • stridor infancy
  • recurrent croup
  • severe → respiratory distress

🧪 Grading (Myer-Cotton)

  • I: ≤50%
  • II: 51–70%
  • III: 71–99%
  • IV: complete

🩹 Tx

  • mild → observe
  • moderate → balloon dilation
  • severe → tracheostomy + LTR (laryngotracheal reconstruction)

7. Subglottic Hemangioma

🔑 Key features

  • vascular tumor (1–2%)
  • onset: infancy (rapid growth phase)

🧾 Presentation

  • stridor ± barking cough
  • ± cutaneous hemangioma (beard distribution)

🧪 Dx

  • laryngoscopy

🩹 Tx

  • Propranolol = first-line

🧠 Clinical Approach (high-yield summary)

👶 Neonate + stridor → think:

1.       Laryngomalacia (most common)

2.       Vocal cord paralysis

3.       Subglottic stenosis

4.       Hemangioma

5.       Structural anomaly (web, cleft)

🔍 Key differentiators

Clue

Suggest

Worse supine

Laryngomalacia

Weak cry

Vocal cord paralysis

Aspiration

Cleft

Progressive after birth

Hemangioma

Recurrent croup

Subglottic stenosis

🧪 Gold standard diagnosis

👉 Flexible laryngoscopy + bronchoscopy

🚨 Red flags

  • apnea
  • cyanosis
  • feeding intolerance
  • failure to thrive

🎯 Take-home

  • Congenital laryngeal disease = common cause of infant stridor
  • Laryngomalacia = most common & usually benign
  • ต้องแยก life-threatening lesions (atresia, severe stenosis, bilateral paralysis)
  • Diagnosis = direct airway visualization

🩺 Congenital Laryngomalacia

🔎 Definition & Epidemiology

  • Laryngomalacia = most common cause of chronic stridor in infants
  • กลไก: supraglottic tissue prolapse → glottic inlet ระหว่าง inspiration
  • คิดเป็น ~45–75% ของ infant stridor
  • พบ ~3–4/10,000 live births
  • ชาย > หญิง

⚙️ Pathophysiology (high-yield)

Multifactorial:

  • Neuromuscular immaturity (vagal reflex dysfunction)
  • Anatomic factors (redundant tissue, short aryepiglottic fold)
  • ± GER/LPR (พบร่วม 50–90%)

👉 core concept = supraglottic collapse during inspiration

🧠 Anatomy & Classification (Olney)

Type

Feature

Type 1

redundant arytenoid tissue

Type 2

short aryepiglottic folds + omega epiglottis

Type 3

posterior prolapse epiglottis

🧾 Clinical Features

👶 Typical presentation

  • Inspiratory stridor ตั้งแต่ newborn
  • peak: 4–8 เดือน
  • worse:
    • crying / feeding
    • supine
  • better: upright

👉 เสียงอาจ “wet” (สัมพันธ์กับ reflux)

⚠️ Not typical → ต้องคิด diagnosis อื่น

  • Expiratory stridor
  • Hoarseness

🍽️ Feeding-related symptoms

  • choking / coughing
  • regurgitation
  • poor feeding coordination

🚨 Severe features

  • apnea / cyanosis
  • retraction
  • failure to thrive

🧩 Associated Conditions

  • GERD / LPR (very common)
  • Neuromuscular disease
  • Genetic syndrome (Down, 22q11)
  • Other airway lesions (15–30%)

📈 Natural History

  • peak 4–8 เดือน
  • improve 12–18 เดือน
  • resolve ~<2 ปี (≈90%)

🧪 Diagnosis

✅ Clinical suspicion

  • Inspiratory stridor + worse supine + onset early

🔍 Gold standard

👉 Flexible laryngoscopy (awake)

Typical findings

  • omega-shaped epiglottis
  • supraglottic collapse

🧪 Additional evaluation (selected cases)

  • Swallow study → aspiration
  • Bronchoscopy → secondary lesion
  • PSG → sleep variant (older child)

📊 Severity Classification (clinical-based)

Severity

Features

Mild

intermittent stridor, growth OK

Moderate

persistent stridor + feeding difficulty

Severe

cyanosis, apnea, FTT, hypoxia

🩹 Management

🟢 Mild (MOST)

  • Observe
  • parental reassurance
  • feeding advice (upright, thickened feeds)

🟡 Moderate

  • multidisciplinary care
  • Medical management
    • acid suppression (H2RA/PPI)
    • feeding modification
    • nutrition support

👉 ~20–30% progress → surgery

🔴 Severe (ต้อง intervene)

Indications:

  • apnea / cyanosis
  • failure to thrive
  • respiratory distress
  • pulmonary HT / cor pulmonale

🔪 Surgery = Supraglottoplasty

  • ตัด redundant supraglottic tissue
  • success rate: 60–95%
  • improves:
    • breathing
    • feeding
    • growth

🛠️ Alternatives (selected cases)

  • CPAP / HFNC
  • NG/G-tube feeding

⚠️ Complications

  • aspiration
  • scarring
  • dysphonia (<10%)

🧠 Clinical Pearls (ใช้จริง)

  • Infant stridor → think laryngomalacia first
  • Inspiratory + worse supine = classic
  • ถ้ามี:
    • hoarseness
    • biphasic stridor
      👉 ต้องหา pathology อื่น
  • ต้อง exclude:
    • vocal cord paralysis
    • subglottic stenosis
    • hemangioma

🎯 Take-home

  • Most cases = benign, self-limited
  • Severity based on feeding + oxygenation
  • Flexible laryngoscopy = diagnostic
  • Surgery reserved for severe disease
ที่ ไม่มีความคิดเห็น:
ป้ายกำกับ: ,

Stridor In children

Stridor In children

🔎 Definition & Significance

  • Stridor = เสียงหายใจ high-pitched, monophonic จาก turbulent airflow ใน upper airway
  • บ่งชี้ว่า มี airway obstruction ระดับ supraglottis → trachea
  • เป็น symptom ที่ต้องประเมินเร่งด่วน เพราะอาจนำไปสู่ respiratory failure

⚙️ Pathophysiology (key concept)

  • เกิดจาก airway narrowing → ↑ airflow velocity → ↓ pressure (Bernoulli effect) → airway collapse + vibration → stridor
  • Airway resistance ∝ 1 / r⁴
    → เด็กเล็ก narrowing เล็กน้อย → resistance เพิ่มมาก

📍 Anatomical Classification

1. Extrathoracic airway

  • Supraglottis / glottis / subglottis
  • collapse ง่าย → inspiratory stridor

2. Intrathoracic airway

  • Trachea (intrathoracic), bronchi
  • → expiratory stridor หรือ wheeze-like

🎧 Auscultatory Clues (สำคัญมากใน ER)

Type

Suggest

Inspiratory stridor

Extrathoracic obstruction

Expiratory stridor

Intrathoracic obstruction

Biphasic stridor

Fixed airway obstruction

Stertor (low-pitched)

Naso/oropharyngeal obstruction


🧠 Differential Diagnosis (แบ่งตามเวลา)

⚡ Acute / Subacute (life-threatening ต้องคิดก่อน)

Common + Important

  • Croup (laryngotracheitis) → most common
  • Epiglottitis → drooling, toxic, tripod
  • Bacterial tracheitis
  • Foreign body aspiration
  • Anaphylaxis
  • Retropharyngeal / peritonsillar abscess
  • Airway burn / caustic ingestion

👉 Key pattern

  • Fever + toxic → bacterial infection
  • Sudden onset, no fever → FB / anaphylaxis
  • Barking cough → croup

🔁 Intermittent

  • Spasmodic croup
  • Vocal cord dysfunction (ILO)
  • Hypocalcemia (laryngospasm)
  • Papillomatosis

🕰️ Chronic

Congenital

  • Laryngomalacia (most common infant)
  • Tracheomalacia
  • Vocal cord paralysis
  • Vascular ring
  • Subglottic stenosis

Acquired

  • Tumor / mediastinal mass
  • Post-intubation stenosis
  • RRP (HPV)

🧾 Clinical Assessment (practical approach)

🚨 1. Initial rapid assessment (ABCs)

  • Airway patency
  • Work of breathing (retraction, nasal flaring)
  • Hypoxemia / fatigue
  • Do NOT delay airway management for investigations

🗣️ 2. History (key clues)

  • Age → congenital vs acquired
  • Onset → acute vs chronic
  • Associated:
    • Drooling → supraglottic obstruction
    • Hoarseness → vocal cord
    • Barking cough → croup
    • Rash → anaphylaxis
    • Feeding-related → aspiration / TEF

🔍 3. Physical exam

  • Observe breathing pattern
  • Position (tripod in epiglottitis)
  • Listen over neck (not just chest)
  • Look for:
    • Retraction, cyanosis
    • Neck swelling
    • Skin hemangioma → airway hemangioma

🧪 Investigations (เฉพาะ stable patient)

Imaging

  • X-ray neck
    • Croup → steeple sign
    • Epiglottitis → thumb sign
  • Chest X-ray
    • FB, mass, vascular ring
  • CT
    • structural lesion, abscess, tumor

Airway visualization (gold standard)

  • Flexible laryngoscopy
  • Bronchoscopy (especially FB)

Spirometry (เด็กโต)

  • Flow-volume loop → localization

⚠️ Red Flags (ต้องจัดการ airway ทันที)

  • Drooling + tripod
  • Severe retraction / fatigue
  • Altered mental status
  • Cyanosis / hypoxia
  • Rapid progression

🩹 Management Principles

  • Priority = airway first
  • Oxygen + minimal agitation
  • Avoid unnecessary exam in unstable (เช่น tongue depressor ใน suspected epiglottitis)
  • Prepare for:
    • Intubation
    • Surgical airway (rare)

Cause-specific

  • Croup → steroid + nebulized epinephrine
  • Epiglottitis → airway + IV antibiotics
  • Anaphylaxis → IM epinephrine
  • FB → bronchoscopy

🧠 Key Takeaways (สำหรับใช้งานจริง)

  • Stridor ≠ wheeze → think upper airway
  • Timing of sound = localization clue
  • Acute onset → life-threatening causes first
  • Do not send unstable patient to X-ray
  • Definitive diagnosis = airway visualization
ที่ ไม่มีความคิดเห็น:
ป้ายกำกับ: ,
สมัครสมาชิก: ความคิดเห็น (Atom)