Hiroshi Fukumasa, C. Tanaka, M. Kobayashi
Apr 28, 2020
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Pediatrics International
Abstract
Infectious mononucleosis (IM) is usually caused by an Epstein–Barr virus (EBV) infection. Although IM is usually a self-limiting disorder, upper airway obstruction (UAO) can occur due to enlarged tonsils and adenoids. Here, we report a case of UAO in a 4-year-old boy with IM who was successfully managed with a nasopharyngeal airway (NPA). The previously healthy patient was admitted for 7 days owing to fever and cervical lymphadenopathy. His vital signs were as follows: respiratory rate, 20 breaths per minute; heart rate, 124 beats per minute; body temperature, 38.2 °C. Oxygen saturation in room air was 98%. He presented with bilateral hypertrophy of the pharyngeal tonsils with white spots and bilateral cervical lymphadenopathy. Abdominal ultrasonography revealed the presence of mild splenomegaly without fluid accumulation. Hematology test results revealed a white blood cell count of 17.6 9 10/L, with 45.8% lymphocytes and Creactive protein levels of 12.47 mg/L. The blood film revealed 2% atypical lymphocytes. Lateral soft tissue neck (LSTN) radiography revealed enlarged pharyngeal tonsils and adenoids (Fig.1 a). After admission, the patient developed dyspnea with suprasternal retraction on inspiration while waking up and obstructive sleep apnea with a decrease in the oxygen saturation to 86%; consequently, he was admitted to the intensive care unit. Contrast-enhanced computed tomography revealed tonsillar swelling and enlarged adenoids (Fig.1 d, e). Flexible laryngoscopy performed by an otolaryngologist revealed marked edema of the nasopharyngeal mucosa. The NPA, Koken nasal airway curve-type ID 4.5 mm (Koken Co., Ltd, Tokyo, Japan), was inserted gently, and LSTN radiography was performed to confirm its appropriate placement (Fig.1 b). The NPA was secured by fastening the fixed wing, which was attached to the end of the tube, to the nose wings with a tape. The airway was secured; dyspnea and obstructive sleep apnea were ameliorated after NPA insertion. Further interventions, such as intubation or tracheotomy, were unnecessary. The NPA was removed as respiratory distress improved after 3 days’ administration of 1 mg/kg/day of prednisolone. The patency of the upper airway was maintained without the NPA all day long. Subsequent serologic tests showed positive results for EBV capsid antigens IgM and IgG but negative results for EBV nuclear antigen antibody. He was discharged on the day 11 of hospitalization. Upper airway obstruction in patients with IM is uncommon, and the incidence of UAO has been reported to be 1–3.5%. However, it is a potentially life-threatening complication. It should be treated by appropriate airway management, and in severe cases, endotracheal intubation or acute tracheostomy may be required. An NPA can be useful in maintaining airway patency in conscious children, with less likelihood of stimulating vomiting. However, tolerability is always a problem associated with NPA usage in conscious children in actual clinical practice. Although airway patency is secured by NPA insertion, maintaining the position of such a device is challenging in conscious children, particularly in preschool-age children because they hate NPA insertion and remove it themselves. Such patients experience excitability in response to the insertion stimulus; hence, they become restless. For successful treatment, the following steps can be taken. First, instructing the child about the procedure. A detailed explanation should be provided to the patient before treatment so that the patient cooperates. Second, the patient should be counseled to overcome fear. Once patients realize that NPA insertion is painful, they will resist undergoing such a procedure again. In this case, we had the time to explain to the patient the need for NPA because the airway patency was somehow maintained when he was awake and he could cooperate with us. The NPA was gently inserted into the nostril with assistance from the otolaryngologist, ensuring minimal pain. The patient never complained of pain or nausea. Surprisingly, he was able to drink with the NPA inserted. This may be considered as a success as it satisfied his hunger and reduced stress. The NPA may cause trauma in enlarged adenoids, resulting in severe epistaxis and compression. The pediatrician must therefore re-evaluate airway patency and tissue swelling. We assessed the effect of the NPA continuously by observing the patient’s respiratory effort and apnea by monitoring electrocardiogram and pulse oximetry; however, end-tidal CO2 could Correspondence: Hiroshi Fukumasa, MD, Children’s Medical Center, Kitakyushu City Yahata Hospital, 2-6-2 Ogura, Yahatahigashi-ku, Kitakyushu City, Fukuoka 805-8534, Japan. Email: fukumasah@gmail.com Received 11 November 2019; revised 20 December 2019; accepted 7 January 2020. doi: 10.1111/ped.14143