Mangaluru: A child who was born normally 24 days ago, came to us with difficulty feeding including turning blue while feeding and breathing. The only Paediatric cardiologist of AJ hospital as well as in Mangalore, Dr Prem Alva, realising the urgency did an echocardiogram which showed very high pulmonary artery pressures. This condition by itself is a potentially life-threatening situation. But it could not explain the reason for the child’s distress. Therefore he requested the senior neonatologist at AJ hospital Dr Ashwij Shriyan to look for any other causes.
After his detailed assessment including X-ray and blood investigations, there was no cause found for the problem. The child was promptly and immediately admitted to intensive care as the situation was very critical. A cardiac CT scan too did not reveal any reason for the baby’s distress. Therefore a referral was made to the ENT surgeon Dr Gautham Kulamarva. After doing a neonatal video endoscopy of the airway, the cause was suspected as a cyst (A fluid-filled bag) at the back of the tongue.
Without wasting any time an MRI scan was done by Dr Ganesh Kallakatta, who confirmed the presence of the cyst. The team realised that the poor baby was struggling to suck in the air because of the large cyst sitting at the entrance to the windpipe. Instead of sucking in air, the child was sucking in its own tissues leading to severe distress. The cyst kept growing by the day and therefore we didn’t have much time to take decisions and act on it. Unfortunately, the only treatment available in such situations is surgery. Any surgery on a newborn baby is difficult. But this was an extreme case where apart from being a neonate, the baby also had severe heart issues as confirmed by the echocardiogram, as well as the airway problem.
For any surgery to be performed on any patient, we need the airway to be normal, because that is the route by which we give anaesthesia and oxygen to the patient during surgery. But here, that by itself was challenging as the airway itself was blocked. After several rounds of discussions internally the team took up the challenge of managing this child as the only other option was to refer the child to bigger centres in Bangalore or elsewhere. (Only a very few specialised centres in the country deal with such cases) This by itself was dangerous as the child could not even be shifted out of the NICU for a few minutes.
Then we had an elaborate plan to do the surgery and manage the post-operative care. We discussed the details with the – by now naturally distressed – parents of the child, including the option of choosing to go to a higher centre. With discussion internally within the family, they continued their trust in the team of doctors at AJ hospital and decided to go ahead with the surgery. Now, the team swung into action and prepared the child as best as possible medically with intensive monitoring and medicines. Dr Gururaj Tantry, a senior cardiac anaesthetist at AJ hospital, took the challenge and responsibility of anaesthetising the child.
Finally, the patient was operated upon with the help of all the high-end and advanced technologies necessary. The entire surgery was done endoscopically without any scar from the outside. The anxiety for the team had only started with the surgery. Though well begun is half done, it was important and critical to manage the post-operative period. There can be several things which can go wrong with the patient on a ventilator, but all of them were managed efficiently by the able NICU team led by Dr Shriyan and Dr Prem Alva.
The patient was finally extubated on the 3rd post-operative day under endoscopic guidance. Prof. Dr Sandhya I, the senior pathologist at AJ hospital identified the cyst to be a thyroglossal cyst, which is a congenital malformation. The patient was then gradually started on breastfeeding and was discharged home on the 7th postoperative day. His repeat echocardiogram at the time of discharge had almost come back to normal with normal pulmonary artery pressures. (The starting point of the alarming and life-threatening condition) The entire process of assessment to discharge happened in a matter of 10 days. Being a considerate and kind hospital, the cost too was kept to a minimum by the management, thereby helping the child’s family. After all, this is the whole motto of the hospital – to deliver cutting-edge care at an affordable cost to the community.
Abstract: A rare and risky surgery was successfully performed on a 24-day-old baby, at AJ Hospital recently. The baby presented with a history of refusing breast milk due to difficulty in breathing.
The team of doctors including Dr Prem Alva, Paediatric cardiologist, Dr Ashwin Sriyan, neonatologist, Dr Gautham Kulamarva, ENT Surgeon and Paediatric airway specialist, Dr Ganesh Kallakatta, Radiologist, Dr Gururaj Tantry, Cardiac anaesthetist, and Dr Sandhya I, Pathologist managed the high-risk surgery and its intensive care successfully and discharged the child home in 10 days’ time.
The child was completely asymptomatic at the time of discharge and was breastfeeding normally. Initially suspected to be a cardiac problem, later on, turned out to be a rare cyst at the opening of the airway. It was surgically corrected endoscopically using all the necessary advanced technology. The cost was kept to a minimum by the management, thereby helping the child’s family. After all, this is the whole motto of the hospital – to deliver cutting-edge care at an affordable cost to the community.
Dr Prashanth Marla, director of AJ Hospital and Research Centre said that, it is important for all of us to not ignore symptoms like refusal of feeds in a small child and seek medical attention immediately. What is a seemingly common symptom can sometimes be due to some serious underlying conditions. In such situations only timely intervention can save the child’s life.
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