Journal of Neonatology & Clinical Pediatrics Category: Clinical Type: Case Report
A Rare Event at Birth: A Case Report of Multiple Cranial Nerve Palsy
- Carina Cardoso1*, Francisca Palha2, Inês Candeias1, Ana Tavares3, Manuel Cunha1
- 1 Neonatology Unit, Children’s Department-Hospital De Cascais Dr. José De Almeida, Cascais, Portugal
- 2 Department Of Pediatrics, Hospital De Santa Maria, Lisboa, Portugal
- 3 Neonatology Unit, Children’s Department-hospital De Cascais Dr. José De Almeida, Cascais, Portugal
*Corresponding Author:Carina Cardoso
Neonatology Unit, Children’s Department-Hospital De Cascais Dr. José De Almeida, Cascais, Portugal
Tel:+351 961612296/ +351 916573661,
Received Date: Jan 10, 2019 Accepted Date: Jan 30, 2019 Published Date: Feb 13, 2019
These injuries seem to frequently occur during the second stage of labor, in which the fetus descends through the birth canal . Various and complex mechanisms are accounted for as the basis of this complications, affecting mainly musculoskeletal structures, peripheral nerves and the spinal cord, through compression, uterine contractions, torques, stretching and a variable degree of hypoxia. The degree of severity can vary from neuropraxia and axonotmesis to severe paralysis . Known risk factors can be divided into maternal, fetal and delivery mechanisms. Maternal risk factors include extreme maternal ages (less than 16 and greater than 35 years), primigravida, cephalopelvic disproportion, short maternal stature, diabetes, excessive maternal weight gain and maternal pelvic abnormalities. Fetal risk factors appear to be associated with in-utero malpresentation, prematurity, birth weight greater than 3500g and congenital anomalies. As for the delivery itself, mechanisms such as vaginal breech delivery, endogenous compression from bony pelvis and maternal expulsive efforts, passage through birth canal, fetopelvic disproportion, nuchal cord, vacuum or forceps-assisted delivery increase the risk of neurological lesion [4-7].
Post traumatic involvement of lower cranial nerves, which is by itself a rare event, is poorly described in literature as a postpartum complication. Injuries of the IX, X and XII nerves appear to arise in specific circumstances such as shoulder surgery, otorhinolaryngologic surgery or airway manipulation, i.e. orotracheal intubation [8,9]. Most of the written works on this topic highlight the benign clinical course, with complete neurological recovery in a period of only a few months. A favorable prognosis depends on a rapid multidisciplinary assessment and a structured physical rehabilitation program.
Forty-eight hours after birth observation by otorhinolaryngologic and nasofibrolaryngoscopy was performed, revealing left vocal cord and glottis paresis; diagnosis of IX, X (no established lateralization) and left XII cranial nerves was admitted, possibly as a consequence of brain stem transient injury. He was also examined by a pediatric neurologist, carefully excluding other neurological deficits. Meticulous central nervous system imaging comprised cranial ultrasonography and Magnetic Resonance Imaging (MRI) of brain, brainstem and spinal cord. Cranial ultrasonography on first day of life showed normal periventricular and subcortical white matter, normal posterior fossa, no hydrocephalus and resistive index of 0.65. MRI examination, only performed at day six of life due to administrative contingencies, included coronal, axial and sagittal sections in T1, T2, flair and the thin sliced DWI. The brainstem was highlighted. Overall it didn’t reveal changes compatible with ischemic injuries, cerebral edema, hydrocephalus or intracranial space occupying lesions. Thin views of brainstem showed no asymmetries or injuries.
Seventy-two hours after birth patient started physical rehabilitation with speech therapy, and enteral feeding, interrupted at day one, was restarted with increasing ability. Neurological outcome was favorable since he was able to tolerate breast feeding, with good suck and swallow reflexes. Patient was discharged at day 14 of life, breastfed with feeding autonomy, besides manifesting a discreet tongue deviation and intermittent stridor. Outpatient medical recommendations did not include physical rehabilitation. Follow-up by neurology, otorhinolaryngology and physical rehabilitation was kept until four months of age when he presented with complete clinical resolution; pediatrics continued until 12 months.
Cranial nerves injury related to obstetric trauma is infrequent, especially in an era of great awareness related with obstetric quality care, and is mostly limited to facial or external oculomotor nerves.
This X-ray presented with respiratory distress, but upon physical evaluation there were no asymmetric arm or hand movements, paradoxical respiratory movements nor hem diaphragmatic elevation on chest X-ray, therefore excluding brachial plexus and phrenic nerve injuries .
Despite clinical presentation’s magnitude, we emphasize the complete resolution of all neurological deficits, in agreement with what is described in the literature for traumatic lesions of these cranial nerves. Conservative management, which is enough in most cases, may include steroids and vitamins together with speech and swallowing therapy. Rare patients will need supportive gavage feeding and interim tracheostomy .
This work was presented as Poster at the XLVI National Symposium on Neonatology, of the Portuguese Society of Neonatology, in November 2016.
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Citation:Cardoso C, Palha F, Candeias I, Tavares A, Cunha M (2019) A Rare Event at Birth: A Case Report of Multiple Cranial Nerve Palsy. J Neonatol Clin Pediatr 6: 027.
Copyright: © 2019 Carina Cardoso, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.