Right Phrenic Nerve Injury: A Rare but Possible Complication of Oesophageal Atresia and Tracheoesophageal Fistula Repair

Abstract

Oesophageal atresia (OA) and Tracheoesophageal fistulas (TOF) are congenital anomalies commonly present in between 1 and 4 per 10 000 births, including stillbirths and termination of pregnancies. Currently, patients with these anomalies are are managed surgically, with common complications including oesophageal formation, anastomotic leakage and recurrence of TOF. This case report highlights the possibility of right phrenic nerve injury as a complication of OA and TOF repair. We report a baby boy born at term with worsening respiratory distress at day 15 of life, two weeks after undergoing an operation to repair OA and TOF. Since the surgery on day 2 of life, he could not be weaned off oxygen support successfully and had two episodes of worsening respiratory distress that was treated as pneumonia. Serial Chest X-Rays (CXR) showed a persistent elevation of the right hemidiaphragm. Ultrasound (USG) thorax supported the findings of right diaphragmatic paralysis by revealing minimal right diaphragm excursion with the paradoxical movement of the right diaphragm. He was initially managed non-operatively with non-invasive ventilation (NIV)/continuous positive airway pressure (CPAP) while monitoring for spontaneous recovery of the right diaphragm, which unfortunately did not occur. He was on NIV/CPAP for a total of 25 days and was tachypnoeic with mild subcostal recessions (SCR) and reduced breath sounds on the right throughout. Six weeks after the initial OA/TOF repair surgery, he was posted for Right Diaphragmatic Plication. Afterwards, he recovered well and was weaned off oxygen support within the next seven days and subsequently discharged.