Edward M. Burton

Swallowing dysfunction in infants less than 1 year of age

Background. Gastroesophageal reflux (GER) occurs frequently in infants and children and is implicated as a trigger for reactive airways disease. While evaluating patients for GER by upper gastrointestinal studies (UGI), we frequently noticed laryngeal penetration or tracheal aspiration in infants < 1 year of age. We conducted this prospective study to assess the incidence of swallowing dysfunction in infants with vomiting or respiratory symptoms. Methods. Between February 1994 and August 1997, 1,003 UGI in infants < 1 year of age were performed by two experienced pediatric radiologists. Fluoroscopy of swallowing using an appropriate image intensifier was observed as part of the UGI in all patients. In addition to evaluating premature infants, former premature infants, and infants with underlying conditions such as bronchopulmonary dysplasia (BPD), congenital heart disease (CHD), esophageal atresia and/or tracheoesophageal fistula (EA), and neurologic disorders, we assessed swallowing in 472 full-term infants in the general population who had respiratory symptoms or suspected GER, but no other apparent abnormalities. Swallowing was not assessed in patients with congenital bowel obstruction. The presence of normal swallowing or swallowing dysfunction was recorded immediately following the study. Chest radiographs obtained on the same day as the UGI were evaluated in the study. Forty-four videotaped modified barium-swallow studies (MBSS) were obtained in 25 general-population infants and reviewed frame-by-frame to determine the length of time that barium could be visualized in the subglottic trachea. Results. The incidence of swallowing dysfunction is significant in premature and former premature infants, those with BPD, CHD, EA, various syndromes, and neurologic abnormality. In the general population of full-term infants referred for evaluation of vomiting or respiratory symptoms, 63 (13.4 % of 472) had swallowing dysfunction. Forty-four had tracheal aspiration (TA) and 19 had laryngeal penetration (LP). Gastroesophageal reflux was found in 79.5 % with TA and in 68.4 % with LP. The MBSS confirmed swallowing dysfunction in all patients shown to have vocal cord penetration or tracheal aspiration by UGI. Conclusions. Careful evaluation of swallowing during an UGI can identify swallowing dysfunction in full-term infants who have respiratory problems, as well as in infants with an abnormality that predisposes the patient to aspiration. Episodes of tracheal aspiration may be fleeting and overlooked if swallowing is not assessed carefully. An MBSS can confirm the observation of swallowing dysfunction found during an UGI and assist in planning appropriate dietary therapy that minimizes the likelihood of tracheal aspiration during feeding.

Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis

The acute complications of diabetic ketoacidosis in children and adolescents are well recognized but not completely understood. Clinical studies have focused primarily on brain edema. We have investigated the prevalence and course of interstitial pulmonary edema in patients with severe diabetic ketoacidosis all of whom had uneventful clinical courses. High resolution computed tomography scans of the lungs were analyzed by determining the Hounsfield attenuation level and then converting to physical density values. All seven patients had evidence of interstitial pulmonary edema on the first scan, which was performed within 1 h of hydration and prior to receiving insulin; six of the seven patients had increased pulmonary density 6-8 h into treatment, and all had complete resolution of the interstitial changes at discharge. Our study suggests that subclinical interstitial pulmonary edema may be a frequent occurrence in children and adolescents with severe diabetic ketoacidosis and may very well be present prior to treatment. The study also supports the philosophy of cautious rehydration and the close monitoring of children and adolescents with diabetic ketoacidosis until a more complete understanding of this pathophysiologic event is achieved.

Stress fracture of the great toe sesamoid in a ballerina: MRI appearance.

This case is the first to depict a stress fracture of the great toe sesamoid bone using magnetic resonance imaging. We used a 3″ surface coil to produce high resolution images of the sesamoid.

Fluoroscopy-guided retrieval of a sheared endotracheal stylet sheath from the tracheobronchial tree in a premature infant

Abstract Endotracheal intubation of premature infants with respiratory distress is a commonly performed procedure in the neonatal intensive care unit. We report a rare complication of this procedure, shearing of the plastic sheath that is bonded to and surrounds the stylet used to assist intubation and lodging of the sheared stylet in the tracheobronchial tree of a small premature infant. We suggest a method for removing the plastic foreign body using fluoroscopy and an Amplatz gooseneck snare directed through the existing endotracheal tube, a technique not previously reported.

Prostaglandin-induced foveolar hyperplasia simulating pyloric stenosis in an infant with cyanotic heart disease

Prostaglandin infusion is used to maintain patency of the ductus arteriosus in infants with cyanotic congenital heart disease. Recently, gastric outlet obstruction as a result of prostaglandin infusion has been described. In our case, an upper gastrointestinal contrast study seemed to depict the typical appearance of pyloric stenosis in an infant who had received an infusion of prostaglandin for a prolonged period. Serial ultrasonograms, however, disclosed progressive elongation of the antropyloric channelwithout wall thickening. This report is the second to illustrate prostaglandin-induced gastric outlet obstruction in a vomiting infant with a gastrointestinal series diagnosis of pyloric stenosis.

Superior vena cava thrombosis and chylothorax: Relationship in pediatric nephrotic syndrome

Abstract. We report a 40-month-old black male with nephrotic syndrome who developed chylothorax associated with superior vena cava (SVC) thrombosis. To our knowledge, this is the third reported case of spontaneous SVC thrombosis in a nephrotic patient and the first in which chylothorax was also present. Ultrasonography of the pleura and thoracic vasculature was invaluable in making the diagnosis and monitoring the resolution of this condition during treatment. Contrary to previous reports, thoracic chylous effusions complicating uncontrolled nephrotic syndrome do not originate exclusively as a consequence of abdominal pathology, but rather as this case demonstrates, they can occur from lymphatic obstruction caused by thoracic vein thrombosis.

Pancreatic pseudotumor in an 11-year-old child: imaging findings

Background. An inflammatory pseudotumor is a benign, solid lesion of unclear etiology. Some authors believe it is a true neoplasm, while others consider it a post-infectious or post-traumatic process. It is most commonly found in the lung; an inflammatory pseudotumor of the pancreas is rare. This case report is the sixth of a pancreatic pseudotumor in a child.¶Patients and methods. An 11-year-old girl presented with obstructive jaundice due to a mass in the head of the pancreas. The mass was identified by sonography. This was confirmed by MRI and CT. The mass enhanced with gadolinium, but its enhancement at CT was similar to the remainder of the pancreas.¶Results. At operation, a pancreatic inflammatory pseudotumor was totally resected.

Cervical thymic cysts: CT appearance of two cases including a persistent thymopharyngeal duct cyst

The differential diagnosis of cervical cysts in children includes common entities such as branchial cleft cysts, thyroglossal duct cysts, and cystic hygromas. Congenital thymic cysts are uncommon and often misdiagnosed as either branchial cleft cysts or cystic hygromas. However, they may have an appearance on CT that can be characteristic. The course of the descent of embryologic thymic tissue in the neck to the mediastinum indicates the potential site of deposition of an ectopic cervical thymic cyst. In a child, a cystic lesion that has an intimate relationship to the carotid sheath is likely to be a thymic cyst.Of the approximately 100 cases of vestigial cervical thymus or thymic cysts that have been reported in children, only 5 cases of a persistent thymopharyngeal duct cyst have been described [1–5]. In two of these five, the persistent thymopharyngeal duct cyst was demonstrated by CT [1, 2]. We report one additional case of a cervical thymic cyst and one case of a persistent thymopharyngeal duct cyst both depicted by CT.

Transverse colon volvulus in pediatric patients

Volvulus of the transverse colon is rare in the pediatric population. We present the tenth known case of a volvulus of the transverse colon in a child. A barium enema demonstrated the bird beak appearance of the colon and showed an air-contrast mirror image in the proximal end. The 360° volvulus found at surgery was treated successfully by detorsion of the bowel.

Unilateral pulmonary agenesis without mediastinal displacement

A radiographic hallmark in pulmonary agenesis is opacification of the ipsilateral hemithorax with displacement of the mediastinum in the direction of the agenetic lung. We believe this case report is the first in which the mediastinum was not displaced; instead, the liver and intact hemidiaphragm were displaced cephalad, preventing cardiac malposition. Contrast-enhanced computed tomography enabled us to diagnose this anomaly precisely.