Edward Y. Lee

The treatment of spine and chest wall deformities with fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib: growth of thoracic spine and improvement of lung volumes.

Study Design. Prospective clinical trial of vertical expandable prosthetic titanium rib (VEPTR) in patients with combined spine and chest wall deformity with scoliosis and fused ribs. Objective. Report the efficacy and safety of expansion thoracostomy and VEPTR surgery in the treatment of thoracic insufficiency syndrome (TIS) associated with fused ribs. Summary of Background Data. Traditional attitudes toward early-onset combined chest and spine deformity assume that thoracic deformity is best controlled by treatment directed at spine deformity, often involving early spinal arthrodesis. Campbell and others have heightened awareness of the interrelationship between lung, chest, and spine development during growth and characterized TIS as the inability of the thorax to support normal respiration or lung growth. Expansion thoracostomy and VEPTR insertion was developed to directly control both spine and chest wall deformity during growth, while permitting continued vertebral column and chest growth at an early stage. Methods. Multidisciplinary evaluation of children with combined spine and chest wall deformity included pediatric pulmonologist, thoracic, and orthopedic surgeon evaluations. One or more opening wedge expansion thoracostomies and placement of VEPTR devices were performed as described by Campbell, with repeated device lengthenings during growth. Parameters measured included Cobb angle, length of thoracic spine, CT-derived lung volumes, and in older children pulmonary function tests. Results. Thirty-one patients with fused ribs and TIS were treated, 4 of whom had undergone prior spinal arthrodesis at other institutions with continued progression of deformity. In 30 patients, the spinal deformity was controlled and growth continued in the thoracic spine during treatment at rates similar to normals. Increased volume of the constricted hemithorax and total lung volumes obtained during expansion thoracostomy were maintained at follow-up. Complications included device migration, infection, and brachial plexus palsy. Conclusions. Expansion thoracostomy and VEPTR insertion with serial lengthening may be the preferred treatment for young children with chest wall deformity and scoliosis associated with fused ribs but requires multidisciplinary care and attention to details of soft tissue management. When indicated, surgical intervention with VEPTR can be considered early in growth, before deformity is severe, since spinal growth will continue with treatment.

Multidetector CT Evaluation of Congenital Lung Anomalies

Congenital lung anomalies vary widely in their clinical manifestation and imaging appearance. Although radiographs play a role in the incidental detection and initial imaging evaluation in patients with clinical suspicion of congenital lung anomalies, cross-sectional imaging such as computer tomography (CT) is frequently required for confirmation of diagnosis, further characterization, and preoperative evaluation in the case of surgical lesions. Recently, with the development and widespread availability of multidetector CT scanners, CT has assumed a greater role in the noninvasive evaluation of congenital lung anomalies. The combination of fast speed, high spatial resolution, and enhanced quality of multiplanar reformation and three-dimensional reconstructions makes multidetector CT an ideal noninvasive method for evaluating congenital lung anomalies. In this article, the authors review the multidetector CT technique for evaluation of congenital lung anomalies. Important clinical aspects, characteristic imaging features, and key points that allow differentiation among various anomalies are highlighted for a variety of common and uncommon conditions.

Swine-Origin Influenza A (H1N1) Viral Infection in Children: Initial Chest Radiographic Findings

PURPOSE To evaluate initial chest radiographic findings of swine-origin influenza A (S-OIV) (also known as H1N1) viral infection in children. MATERIALS AND METHODS This was an institutional review board-approved, HIPAA-compliant retrospective study of 108 patients who had microbiologically confirmed S-OIV infection and available initial chest radiographs obtained between April 2009 and October 2009. The final study group was divided on the basis of clinical course (group 1, outpatients without hospitalization [n = 72]; group 2, inpatients with brief hospitalization [n = 22]; group 3, inpatients with intensive care unit admission [n = 14]). Two pediatric radiologists blinded to patient group and lung parenchymal, airway, pleural, hilar, and mediastinal abnormalities systematically reviewed initial chest radiographs. Lung parenchyma and airways were evaluated for pattern (peribronchial markings, consolidation, and ground-glass, nodular, and reticular opacity), distribution, and extent of abnormalities. Radiographs were assessed for presence of pleural effusions or lymphadenopathy. Medical records were reviewed for underlying medical conditions and patient outcomes. Association between frequency of underlying medical conditions and clinical course of S-OIV infection among study groups was evaluated with the Pearson chi(2) test. RESULTS The frequency of normal chest radiographs was significantly higher in group 1 (n = 48) than in groups 2 (n = 1) and 3 (n = 0) (P < .001, Pearson chi(2) test). Among patients with abnormal radiographs, the most common finding in group 1 was prominent peribronchial markings with hyperinflation (n = 17), whereas the most common findings in groups 2 (n = 12) and 3 (n = 12) were bilateral, symmetric, and multifocal areas of consolidation, often associated with ground-glass opacities. Nodular opacities, reticular opacities, pleural effusion, or lymphadenopathy were not observed in any patient. An increased frequency of underlying medical conditions was observed in patients with greater severity of illness due to S-OIV infection (group 3, 71%; group 2, 59%; group 1, 31%) (P = .003, Pearson chi(2) test). All 84 patients with available follow-up information have fully recuperated from S-OIV infection. CONCLUSION Initial chest radiographs in children with a mild and self-limited clinical course of S-OIV infection are often normal, but they may demonstrate prominent peribronchial markings with hyperinflation. Bilateral, symmetric, and multifocal areas of consolidation, often associated with ground-glass opacities, are the predominant radiographic findings in pediatric patients with a more severe clinical course of S-OIV infection. (c) RSNA, 2009.

Tracheobronchomalacia in Infants and Children: Multidetector CT Evaluation

Tracheobronchomalacia (TBM) is the most common congenital central airway anomaly, but it frequently goes unrecognized or is misdiagnosed as other respiratory conditions such as asthma. Recent advances in multidetector computed tomography (CT) have enhanced the ability to noninvasively diagnose TBM with the potential to reduce the morbidity and mortality associated with this condition. Precise indications are evolving but may include symptomatic pediatric patients with known risk factors for TBM and patients with otherwise unexplained impaired exercise tolerance; recurrent lower airways infection; and therapy-resistant, irreversible, and/or atypical asthma. With multidetector CT, radiologists can now perform objective and quantitative assessment of TBM with accuracy similar to that of bronchoscopy, the reference standard for diagnosing this condition. Multidetector CT enables a comprehensive evaluation of pediatric patients suspected of having TBM by facilitating accurate diagnosis, determining the extent and degree of disease, identifying predisposing conditions, and providing objective pre- and postoperative assessments. In this article, the authors present a step-by-step primer of multidetector CT imaging for evaluating infants and children with suspected TBM, including clinical indications, patient preparation, multidetector CT techniques and protocols, two- and three-dimensional processing of multidetector CT data, and image interpretation. The major aim of this article is to facilitate the readers ability to successfully employ multidetector CT imaging protocols for evaluation of TBM in infants and children in daily clinical practice.

Magnetic Resonance Imaging of Temporomandibular Joints in Children With Arthritis

PURPOSE The aim of the present study was to describe the gadolinium-enhanced magnetic resonance imaging (MRI) features of temporomandibular joints (TMJs) in children with arthritis. These findings would facilitate the early diagnosis of disease and/or relapse. MATERIALS AND METHODS In the present retrospective study, 2 pediatric radiologists reviewed consecutive MRI scans of the TMJs of children with a definitive diagnosis of juvenile idiopathic arthritis (JIA), including oligoarthritis, polyarthritis, and juvenile psoriatic arthritis. For each MRI scan, specific criteria were evaluated, including the condylar head, condylar fossa, articular eminence, disk shape and position, joint effusion, synovium, intra-articular space, and jaw motion. RESULTS A total of 48 patients with mean age of 11.2 years who had been diagnosed with JIA were reviewed. The most common abnormal findings (in order of frequency) were erosion of the condylar head (n = 38), synovial enhancement (n = 35), articular surface flattening (n = 20), abnormalities in jaw motion (n = 26), intra-articular space enhancement (n = 20), subchondral sclerosis of articular eminence (n = 12), joint effusion (n = 9), deformed/displaced disk in the open or closed position (n = 9), bone marrow edema (n = 8), sclerosis of fossa (n = 3), sclerosis of head (n = 3), and the presence of osteophytes (n = 1). Comparing each category of MRI findings, no significant gender differences were found. CONCLUSIONS Children with JIA who have undergone MRI of their TMJs typically present with more than 1 abnormal radiographic finding consistent with synovitis. Although the presence or absence of each MRI finding did not differ among the arthritis types, bilateral synovial enhancement and bilateral condylar head articular surface flattening were more common in JIA than in juvenile psoriatic arthritis. These findings suggest that MRI should play an important role in the diagnosis and assessment of TMJ involvement in children with JIA.

Clinical predictors of pneumonia among children with wheezing.

OBJECTIVE: The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting. METHODS: A prospective cohort study was performed with children ≤21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists. RESULTS: A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7–4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3–7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13–1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08–7.54]), triage temperature of ≥38°C (positive LR: 2.03 [95% CI: 1.34–3.07]), maximal temperature in the ED of ≥38°C (positive LR: 1.92 [95% CI: 1.48–2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15–8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38°C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0–4.7]). CONCLUSIONS: Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Multidetector CT evaluation of tracheobronchomalacia.

Tracheobronchomalacia (TBM) refers to excessive expiratory collapse of the trachea and bronchi as a result of weakening of the airway walls and/or supporting cartilage. This disorder has recently been increasingly recognized as an important cause of chronic respiratory symptoms. Multidetector CT (MDCT) technology allows for noninvasive imaging of TBM with similar accuracy to the historical reference standard of bronchoscopy. Paired end-inspiratory, dynamic expiratory MDCT is the examination of choice for assessing patients with suspected TBM. Radiologists should become familiar with imaging protocols and interpretation techniques to accurately diagnose this condition using MDCT.

MDCT Pulmonary Angiography Evaluation of Pulmonary Embolism in Children

OBJECTIVE The purpose of our study was to determine the prevalence and anatomic distribution of pulmonary embolism (PE) in a group of consecutive pediatric patients with clinically suspected PE using MDCT pulmonary angiography (pulmonary CTA). MATERIALS AND METHODS We used our hospital information system to retrospectively identify all consecutive pediatric patients (< 18 years of age) with clinically suspected PE who underwent pulmonary CTA from July 2004 to August 2007. Two experienced pediatric radiologists retrospectively reviewed by consensus a series of 98 consecutive pulmonary CTA studies. Each examination was reviewed for the ability to visualize pulmonary arteries and the presence of PE. For positive cases, the level of involvement was classified as central, lobar, segmental, or subsegmental. Lobar location was also recorded using standard nomenclature. Pulmonary CTA results were compared with the results of lower extremity ultrasound studies in the subset of patients who underwent both procedures. RESULTS The study population consisted of 84 children who underwent a total of 98 pulmonary CTA studies. All pulmonary CTA studies were technically successful in visualizing arteries to the level of segmental pulmonary arteries, but the evaluation of subsegmental pulmonary arteries was limited in 78 (80%) examinations. Thirteen (15.5%) of 84 children were found to have PE on pulmonary CTA. PE was localized in the lobar pulmonary artery in 12 (39%), the segmental pulmonary artery in 11 (35%), the subsegmental pulmonary artery in five (16%), and the main or central pulmonary artery in three (10%) patients. PE was distributed in the right lower lobe in 12 (37%), the left lower lobe in eight (24%), the right upper lobe in five (15%), the right middle lobe in four (12%), and the left upper lobe in four (12%) patients. Ten of 13 patients with PE underwent lower extremity Doppler ultrasound, of whom one (10%) was positive for deep venous thrombosis. CONCLUSION The prevalence of PE may be more common among pediatric patients than previously reported and has a similar distribution to that in adult patients.

MDCT of tracheobronchial narrowing in pediatric patients.

Chest radiographs have been useful for the incidental detection and initial imaging evaluation of clinically suspected central airway narrowing in pediatric patients. However, cross-sectional imaging, such as computed tomography (CT), is frequently required for confirmation of diagnosis, further characterization, and preoperative evaluation of surgical lesions. Recent rapid technologic advancement in CT has allowed CT to assume a pivotal role in the noninvasive evaluation of tracheobronchial narrowing in children, in particular with multidetector computed tomography with postprocessing techniques, including multiplanar reformations and 3-dimensional reconstructions. In this article, the authors review the multidetector computed tomography technique for evaluation of central airway narrowing in children, with emphasis on the use of multiplanar reformations and 3-dimensional reconstructions in the imaging evaluation of the spectrum of intrinsic and extrinsic causes of central airway narrowing in children.

Management of children and adolescents with a critical airway due to compression by an anterior mediastinal mass

This study used retrospective review of patients with critical airway due to compression by an anterior mediastinal mass treated at a single pediatric teaching institution. Diagnostic workup is reviewed with a focus on diagnostic biopsy. Algorithm for streamlining the choice of biopsy technique and minimizing invasive procedures is suggested.