Melvin O. Senac

Prevalence of incidental paranasal sinuses opacification in pediatric patients: a CT study.

A prospective evaluation of the paranasal sinuses was performed on a consecutive series of 137 pediatric patients referred for cranial CT. Approximately one-half of the patients less than 13 years of age had some degree of maxillary or ethmoid sinus opacification. The prevalence and severity of opacification was approximately the same for the maxillary and ethmoid sinuses. Sphenoid sinus abnormality was less common (16% of patients) and was usually minimal or mild. No incidental frontal sinus abnormalities were observed. This study confirms previous reports, based on plain film radiography, of the prevalence of incidental maxillary sinus opacification in children. However, contrary to some prior studies, we did not find a relatively higher rate of opacification in children less than 1 year of age. This may be due to overdiagnosis of maxillary sinus opacification on plain films, in small children. The diagnosis of sinusitis in childhood must take into account not only the radiographic findings but clinical signs and symptoms. Correlation is needed to avoid overdiagnosis in patients referred for sinus radiography for nonspecific indications or who have incidental opacification noted on radiographic or CT studies of the skull and brain.

Malrotation of the intestine in children.

Intestinal malrotation may be complicated by volvulus and intestinal necrosis. One hundred two children (64 male, 38 female) undergoing surgical abdominal exploration from 1977 to 1987 had malrotation. Fifty-two patients were less than 7 days of age, 13 from 8 to 30 days, 26 from 31 to 365 days, and 11 were older than 1 year of age. Of infants, 39 of 65 had 40-week gestations, 18 of 65 had 36− to 39-week gestations, and 8 of 65 had less than 36-week gestations. Chief symptomatology included: bilious emesis (47), intestinal obstruction (19), abdominal pain (11), and bloody stools (7). Seventy patients had congenital anomalies (50 single, 20 multiple). Diagnostic evaluations included 56 upper gastrointestinal series and 27 barium enemas. Each patient underwent correction of malrotation and appendectomy, and correction of congenital anomalies (omphalocoele—9, gastros-chisis—6, diaphragmatic hernia—7). Complications included short gut (2), sepsis (5), feeding difficulties (2), pneumonia (3), small bowel obstruction (2), and other (15). Nine patients (8.8%) died (trisomy 18—1, trisomy 13—1, intestinal necrosis—3, hepatic failure—1, prematurity—1, other sepsis—2). Two hundred sixteen children with intestinal malrotation have been treated from 1937 to 1987. Mortality rate has improved from 23% to 2.9%.

Hamartomas of the chest wall in infants

Chest wall hamartomas in infancy are rare lesions with distinct clinical, radiologic, and pathologic characteristics. Four cases treated at Childrens Hospital of Los Angeles are presented and previously reported cases are reviewed. Chest wall hamartomas arise antenatally and present as hard, immobile masses, which may cause respiratory insufficiency. An extrapleural mass arising from the ribs can be seen radiographically. Histologically, these lesions are hypercellular and consist of a disorganized array of mesenchymal tissues endogenous to the chest wall. Rapid growth may occur, but usually is self-limited. Chest wall hamartomas are usually benign. This series includes the malignant transformation of one of these lesions. En bloc resection is curative, but the large residual chest wall defect frequently results in scoliosis.

Utility of the cervical spine radiograph in pediatric trauma

To determine the utility of the routine cervical spine radiograph, we reviewed all cervical spine radiographs obtained in pediatric trauma patients over a 2 1/2-year period at the Childrens Hospital of Los Angeles. Records of patients admitted with a documented cervical spine injury over a 20-year period were also reviewed. One hundred eighty-seven children had at least one cervical spine radiograph. Forty-six patients (25 percent) required at least one repeat study in an attempt to see all 7 vertebrae. Thirty-eight children (20 percent) had a second radiograph and 8 patients had a third study, all of which showed no injury. There was only one fracture seen during the 2 1/2-year time period. Of the 16 children admitted over the 20-year period, only 3 sustained an injury below the fourth cervical vertebra (C4), and all were over 8 years of age. All patients with cervical spine injury were either comatose or had symptoms referable to the neck. We conclude that the routine cervical spine radiograph in pediatric trauma is a very low-yield test.

It may be more significant than you think: BB air rifle injury to a child's head

BB guns of 20 years ago were constructed of coils and springs which generated relatively little force, so that a projectile posed little threat of serious injury. Today, the coil and spring construction has been replaced by pump action pneumatic chambers which allow generation of muzzle velocities near 350 ft/sec. Speeds of 150 ft/sec and 200 ft/sec are required for skin penetration and bone penetration, respectively. We present a seven-year-old boy who suffered intracranial parenchymal injury from an air-powered BB gun projectile while playing with friends. We discuss literature which suggests these once-innocent toys are now harbingers of severe, if not fatal, injury.

Incidence of short trachea in patients with myelomeningocele

Short trachea, typically due to reduced tracheal cartilage ring number, produces high tracheal bifurcation which can be demonstrated in radiographs with evaluable air bronchograms. Accidental bronchial intubation with sequelae has been reported in short trachea patients who have tracheal intubation. Short trachea is associated with a number of syndromes, including DiGeorge anomaly and several types of congenital heart disease and skeletal dysplasias. Review of chest radiographs of 87 patients with myelomeningocele revealed that 31 (36%) had short tracheas. Two patients had a total of 3 episodes of bronchial intubation. This degree of association of short trachea with myelomeningocele, the frequency of myelomeningocele, and the number of surgical procedures performed on many such patients suggest that special attention to the short trachea is warranted in myelomeningocele patients because of the risk of accidental bronchial intubation and subsequent sequelae. Twelve (14%) of the myelomeningocele patients lacked radiographic evidence of the presence of twelfth ribs and 11 (13%) had hypoplasia of the twelfth ribs.

Clinical presentation and radiographic identification of small bowel rupture following blunt trauma in children

The incidence of significant intraabdominal injuries from blunt trauma in children is low (1–8%); however, a missed intestinal laceration may result in a devastating, if not morbid, consequence. We present retrospective case studies of eight children with intestinal lacerations following blunt trauma. Each patient has a unique anatomic defect with misleading initial laboratory and radiographic studies. We did not find a single laboratory or roentgenographic study to be consistently reliable for diagnosis of hollow viscus laceration. The combination of a high index of suspicion and serial abdominal examinations, coupled with subsequent comparative laboratory and radiographic evaluations, proved most reliable in identifying patients with intestinal injury.

Ossification centre of the hyoid bone in DiGeorge syndrome and tetralogy of Fallot

The incidence of radiographic visibility of the ossification centre of the body of the hyoid bone in radiographs taken during the first month of life was analysed for 34 autopsied infants: 16 with DiGeorge syndrome (DGS), 14 with tetralogy of Fallot (TOF), four with interrupted aortic arch (IAA) and a further 13, surviving infants with non-DGS TOF or non-DGS IAA. The incidence of visible hyoid ossification centre (HOC) was 75.7% in a control series of infants with neither congenital heart disease (CHD) nor DGS. Autopsied patients with DGS, TOF without DGS, and IAA without DGS showed a significantly low incidence of visible HOC. Infants with TOF (and possibly those with IAA) who did not have DGS and who did not die during infancy showed a normal incidence of visible HOC in radiographs taken during the first post-natal month. Radiological visibility of the HOC in the first post-natal month appears useful in the diagnosis of DGS and forms of CHD often seen in association with DGS and in assessing prognosis of neonates with certain types of CHD.

Neuroblastoma masquerading as retroperitoneal Salmonella abscess

Symptomatic Salmonella infections usually manifest as self-limited gastrointestinal distress. Patients with chronic systemic illnesses or those who are immunosuppressed may rarely present with Salmonella infection as distant suppurative abscesses. We present a previously healthy Armenian boy who came to medical attention with abdominal pain, fever, and anemia. Abdominal computed tomography (CT) scan showed a cystic suprarenal mass that was surgically explored and found to be a retroperitoneal Salmonella abscess. Postoperative CT scan showed resolving inflammation. A 6-month follow-up CT showed a large suprarenal tumor, which at exploration was found to be neuroblastoma. To our knowledge, Salmonella has never been reported presenting as a solitary retroperitoneal abscess, and neuroblastoma has not been described presenting as a Salmonella abscess. The patient is also unusual because the abscess contained a species unusual for suppurative salmonellosis.

Ossification centre of the hyoid bone in complete transposition of great vessels, Ivemark asplenia syndrome, and Down's syndrome with congenital heart disease: correlation with the humeral capital epiphysis

The incidence of radiographic visibility of the ossification centres of the body of the hyoid bone and of the humeral capital epiphysis in antero-posterior or lateral chest radiographs taken during the first month of life of 63 autopsied infants were analysed. The group comprised patients with Downs syndrome (DS) with congenital heart disease, 15; complete transposition of the great vessels (TGV), 10; Ivemark asplenia syndrome (IS), 17; and a control group of infants with congenital heart disease (CHD) who had none of the above conditions, nor tetralogy of Fallot, interrupted aortic arch, DiGeorge syndrome or hypoplastic left-heart complex, 31. The incidence of radiographically visible hyoid ossification centre (HOC) in the control group was 71% and of humeral capital epiphysis (HE), 16.1%. Autopsied infants with TGV, IS or DS with CHD showed increased visibility of HOC (100%); the incidence of visible HE was increased in neonates with IS (71.4%) and with TGV (50%). The differences in the incidence of radiographic visibility of HOC and HE in neonates with CHD, in this study and in others in the literature, appear to have diagnostic value.