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MSCT
chest and Virtual Bronchoscopy in patients with suspected foreign body
inhalation having no specific clinical localizing signs and apparently
normal chest radiographs has an important role. The study of two such
patients was performed which concluded that MSCT of chest with virtual,
bronchoscopy helps us in accurately localizing the site of obstruction
and gives 3D road maps to surgeons to tackle the obstructed bronchus
directly. Thus it reduces general anaesthesia time and conventional
bronchoscopy time thereby preventing excessive mucosal damage especially
in children. Thus this technique is noninvasive, accurate and useful
in cases of suspected foreign body inhalation. |
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INTRODUCTION |
Foreign
body inhalation are commonly encountered in paediatric age group. Patients
with known foreign body aspiration associated with localizing auscultatory
findings are immediately dealt with fibre optic bronchoscopy for removal.
However in cases with suspicion of foreign body aspiration and no localizing
auscultatory signs, the multislice CT followed by virtual bronchoscopy
becomes a useful tool to facilitate diagnosis and to guide decision
making regarding therapy.
We have encountered two such patients. |
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CASE
REPORT1
First patient was a 1½ yr old female child who
presented with cough, and dyspnoea with a suspicious foreign
body inhalation (? Groundnut), 5 days ago. On examination there
were no signs of obstruction and the chest roentgenogram was
normal. A plain axial CT scan of the chest was performed on
a multislice CT scanner (Siemens volume 200 m, siemens corp.,
siemenstrasse, forchheim Germany) with 5 mm slice thickness
and 1 mm collimation. The axial and coronal reconstructions
were performed in lung window. These smoothened axial images
were transferred to a dedicated work station with fly through
virtual endoscopy package for virtual bronchoscopy (Irix based
work station, 3D virtuoso, silicon graphics, Mountain view,
CA). CT scan revealed an oblong foreign body in the right main
bronchus extending into the right upper bronchus. Virtual bronchoscopy
showed a intrabronchial lesion in the right main bronchus. However
only on virtual bronchoscopy we cannot differentiate a foreign
body form adenoma, as VB lacks surface characterization. Hence
multiplanar images with virtual bronchoscopy have to be studied
together to come to a diagnosis. On direct bronchoscopy a peanut
was retrieved from the same site as seen on virtual bronchoscopy.
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CASE
REPORT 2
Second patient was 2 yr. old male child who had h/o
cough and fever since 2 months. On examination the air entry
was bilaterally equal and there was presence of bilateral rhonchi.
The chest radiograph was also apparently normal. Again axial
CT scan with lung windows followed by virtual bronchoscopy was
performed on Siemens multislice CT scanner. The axial and 2D
sagittal and coronal images revealed metallic foreign body in
right main bronchus. Virtual bronchoscopy showed a linear intraluminal
lesion in left main bronchus. In this the shape of the foreign
body helped virtual bronchoscopy to come to a diagnosis and
it had to be reviewed without looking at axial/coronal images.
On direct bronchoscopy a screw was retrieved from the same site
as seen on virtual bronchoscopy.
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DISCUSSION |
In
patients with suspected foreign body though clinical symptoms and roentgenographic
findings are helpful, many a times no localizing signs are present as
in our case, thereby making us speculate the site of obstruction. CT
scan of the chest with virtual bronchoscopy as a screening modality
for suspected foreign body proves to be a good choice. This helps us
in accurately localizing the site of obstruction and gives us an overview
of the path of bronchoscope to the surgeon. Additionally it also depicts
the entire bronchial tree.
Direct bronchoscopy has risk of damaging the lining in addition to general
anaesthesia risk, the role of virtual bronchoscopy appears to be immense.
CT helps not only to show the site of foreign body thereby helping the
surgeon to tackle the obstructed bronchus directly, but also reduces
the general anaesthesia time and scopy time thereby preventing excessive
mucosal damage especially in children.
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Advantages
of CT and VB |
Noninvasive,
wAccurate, w3D road map, wCan go beyond the stenosed airway, allowing
visualization of bronchial tree beyond the stenosis/lesion. wBoth extraluminal
and endoluminal information is provided.Can go beyond the stenosed airway,
allowing visualization of bronchial tree beyond the stenosis/lesion.
wBoth extraluminal and endoluminal information is provided. |
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Disadvantages
of CT and VB |
No
information on colour and texture of airway mucosa and foreign body.
w2 factors limit VB scopic imaging in children. wSmall airway size.
Inability of infants to suspend respiration during data, acquisition.
Cost
Virtual bronchoscopy provides no information on colour/texture of airway
mucosa or foreign body. Two factors limit virtual bronchoscopy in children
: small airway size and inability of infants to suspend respiration. |
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CONCLUSION |
CT
(axial, reconstructed) and virtual bronchoscopy can give 3-Dimension
road maps to surgeons. This technique is noninvasive, accurate and useful
in cases of suspected foreign body in children. |
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REFERENCES |
1. |
Christopher J Hartnick, Sung Chug, Kathleen H Emery, et al.
Pediatric virtual bronchoscopy. Annals 2002. |
2. |
Wendy
Wai-man Lam, Paul KH Jam, Fu-Luk Chan, et al. Esophageal atresia
and tracheal stenosis : use of 3D CT and virtual bronchoscopy
in neonates, infants and children. AJR 2000; 174 : 1009-1012. |
3. |
Eli
Konen, Miriam Katz, Judith Rozenman, et al. Virtual Bronchoscopy
in children : early clinical experience. AJR 1998; 171 : 1699-1702. |
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FAILED
BACK SURGERY SYNDROME
Around 2000 cases of failed back surgery syndrome are produced
each year in the United Kingdom. They have been through the
gamut of orthopaedic, neurological, and radiological opinions
followed by physiotherapy, occupational therapy, and possibly
clinical psychology, funnelling them inexorably towards the
pain clinic.
Nowadays, we may increasingly be questioning the advisability
of surgery for prolapsed disc, but not operating can also produce
long term disability. Yet 5-10% of patients who have back surgery
return home without relief of their radicular pain. Worse still,
after about six months the pain may be showing an unpleasant
whiff of neuropathy.
Postdiskotomie-Syndrom : I then began to understand that, although
the nerve roots were not damaged directly by the surgery they
were now encased in a web of scar tissue causing pain and spasm
every time this was tweaked enough by movements of the spine
and legs.
Magnetic resonance imaging and computed tomography are necessary
to rule out lesions amenable to surgical intervention, but they
cannot determine whether the intraspinal scarring is causing
the symptoms.
Lina Talbot BMJ 2003 : 327 : 985-986 |
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