Paediatric tracheobronchomalacia and its assessment by tracheobronchography.

Tracheobronchomalacia (TBM) is a rare condition that results in abnormal compliance of the airways with airway collapse being most marked in expiration. In a series of 28 patients, it was observed that a majority of cases presented with malacia involving the trachea (64%) and the left main bronchus (64%) alone. The right main bronchus was involved in combination with the trachea in 32%, but rarely was involved by itself. Most patients demonstrated associated congenital abnormalities, such as tracheo-oesophageal fistulae, vascular rings or congenital heart disease (78%). A small proportion were premature infants with no obvious associated abnormality (11%). Evaluation of the dynamic process, tracheobronchomalacia; requires 'real-time' investigation. While computed tomography (CT) and magnetic resonance imaging (MRI) have their role in the management of chronic airway obstruction in the child, only cine-CT, bronchoscopy, fluoroscopy and tracheobronchography provide real-time assessment for the evaluation of a dynamic process such as TBM. In our experience, tracheobronchography provides excellent anatomic, physiologic and therapeutic information in the assessment of those infants with primary or secondary TBM. By using continuous positive airway pressure in incremental doses, the amount of positive pressure required to maintain an open airway in expiration is a valuable adjunct to the clinical management of the patient. When careful attention is paid to technique, tracheobronchography is a safe investigation in experienced hands.

Sinusitis and intracranial sepsis: the CT imaging and clinical presentation.

The CT imaging and clinical presentation in 14 children with coexistent intracranial sepsis and sinusitis were reviewed. A routine CT head scan (10-mm thick semi-axial slices through the cranium done before and after intravenous contrast medium administration) was found to be an inadequate initial investigation as the intracranial collection was missed in four patients and the abnormal sinuses not shown in six. In half the children the diagnosis of sinusitis was unsuspected at the time of admission. The dominant clinical features were fever, intense headache and facial swelling in early adolescent males. In this clinical setting we recommend: (1) the routine scan is extended through the frontal and ethmoidal sinuses and photographed at a window level and width showing both bone detail and air/soft tissue interfaces; (2) direct coronal projections are performed through the anterior cranial fossa if no collection is seen on the routine study; (3) an early repeat scan within 48 h if the initial study shows no intracranial pathology but the fronto-ethmoidal sinuses are abnormal and there is a high clinical suspicion of intracranial sepsis; and (4) in the presence of intracranial sepsis the vault is viewed at bone window settings to exclude cranial osteomyelitis.

Diseases of the spinal canal in children: diagnosis with noncontrast CT scans.

The spinal cord and its coverings were assessed in 131 CT studies performed without intrathecal contrast material in 108 patients ages newborn to 20 years old. The spinal cord, including the conus medullaris, and the theca can be readily identified in most patients, except in the upper thoracic region. Correlation with other radiologic studies and surgery showed few false-positive and false-negative results. Of particular importance, in no patient was unnecessary surgery performed nor was necessary surgery not performed as a result of the method. The technique was a useful screening test, often sufficient alone, for the assessment of congenital disease (proved lesions included 20 tethered spinal cords, 11 congenital mass lesions, five split cords, and 11 hydromyelic cysts or syrinxes). There were nine confirmed intraspinal neoplasms. The technique was good for identifying epidural lesions; however, we recommend myelography and/or CT myelography for suspected intradural tumors because of the greater anatomic definition required. Noncontrast CT requires careful attention to technique, and may be successful only with the use of late-model, high-resolution CT units. Noncontrast CT is a rapid, cost-effective method of assessing suspected disease in the pediatric spinal canal, at least while access to MR is still limited.

Inappropriate use of contrast studies prior to referral of neonatal gastrointestinal anomalies and bowel obstruction.

Ten cases of neonatal gastrointestinal anomalies and bowel obstruction are described, in which contrast studies were carried out prior to transfer. Nine of the 10 infants had bile-stained vomiting, indicating the need for immediate surgical referral. The contrast studies resulted in delayed referral, deferment of appropriate resuscitation, and complications associated with the study. In several cases the wrong type of study, or the wrong contrast medium was used. These 10 infants required urgent surgical referral, not a sophisticated radiological procedure in geographic and surgical isolation.

Acute pseudobulbar palsy due to bilateral focal cortical damage: the opercular syndrome of Foix-Chavany-Marie.

Two children are described who suddenly developed an encephalitic illness with intractable bilateral facial seizures. The seizures subsided over several days, but the children were left with the signs of pseudobulbar palsy and are unable to speak or swallow effectively. Bilateral destructive lesions in the opercular regions evolved on computed tomographic scans. Both children were treated with acyclovir relatively early in the illness, and cerebrospinal fluid and serum antibodies support the diagnosis of herpes simplex virus encephalitis.

Paediatric pulmonary nodules: a comparison of computed tomography, thoracotomy findings and histology.

Eighteen computed tomography (CT) studies of the lungs prior to thoracotomy in 15 children with presumed pulmonary metastases were compared retrospectively with surgical and pathological findings. Computed tomography detected 86% of the malignant lesions and technical factors were thought to be important where larger nodules were missed. Although CT does not differentiate benign and malignant lesions, 90% of lesions detected at CT in this study contained tumour. In four patients it was found that nodules that increased in size on serial CT contained viable tumour, whereas nodules that decreased in size while a patient was on chemotherapy might or might not contain viable tumour.

Bilateral metachronous periosteal osteosarcoma.

The first case of bilateral metachronous periosteal osteosarcoma (OS) is reported. A 14-year-old white boy presented with a 1-month history of pain and swelling in his right thigh. Periosteal OS was diagnosed on a basis of the radiologic and pathologic findings. Treatment was with local resection and total hip replacement after a short course of high-dose methotrexate; multi-agent chemotherapy was continued postoperatively for 3 months. He remained well for 3 years. He then represented with a mass in the left femur that had been slowly growing for about 1 year. Radiologic and biopsy studies showed periosteal OS. Full investigations showed no evidence of metastatic disease. Treatment consisted of local resection without chemotherapy. He remained well for 6 months after the second excision until developing multiple pulmonary metastases. All further therapy was refused. The question as to whether the second tumor was a new primary lesion or a metastasis is discussed, together with possible differential diagnoses.

Computed tomography of partial growth plate arrest: initial experience.

Twelve growth plates in 11 patients with clinical evidence of partial growth plate tethering underwent thin slice (1.5 mm) axial high resolution computed tomography (CT), or direct coronal CT. The normal epiphyseal plate was readily visualised as a low density layer of soft tissue density between adjacent sclerotic margins of epiphysis and metaphysis. Two growth plates had greater than 50% obliteration and ten had partial obliteration. Our preliminary results show excellent correlation between the CT findings and surgical pathology. We expect that CT will replace polytomography in the operative evaluation of partial growth plate arrest, as it has in our institution.

Carrier detection in Duchenne muscular dystrophy using computed tomography.

In Duchenne dystrophy computed tomography of muscles shows total or partial replacement of normal muscle by low density tissue, presumably representing fat. It was hypothesised that female carriers would have increased fat deposition, and hence lower density readings in certain muscle groups when compared with controls. Three C.T. scans, two through the thigh and one through the calf, were obtained on 9 obligate carriers, 12 "possible" carriers, and 10 controls. A total of 15 density readings in different muscle groups were obtained for each subject. The results, analysing the mean densities in Hounsfield units, show that the obligate carriers have statistically significant lower density readings than controls. The 9 obligate carriers and 10 controls were correctly allocated using discriminant function analysis of muscle density readings. An attempt to assign the "possible" carriers was made. The use of C.T. scanning in addition to creatine kinase (C. K.) estimations will significantly improve accuracy of genetic counselling and has the advantage of being non-invasive.

Progression of muscular dystrophy assessed by computed tomography.

To determine whether computerised tomography (CT) offers an accurate means of following the progression of Duchenne muscular dystrophy, CT scans through the thigh and calf were done on two occasions, six months apart, for 13 boys with the disease. The results suggest that CT scans of muscles may be used as an adjunct to other methods in the accurate assessment of progression.

Radiological findings in total aganglionosis coli.

The radiological findings in 13 patients with total aganglionosis coli were reviewed. There was a male to female ratio of 7:6. Fifty-four percent of patients presented in the first week of life, but a significant number (31%) did not present until after 1 month of age. All patients had plain film evidence of bowel obstruction when referred for a barium enema. There were no pathognomonic barium enema findings, and barium enema results covered the entire spectrum of findings which can be encountered in the neonate and young infant with bowel obstruction. Seventy-seven percent had normal calibre colon, 23% had micro colon, 23% had a shortened colon, 46% had colonic wall irregularity, 33% had significant ileal reflux. Delayed evacuation of barium from colon occurred in the two patients who had delayed films. Total colonic aganglionosis should be considered in any infant or young child with plain film evidence of bowel obstruction, whatever the barium enema findings. Hirschsprung's disease and the level of transition can only be definitively diagnosed by biopsy.

Computed tomography in craniopharyngiomas.

Computed tomographic examinations of 28 children and 12 adults with surgically proved craniopharyngiomas were retrospectively studied for characteristic findings that might be diagnostic of this tumor. It was found that 8 of 10 children and 2 of 4 adults examined pre-operatively had at least 2 of 3 findings: calcification, cyst, or contrast enhancement on CT. The remaining pre-operative patients did not receive contrast in their initial exams. Unusual presentation of the tumor in adults is also discussed.

The radiographic features of unilateral megalencephaly.

Unilateral megalencephaly is a rare anomaly of the brain which causes enlargement of a lobe or an entire hemisphere. The radiological features of the disease are a poorly defined unusual mass effect on PEG, angiography and CT scan. Pathologically, the disease is thought to be due to abnormal cell migration in the 3rd month in utero.

Coronal computed tomography of the skull and brain in infants and children. Part I: Technique and results.

The advent of scanners with an air gap and a tilting gantry have made possible the use of the coronal view in computed tomography of the skull and brain in infants and children. Of 400 axial scans performed over a four-month period, 50 were supplemented by the coronal projection. Although the artifacts, uncomfortable position, and prolonged scanning time associated with coronal scanning make it impractical as the only modality, when used as an adjunct to the axial view it can provide valuable additional diagnostic information.

Coronal computed tomography of the skull and brain in infants and children. Part II. Clinical value.

Coronal computed tomography is an important adjunct to the routine axial view in the evaluation of lesions of the skull and brain in infants and children. Of 400 axial scans performed over a four-mounth period, 50 were supplemented by coronal scans. Intracranial or cranial abnormalities were present in 39 (78%). Although the disadvantages of the coronal projection make it impractical as the only modality, when used as an adjunct to the axial view certain lesions of the skull and brain are diagnosed and delineated better.

Metrizamide in pediatric myelography.

Metrizamide, a new water-solution iodinated contrast medium, was evaluated in 63 infants and children, most of whom had lumbosacral or low thoracic lesions. The diagnostic quality was found to be good, and no serious complications or permanent sequelae were encountered. Chief complications were headache, nausea, vomiting and fever. No myoclonic spasms or convulsions were seen. The advantages and disadvantages of metrizamide are discussed.

Computed tomography of abdominal mass lesions in children. Initial experience.

Use of a Delta scanner has resulted in delineation of neoplastic, obstructive and inflammatory renal diseases, hepatic tumors, and other abdominopelvic mass lesions. Of 47 patients examined, 32 had proved mass lesions. Computed tomography provided unique information about the complete delineation and nature of lesions and detected unrecognized lesions. Technical problems and solutions are discussed.