Foreign body aspiration in children: value of radiography and complications of bronchoscopy.

PURPOSE: The authors undertook a 10-year review of bronchoscopies for airway foreign bodies in children to test assertions in previous reports that (1) characteristic abnormalities in chest radiographs are important indicators of the need for bronchoscopy and (2) experienced operators incur negligible complications. METHODS: The medical records of 293 children who underwent bronchoscopies by experienced pediatric surgeons for suspected airway foreign bodies were reviewed for patient age, symptoms, duration of symptoms before bronchoscopy, prebronchoscopy radiographs, type of foreign body, anatomic location of foreign body, success of bronchoscopic removal, length of hospital stay, and complications. RESULTS: Of the 293 bronchoscopies, 265 showed airway foreign bodies. A choking episode was recorded in 228 of the 265 patients with foreign bodies and 5 of the 28 with negative bronchoscopy. The surgeon thought that radiographs were normal at the time of bronchoscopy in 110 patients who had foreign bodies. Nine patients with foreign bodies had atypical radiographs; three had bilateral emphysema and six had upper lobe or bilateral atelectasis or pneumonia. There were three complications: one vocal cord injury requiring temporary tracheostomy, one tracheal laceration from removal of an aspirated tooth, and one severe postoperative subglottic edema requiring a 4-day hospital stay. The age of the patients, symptoms, types of foreign bodies, locations of foreign bodies, management, and outcomes were similar to those of previous reports. CONCLUSIONS: In children with airway foreign bodies, chest radiograph findings are frequently normal and can display abnormalities uncharacteristic for foreign body aspiration. Children witnessed to choke while having small particles in their mouths and noted subsequently to have raspy respiration, wheezing, or coughing should undergo prompt bronchoscopy regardless of radiographic findings. Complications of bronchoscopy for foreign body aspiration are uncommon but occur even in experienced hands.

The inconspicuous penis.

OBJECTIVE: To describe the etiology and management of the group of abnormalities referred to as the inconspicuous penis. DESIGN: Analysis of 19 cases seen over a period of 2 years by chart review. SETTING: Children's hospital in a major metropolitan area. PATIENTS: Nineteen boys referred to two pediatric urologists over a period of 2 years with penises that appeared abnormally small, but on palpation and measurement, were found to have a normal shaft with a normal stretched length. Diagnoses included were buried penis, webbed penis, and trapped penis. Patients ages ranged from 1 week to 13 years. FINDINGS: There were eight patients (42%) with trapped penis, and all were complications of circumcision (age 1 week to 7 months). Of nine (47%) patients with buried penis, two had been circumcised prior to diagnosis. One (5%) patient had webbed penis and one (5%) had combined buried and webbed penis. INTERVENTION: Six trapped penises were surgically repaired, and two resolved spontaneously. Five patients with buried penis had surgical repair, and two are being followed up for probable repair at age 9 to 12 months. Two were not repaired because of medical conditions or parental concerns. The webbed penis was surgically repaired as was the combined buried and webbed penis. The repair were all successful and had no complications. CONCLUSIONS: Inconspicuous penis encompasses a group of conditions in which the penis appears small but the shaft can be normal or abnormal in size. Circumcision is contraindicated in these patients until they have been evaluated by a urologist. Further study is needed to determine the natural history of these disorders and to better define which patients will benefit from surgical intervention and at what age.

Survival of nonpalpable undescended testicles after orchiopexy.

Among 496 boys who underwent operations for the preoperative diagnosis of undescended testicle, 41 patients had high undescended testicles that were not palpable preoperatively. Four of the 41 were bilateral, for a total of 45 high undescended testicles. Eight of the 45 were lost to long-term follow-up. Thirty-seven testicles were followed for over 1 year, and 30 (81%) of the 37 survived orchiopexy long term. No testicles atrophied later if they survived the first few postoperative months. Twenty-nine (64%) had vascular pedicles long enough to reach the scrotum without dividing the testicular artery. Our findings confirm long-standing impressions of most pediatric surgeons: (1) 81% survival warrants continuation of standard orchiopexy through a groin incision for nonpalpable undescended testicles in patients who will be able to ejaculate and engage in coitus; (2) most nonpalpable undescended testicles can be brought safely into the scrotum while preserving the testicular vasculature through a groin incision; (3) if it is necessary to divide the testicular artery in order to bring the testicle into the scrotum, our results confirm previous reports that preservation of the testicular collaterals will often allow the testicle to survive in a normal scrotal location; and (4) the need for testicular autotransplantation with microvascular anastomosis should rarely arise.

Esophageal rupture in an infant secondary to esophageal placement of a Foley catheter gastrostomy tube.

We report a case of esophageal rupture in a five-month-old female infant caused by a Foley catheter gastrostomy tube inadvertently placed into the esophagus at the time of tube change. The patient presented with vomiting and progressive respiratory distress and when first evaluated had a left-sided pneumothorax. The esophageal location of the Foley balloon was not initially apparent. Metrizamide radiography demonstrated the esophageal rupture. The patient recovered with drainage of the mediastinal and pleural collections. Physicians and caretakers should be alerted to the mechanical complications of Foley catheter tube gastrostomy, since these complications are mostly preventable and easily diagnosed.

Post-infarction peripheral cysts of the lung in pediatric patients: a possible cause of idiopathic spontaneous pneumothorax.

Occlusion of the main pulmonary artery to the right lung in a newborn infant produced peripheral (subpleural) infarction of the lung and cyst formation. Two older infants were found at autopsy to have subpleural cysts of the upper lobes. One had had surgery for repair of an atrial septal defect and a patent ductus arteriosus eight months prior to death, while the second had died suddenly of carbon monoxide intoxication. The authors suggest that pulmonary arterial occlusion may have been responsible for cyst formation in all three cases and may produce cysts in other infants that lead to idiopathic spontaneous pneumothorax in older children and young adults. The presence of bronchopulmonary arteries in fetuses and newborn infants may provide the mechanism for the production of subpleural cysts following pulmonary arterial occlusion.

Extremity swelling in an infant with copper and zinc deficiency.

A female infant born with jejunal atresia and a severely shortened bowel acquired progressive thickening of her thighs at 7 mo of age. While receiving parenteral nutrition, all four extremities rapidly became massively thickened and tender, and the child made no effort to move them. X-rays revealed large subperiosteal hematomas encompassing each femur, tibia, and humerus as the cause of the swelling. Ascorbic acid levels in the serum were not diminished, but copper and zinc levels were extremely low. Treatment with a trace element solution that included copper reversed the extremity thickening and the pseudoparalysis.