Pediatr Radiol (2003) 33: 429–432 DOI 10.1007/s00247-003-0886-9
Dan M. Barlev Beth A. Nagourney Ronald Saintonge
Received: 21 October 2002 Accepted: 31 December 2002 Published online: 4 March 2003 Ó Springer-Verlag 2003
D.M. Barlev (&) Division of Pediatric Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA E-mail:
[email protected] Tel.: +1-718-4703404 Fax: +1-718-8311421 B.A. Nagourney Æ R. Saintonge Division of Neonatology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA Present address: D.M. Barlev Division of Pediatric Radiology, Schneider Children’s Hospital, Long Island Jewish Medical Center, Albert Einstein College of Medicine, 270-05 76th Avenue New Hyde Park, NY 11040, USA
CASE REPORT
Traumatic retropharyngeal emphysema as a cause for severe respiratory distress in a newborn
Abstract Traumatic injury to the pharynx or esophagus in a newborn from intubation or tube suctioning may have various presentations. Difficulty passing a gastric tube or feeding problems may erroneously suggest the diagnosis of esophageal atresia. Associated respiratory distress may be caused by pneumothorax or pleural effusion if the pleural space is entered. We report the case of a full-term newborn presenting with severe respiratory distress caused by a large retropharyngeal air collection resulting from hypopharyngeal perforation from prior intubation and suctioning. Chest abnormality, sufficient to account for the degree of respiratory distress, was not demonstrated.
Introduction Iatrogenic pharyngeal or esophageal perforations in the newborn have been well described, presenting in various ways [1, 2, 3, 4, 5, 6, 7, 8, 9]. Difficulties encountered in advancing a gastric tube, increased oral secretions or feeding intolerance could suggest an erroneous diagnosis of esophageal atresia. Respiratory distress may be caused by associated pneumothorax or pleural effusion if the pleural space has been entered. We report the case of a full-term newborn presenting with severe respiratory distress caused by a large amount of retropharyngeal emphysema as a result of hypopharyngeal perforation from prior intubation and suction-
Keywords Hypopharyngeal perforation Æ Respiratory distress Æ Newborn Æ Retropharyngeal emphysema
ing. Other than a very small amount of mediastinal air, the chest remained normal on multiple imaging studies, not demonstrating pneumothorax, pleural effusion, or any pulmonary or cardiac abnormalities to account for the respiratory distress.
Case report This was a full-term female, the product of an uncomplicated gestation, who had thick meconium at delivery. Endotracheal intubation and suctioning was performed immediately after birth because of the meconium, but none was found below the cords. The intubation and suctioning were routine and without recognized complications. The patient was immediately extubated, appeared well, and was sent to the newborn nursery.
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At approximately 30 h of age the infant was found to be congested and was noted to have a weak moist cry. Chest physiotherapy and suctioning were performed without improvement. Respiratory distress quickly developed with tachypnea, retractions, and desaturations. The patient was transferred to the neonatal intensive care unit. Upon admission to the NICU, physical examination was remarkable for tachypnea, stridor, and coarse breath sounds. Initial chest radiograph was normal. At 48 h of life the patient was given racemic epinephrine via nebulizer and a short course of dexamethasone with minimal response. At 72 h, because of deteriorating respiratory status, she was intubated and placed on mechanical ventilation. Chest radiograph performed after intubation continued to show clear lungs, but now demonstrated a large cervical collection of gas (Fig. 1a). A follow-up lateral view of the neck demonstrated the gas collection to be retropharyngeal in location with some anterior extension. The midsection of the endotracheal tube was deviated Fig. 1a–d a Chest film after endotracheal tube placement demonstrates clear lungs and a large gas collection centered over the cervical region (arrows). b Lateral view of the neck demonstrates the gas collection to be retropharyngeal (black arrows) with anterior extension (white arrows). A small pneumomediastinum (asterisk) is seen in the anterior upper chest. c CT image demonstrates retropharyngeal collection of gas (black arrows) with anterior extension (white arrows). d Water-soluble contrast (asterisks) seen in nasopharynx and oropharynx, introduced through nasogastric tube coiled in pharynx. No contrast passed distal to the hypopharynx even after a long delay. Large retropharyngeal collection of gas is again demonstrated, deviating the pharynx anteriorly (arrows)
anteriorly by the retropharyngeal collection (Fig. 1b). A previously unrecognized, very small anterior pneumomediastinum was now appreciated in the upper chest. Non-contrast CT of the neck was performed to assess the extent of the gas collection and confirmed the plain film findings (Fig. 1c). In an attempt to identify the source of the retropharyngeal emphysema, a small quantity of nonionic low-osmolar water-soluble contrast medium was introduced into the oropharynx via a soft catheter placed through the nose (Fig. 1d). The contrast medium did not pass distal to the hypopharynx, even after a long delay. No connection to the retropharynx was demonstrated. Once again, the mass effect of the retropharyngeal collection was recognized with anterior deviation of the pharynx. At 90 h of life the patient was evaluated by direct laryngoscopy, which visualized a retropharyngeal mass. No mucosal tear was demonstrated at this time. Needle aspiration was performed and the mass disappeared. Initial post-procedure plain film of the neck demonstrated improvement, but the gas then quickly reaccumulated.
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Fig. 2 Contrast swallow after extubation demonstrates a connection to the retropharyngeal soft tissues (white arrows) superior to the level of injury (black arrow)
The patient remained intubated and over the ensuing 3 days the gas collection spontaneously began to resolve. After extubation a repeat contrast swallow was performed, which demonstrated a connection to the retropharyngeal soft tissues (Fig. 2). A nasogastric tube was carefully placed and used exclusively for feeds for the next 8 days. It was then removed and oral feeding was restarted without complications. Two days later the patient was discharged home without further incident. Repeat lateral neck radiographs demonstrated complete resolution of the retropharyngeal collection.
Discussion In 1969, Eklof et al. [1] reported three neonates with traumatic perforations of the esophagus. Girdany et al. [2] reported two cases of hypopharyngeal perforations shortly thereafter. Since then, there have been many such reports in both pre-term and full-term infants [3, 4, 5, 6, 7, 8, 9]. Common causes of such injuries have been ascribed to oropharyngeal suctioning, endotracheal intubation with or without the use of a metal stylet, nasogastric tube placement, and use of a finger to clear
the oropharynx at delivery [1, 2, 3, 4, 5, 6, 7, 8, 9]. Intubation and suctioning in the delivery room were presumed to be the cause of injury in the present case, even though it went unrecognized at the time. A reflexive constriction of the cricopharyngeus muscle, along with proximal esophageal narrowing when the infant neck is extended, is proposed to explain the common finding of the perforation occurring just superior to this level [1, 2]. Clinical findings in cases of perforation include excessive oral secretions, coughing, or choking with feeds and respiratory distress [1, 2, 3, 4, 5, 6, 7, 8, 9]. Subcutaneous emphysema has also been reported as an initial finding at presentation [5]. Attempts to pass a feeding tube may be met with resistance, leading to an erroneous diagnosis of esophageal atresia [1, 2, 3, 4, 5, 6, 7, 8, 9]. Imaging studies performed in cases of pharyngeal or esophageal injuries typically demonstrate a posterior mediastinal tract or pseudodiverticulum extending inferiorly from the level of injury for a variable distance posterior to the esophagus [1, 2, 4, 5, 6, 7, 8, 9]. Extension into either the pleural or pericardial space has also been reported [3]. The present case did not demonstrate a posterior mediastinal pseudodiverticulum. Instead the entire pathology was confined to the retropharyngeal soft tissues anterior to the cervical spine, extending superiorly from the level of injury. The radiographic studies in the present case helped explain the probable mechanism of respiratory distress and stridor. The finding on the first contrast study of complete hypopharyngeal and proximal esophageal obstruction owing to extrinsic compression from the retropharyngeal air collection is indicative of probable concomitant partial airway obstruction from the same cause. Such airway obstruction resulting from retropharyngeal emphysema has been described previously in older children [10, 11, 12]. Management of patients with uncomplicated injuries consists of broad-spectrum antibiotics and either gastric or parenteral nutrition until the mucosal injury heals. In general, plain film monitoring is usually sufficient. Complications such as pneumothorax, pleural effusion or pericardial effusion may require appropriate intervention. Severe injuries may need surgical repair [1, 2, 3, 4, 5, 6, 7, 8, 9, 13]. In our patient, a nasogastric tube was placed and the patient was nourished through it for 8 days until the retropharyngeal emphysema was no longer demonstrated. The tube was then removed and the patient has since remained asymptomatic.
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