Longstanding Esophageal Foreign Body Misdiagnosed as Croup

Introduction: More than 100,000 cases of foreign body (FB) ingestion are reported each year in the United States and 80% of cases occur in children. Patients may be asymptomatic or have only transient symptoms at the time of ingestion. We report the case of a 1 year old female with longstanding esophageal FB after roughly 2 months of ongoing stridor that was misdiagnosed as croup. Case: 1 year old healthy female presented to the ED for intermittent stridor with crying. On initial evaluation by PCP 2 months prior, patient had concomitant upper respiratory infectious symptoms and was diagnosed with croup. She improved with steroids and humidified oxygen. Five weeks from the initial diagnosis, parents returned to the PCP with ongoing concern though patient was asymptomatic on evaluation. A soft tissue neck X-ray was obtained and interpreted as normal and routine follow up with ENT was planned. Three days later, parents present to the ED complaining of worsening stridor over the past 48 hours and have not yet been evaluated by ENT. Exam in the ED is notably for biphasic audible stridor that is loudest with inspiration. Decadron and nebulized epinephrine were administered. A two view chest X-ray was obtained and interpreted as normal. However, ED team was concerned for narrowing of the mediastinal trachea on lateral view chest X-ray; the pediatric service was consulted recommending CT chest with IV contrast that showed edema in the superior mediastinum centered around the esophagus and tracheal flattening above the carina with 2 mm AP diameter. She was started on IV Zosyn and flexible bronchoscopy and esophagoscopy were performed. Visualization of the esophagus demonstrated a plastic piece with jagged edges seen at the upper esophagus with mucosal folds surrounding it. The trachea had only mild inflammatory changes but was otherwise without injury. The FB was removed and the patient recovered completely. Discussion: Esophageal FBs occur most commonly in children aged 6 months to 3 years and tend to lodge in areas of physiologic narrowing, including the upper esophageal sphincter, level of the aortic arch, and the lower esophageal sphincter. Patients may be asymptomatic, or may present with dysphagia, refusal to eat, wheezing, choking or stridor. Longstanding esophageal FBs may lead to recurrent aspiration pneumonias and can damage the esophageal mucosa leading to strictures. They may also erode through the esophageal wall creating a fistula with the trachea or other nearby structures

Does the Shape of the L5 Vertebral Body Depend on the Height of CT Slices in the Pedicle?

The shape of the L5 vertebral body was analyzed using a computerized tomography (CT) scan. OBJECTIVE: The aim of this study is to determine if the vertebral L5 body shape varies depending on the height of the CT slices through the L5 pedicle. SUMMARY OF BACKGROUND DATA: The morphometry of L5 has been studied to help the introduction of pedicular screws. The shape of the vertebral body has been seldom looked into, and the findings obtained show a triangular shape and hemispherical shape, supposedly owing to interpersonal variability. The hemisphere shape enables pedicular screws to be introduced nonconvergently, whereas the triangular shape enables pedicular screws to be introduced at a convergent angle but posing the risk of cortical perforation unless these guidelines are followed. METHODS: Abdominal CT multicut with 64 crowns was performed in 101 consecutive patients with diverse indications. Width of CT slices was with a 1-mm reconstruction increase. We selected one axial slice that passed through the upper part of the pedicle and another one that passed through the lower part of the pedicle and compared next parameters in both cuts: pedicular cortical width, pedicular endostal width, pedicular angle, vertebral body length, vertebral body width, vertebral perimeter angles, and visual appearance of vertebral body shape. RESULTS: We found statistical differences between all values except the anterior vertebral perimeter angle on comparing values of upper part with values of lower part and visual vertebral body shape was different in 93% of vertebrae. In the upper part the vertebral body is hemispherical whereas in the lower part it is triangular. CONCLUSION: In most cases, the vertebral body shape is hemispherical in the upper part of the pedicle and triangular in the lower part of the pedicle. It means that in the lower part pedicular screws must be introduced at a more convergent angle than in the upper part if we do not want to break any cortical of the vertebral body

Feasibility of laminar screw placement in the upper thoracic spine: analysis using 3-dimensional computed tomographic simulation

STUDY DESIGN.: Evaluation using 3-dimensional screw trajectory software and computed tomographic scans. OBJECTIVE.: To investigate the anatomic feasibility of laminar screw placement in the upper thoracic spine compared with pedicle screw placement. SUMMARY OF BACKGROUND DATA.: Although laminar screws have been suggested as an alternative to pedicle screws in the upper thoracic spine, previous anatomic feasibility studies have some limitations. METHODS.: Four types of screws were simulated from T1 to T6: unilaminar screw (US), superior bilaminar screw (SBS), inferior bilaminar screw (IBS), and pedicle screw (PS). Maximum allowable screw dimensions and the success rates of 4.5-mm screw placement were compared for each level. Laminar screw dimensions with more than 90% success rate at each level were determined for reference. RESULTS.: Computed tomographic scans of 132 patients were analyzed. Laminar screw diameters gradually increased from T1 (4.4-5.4 mm, for each type) to T6 (4.8-6.7 mm), whereas PS diameter steeply declined from T1 (5.9 mm) to T4 (3.4 mm) and then leveled off. At T1, PS had greater success rate of 4.5-mm screw placement than laminar screws (US > IBS > SBS); at T2, US had greater success rate than IBS, followed by PS and SBS; and at T3 to T6, laminar screws (US > IBS > SBS) had greater success rate than PS in all comparisons. Except for SBS at T1, laminar screw diameters with more than 90% success rates were between 3.5 and 5.0 mm. CONCLUSION.: In view of their anatomic feasibility, laminar screws can be a viable alternative to PSs in the upper thoracic spine. Particularly at T3 to T6 where the pedicle width is inherently small, the success rates of laminar screw placement were significantly and consistently higher than those of PS placement. The comparable success rates of laminar screws using commercially available screw sizes further emphasize their potential clinical use.OAIID:oai:osos.snu.ac.kr:snu2013-01/102/0000004226/6SEQ:6PERF_CD:SNU2013-01EVAL_ITEM_CD:102USER_ID:0000004226ADJUST_YN:NEMP_ID:A076317DEPT_CD:801CITE_RATE:2.078FILENAME:spine-2013_mary ruth_the feasibility of laminar screw placement in the upper thoracic spine.pdfDEPT_NM:의학과EMAIL:[email protected]_YN:YCONFIRM: