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CASE REPORTS

ROLE OF MSCT CHEST AND VIRTUAL BRONCHOSCOPY IN SUSPECTED FOREIGN BODY INHALATION
Anagha R Joshi, Nitin V Agrawal, Gayatri Y Zambre, Ashish R Khandelwal

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.
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.
 

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.
 

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.
 
 
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.
 
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.
 
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.
 
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.
 
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.
 
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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