Acta Pzdiatr Scand 64: 551-554, 1975
CASE REPORT
INFANTILE SUB-LOBAR EMPHYSEMA AND TRACHEAL BRONCHUS T. IANCU,
Y.BOYANOVER, N. EILAM, E . ELIAN and M. A. LERNER
From the Departments of Paediatrics and Radiodiagnosis, Sharon Hospital, Petach-Tikvah, and Tel Aviv University Medical School, Israel
ABSTRACT. Iancu, T., Boyanover, Y., Eilam, N., Elian, E. and Lerner, M. A. (Departments of Paediatrics and Radiodiagnoss, Sharon Hospital, Petach-Tikvah, and Tel Aviv University Medical School, Israel). Infantile sub-lobar emphysema and tracheal bronchus. Acta Paediatr Scand, 64: 551, 1975.--localised disturbance of aeration in children is as often the result of mucosal swelling due to infection as resulting from an inhaled foreign body. The present report adds another cause: tracheal bronchus. Elucidation of the cause of localised disturbance of aerationusually includes bronchoscopy,the anesthesia and direct trauma involved being highly undesirable if infection is the cause. The case for limited, careful bronchography, before or instead of hronchoscopy, when the history of foreign body is lacking, is presented. KEY WORDS: Tracheal bronchus, infantile lobar emphysema, mediastinal shift, paediatric hronchography
Atelectasis and obstructive emphysema, separately or together, from occlusive effect of exudate and mucosal swelling, frequently complicate acute respiratory infection (3), and may persist after clinical recovery. If the mode of onset and the clinical features are not consistent with simple infection,' aspirated foreign body has to be excluded in infants, absence of an eye-witness not withstanding. The routine radiological examination, including the mediastinal shift, cannot distinguish between these two etiologies, nor exclude rare tracheobronchial anomalies. Bronchoscopy, despite its being an additional injury to a diseased airway, is therefore often resorted to, and is as often negative. In a case of localised emphysema here reported, bronchography obviated the need for bronchoscopy by revealing a tracheal bronchus, considered the causative lesion.
CASE REPORT A 7-month-old male baby developed a mild respiratory tract infection; he was feverish for about 4 days and during this period he coughed, and moist rales as well a s crepitations were heard over the left lung; he was given oral ampicillin and the fever and symptoms subsided. Three weeks later, the symptoms and fever recurred, and roentgenographic examination of the chest was performed. The AP film (Fig. 1 a ) disclosed shift of the mediastinum t o the left, and increased transradiancy of the right lung, especially of its upper half. No atelectatic areas were seen in the left lung. The infant was referred to hospital for further examination. He was a healthy looking child, by now 8 months old. He was'coughing, and a mild degree of hyperresonance was found over the right lung, but, in contrast with the usual finding in obstructive emphysema, the breath sounds over the right lung were intensified. No rales were heard. There was no dyspnoea, and the apex of the heart was found in its normal position. The remainder of the clinical examination was non-contributory. No history of foreign body aspiration could be obtained from the family. At fluoroscopy, theie was rnediastinal shift to the left; during expiration the mediastinum did not return to the normal median position. Lateral films confirmed increased Acta PsPdiatr Scand 64
552
T . Iancu et al.
Fig. I . ( a ) PA film at 7 months of age. Mediastinal shift to the left with increased radiance of the upper lung field; fluoroscopic manifestations of obstructive emphysema.
No evidence of atelectasis. ( b ) Lateral film added one month later: emphysema of lung apex still present.
air content in the right upper lung, without disclosing areas of atelectasis elsewhere (Fig. 1 b ) . As the general condition of the infant was good, and the pulmonary findings were static, he was given 5 days of therapeutic trial, consisting of increased humidity (tent), and antibiotics (ampicillin and sodium cloxacillin). It was considered that this therapeutic approach might be effective should the symptoms be the consequence of mucus plug. When fluoroscopic and roentgenographic examinations were repeated a week later, there was no change in the original findings. Bronchography revealed a tracheal bronchus arising 1.5 cm from the canna (Fig. 2). connecting with the apical segment which was of increased volume with splaying of the bronchi. Nothing in the calibre and course of this bronchus could predispose to impaired aeration. The re-
and an anterior one which is the future respira-
lobe bronchus led only to the posterior, and a diminutive anterior segments. The main bronchi and oesophagus showed no impressions of anomalous coursing vessels (4). The clinical symptoms subsided gradually; one month later, the child was found to be in excellent condition; breath sounds over the right lung were still harsher than over the left one, and the increased transradiancy of the right lung with the mediastinum displaced toward left, were unchanged.
DISCUSSION Embryological considerations The origin of the respiratory tract is from the foregut, beginning in the fourth week when the embryo is 3 mm long. During its early development, the foregut divides into a posterior part, from which the gastrointestinal tract develops, Actn Pzdiatr Scand 64
tAF.1
trn,.t
‘“lY ” aLL’
The tracheobronchial which originates in the Dharvnx subseauentlv divides into two primary bronchial branches. These Primary bronchial branches penetrate the mesenchvme, and during ., their growth further ramification into segmental bronchi, bronchioli, terminal bronchi, and alveoli takes Dlace (7). According to Bremer ( l ) , the tracheal bronchus is a stage Of normal development Of *
I
CASE REPORT
INFANTILE SUB-LOBAR EMPHYSEMA AND TRACHEAL BRONCHUS T. IANCU,
Y.BOYANOVER, N. EILAM, E . ELIAN and M. A. LERNER
From the Departments of Paediatrics and Radiodiagnosis, Sharon Hospital, Petach-Tikvah, and Tel Aviv University Medical School, Israel
ABSTRACT. Iancu, T., Boyanover, Y., Eilam, N., Elian, E. and Lerner, M. A. (Departments of Paediatrics and Radiodiagnoss, Sharon Hospital, Petach-Tikvah, and Tel Aviv University Medical School, Israel). Infantile sub-lobar emphysema and tracheal bronchus. Acta Paediatr Scand, 64: 551, 1975.--localised disturbance of aeration in children is as often the result of mucosal swelling due to infection as resulting from an inhaled foreign body. The present report adds another cause: tracheal bronchus. Elucidation of the cause of localised disturbance of aerationusually includes bronchoscopy,the anesthesia and direct trauma involved being highly undesirable if infection is the cause. The case for limited, careful bronchography, before or instead of hronchoscopy, when the history of foreign body is lacking, is presented. KEY WORDS: Tracheal bronchus, infantile lobar emphysema, mediastinal shift, paediatric hronchography
Atelectasis and obstructive emphysema, separately or together, from occlusive effect of exudate and mucosal swelling, frequently complicate acute respiratory infection (3), and may persist after clinical recovery. If the mode of onset and the clinical features are not consistent with simple infection,' aspirated foreign body has to be excluded in infants, absence of an eye-witness not withstanding. The routine radiological examination, including the mediastinal shift, cannot distinguish between these two etiologies, nor exclude rare tracheobronchial anomalies. Bronchoscopy, despite its being an additional injury to a diseased airway, is therefore often resorted to, and is as often negative. In a case of localised emphysema here reported, bronchography obviated the need for bronchoscopy by revealing a tracheal bronchus, considered the causative lesion.
CASE REPORT A 7-month-old male baby developed a mild respiratory tract infection; he was feverish for about 4 days and during this period he coughed, and moist rales as well a s crepitations were heard over the left lung; he was given oral ampicillin and the fever and symptoms subsided. Three weeks later, the symptoms and fever recurred, and roentgenographic examination of the chest was performed. The AP film (Fig. 1 a ) disclosed shift of the mediastinum t o the left, and increased transradiancy of the right lung, especially of its upper half. No atelectatic areas were seen in the left lung. The infant was referred to hospital for further examination. He was a healthy looking child, by now 8 months old. He was'coughing, and a mild degree of hyperresonance was found over the right lung, but, in contrast with the usual finding in obstructive emphysema, the breath sounds over the right lung were intensified. No rales were heard. There was no dyspnoea, and the apex of the heart was found in its normal position. The remainder of the clinical examination was non-contributory. No history of foreign body aspiration could be obtained from the family. At fluoroscopy, theie was rnediastinal shift to the left; during expiration the mediastinum did not return to the normal median position. Lateral films confirmed increased Acta PsPdiatr Scand 64
552
T . Iancu et al.
Fig. I . ( a ) PA film at 7 months of age. Mediastinal shift to the left with increased radiance of the upper lung field; fluoroscopic manifestations of obstructive emphysema.
No evidence of atelectasis. ( b ) Lateral film added one month later: emphysema of lung apex still present.
air content in the right upper lung, without disclosing areas of atelectasis elsewhere (Fig. 1 b ) . As the general condition of the infant was good, and the pulmonary findings were static, he was given 5 days of therapeutic trial, consisting of increased humidity (tent), and antibiotics (ampicillin and sodium cloxacillin). It was considered that this therapeutic approach might be effective should the symptoms be the consequence of mucus plug. When fluoroscopic and roentgenographic examinations were repeated a week later, there was no change in the original findings. Bronchography revealed a tracheal bronchus arising 1.5 cm from the canna (Fig. 2). connecting with the apical segment which was of increased volume with splaying of the bronchi. Nothing in the calibre and course of this bronchus could predispose to impaired aeration. The re-
and an anterior one which is the future respira-
lobe bronchus led only to the posterior, and a diminutive anterior segments. The main bronchi and oesophagus showed no impressions of anomalous coursing vessels (4). The clinical symptoms subsided gradually; one month later, the child was found to be in excellent condition; breath sounds over the right lung were still harsher than over the left one, and the increased transradiancy of the right lung with the mediastinum displaced toward left, were unchanged.
DISCUSSION Embryological considerations The origin of the respiratory tract is from the foregut, beginning in the fourth week when the embryo is 3 mm long. During its early development, the foregut divides into a posterior part, from which the gastrointestinal tract develops, Actn Pzdiatr Scand 64
tAF.1
trn,.t
‘“lY ” aLL’
The tracheobronchial which originates in the Dharvnx subseauentlv divides into two primary bronchial branches. These Primary bronchial branches penetrate the mesenchvme, and during ., their growth further ramification into segmental bronchi, bronchioli, terminal bronchi, and alveoli takes Dlace (7). According to Bremer ( l ) , the tracheal bronchus is a stage Of normal development Of *
I
