Upper Gastrointestinal Tract Mass and Respiratory Failure in a Newborn

Abstract

Upper gastrointestinal tract mass and respiratory failure in a newbornThe infant was switched to high-frequency jet ventilation on postnatal day three. Her respiratory condition improved, with interval enlargement of the air-filled mediastinal abnormality on follow-up radiograph (Fig. 2). Thoracic computed tomography (CT) scan without intravenous contrast revealed a well-defined air-fluid lesion occupying the superior and middle mediastinum. No pneumomediastinum was noted (Fig. 3).Mediastinal mass with respiratory distress:(due to traumatic placement of the nasogastric tube in the delivery room)Chest radiography with contrast media administration through the nasogastric tube demonstrates a well-defined, right-sided mediastinal diverticular abnormality but no communication with the airway (Fig 4).The pouch is aspirated and dye moves freely from the esophagus to the stomach. Esophageal atresia is ruled out (Fig. 5).Endoscopy confirms a laceration of the soft tissue surrounding the diverticulum.Esophageal perforation in the newborn is a rare complication of vigorous pharyngeal suctioning or traumatic intubation during resuscitation. Some cases present as esophageal atresia or, as in this case, pneumomediastinum. Misinterpretation of the initial signs and symptoms may lead to inadequate investigation or therapeutic procedures. Traumatic perforation of the pharyngoesophageal region in the newborn was reported initially by Eklof and associates in 1969. Since then, it has been mentioned increasingly as a possible complication of neonatal resuscitation. Nevertheless, obstetricians, neonatologists, and pediatric surgeons do not seem to be sufficiently aware of this complication. Mollitt and colleagues described three types of injuries associated with esophageal perforation: a pharyngeal pseudodiverticulum created by a local cervical leak (as in this patient), a posterior extending mucosal perforation parallel to the esophagus, and free intrapleural perforation in which there is evident air leakage.The mechanism of injury is believed to be due to the neonatal upper gastrointestinal anatomy and resuscitative measures undertaken in the neonatal nursery or delivery room. The introitus to the esophagus is the narrowest region of the organ, and spasm of the cricopharyngeal muscle during instrumentation may close the lumen. Extension of the neck with instrument placement compresses the esophageal wall against a cervical vertebra, which increases the chance for a submucosal tear. A submucosal tear enables subsequent misplacement of a nasogastric tube.Esophageal perforation is a very rare event in neonates. The differential diagnosis must include a rare true diverticulum and esophageal duplication or perforation of an upper pouch in esophageal atresia as a complication of continuous suction. Traumatic esophageal perforation or formation of an esophageal diverticulum may occur due to nasogastric intubation, suction catheters, direct trauma from a probing finger tip, or attempts at laryngoscopy. A history of polyhydramnios, repeated attempts at intubation, vigorous suctioning, and blood on the tip of a catheter can help to differentiate between esophageal atresia and perforation. Pneumomediastinum, pneumothorax, air-fluid level, and subcutaneous emphysema on radiograph suggest perforation. The diagnosis must be confirmed with a contrast study using water-soluble contrast medium. The true nature of this condition remains unrecognized, and babies may be referred to the neonatal intensive care unit following a tentative diagnosis of esophageal atresia or pneumomediastinum. Raising awareness of the possibility of this injury should help to avoid this complication by gentle and skillful action during newborn resuscitation, particularly in the preterm infant.The diagnosis of pharyngoesophageal perforation may be confirmed by chest radiography, CT scan, and careful contrast esophagography using water-soluble contrast. In this patient, an air-filled structure of the upper mediastinum was seen on chest radiography as a structure containing an air-fluid level that initially was misdiagnosed as pneumomediastinum or pneumatocele. The CT scan was performed to characterize the lesion. Esophagoscopy was used to rule out true esophageal diverticulum, even though esophagoscopy has not been found to be useful for diagnosing neonatal acute pharyngoesophageal injury and perforation because it actually may increase the size of the perforation.Esophageal perforation in the adult is a serious and often catastrophic condition, but seems to be less so in neonates. Children who have iatrogenic pharyngoesophageal perforation should be treated according to each individual situation. The trend has been toward nonsurgical treatment, especially in the infant who has only submucosal perforation, which tends to be self-healing. Withholding oral feedings and administering a 10-day course of intravenous broad-spectrum antibiotics may improve patient outcomes, as indicated by repeat esophagography performed 21 days after the initial diagnosis in this case, documenting a normal esophagus and disappearance of the pseudodiverticulum.Complications correlate with the type of injury. Respiratory failure may present due to tension pneumothorax, infection, and abcess formation. Cervical perforation and dissection causes edema and obstruction of the upper third of the esophagus.JoDee M. Anderson, MD, Division of Neonatal Medicine, Oregon Health & Science University, Portland, Ore.