Aspiration and Dysphagia in the Neonatal Patient.

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Laryngotracheal separation in neonatal brainstem dysfunction.

INTRODUCTION: Neonatal brainstem dysfunction (NBD) associates four symptoms of variable presence and intensity: suction-swallowing dysfunction, abnormal laryngeal sensitivity and motility, gastroesophageal reflux, and cardiac vagal overactivity. MATERIALS AND METHODS: We report three cases of severe NBD with chronic aspiration which required surgical management. Successive failures and clinical deterioration led us to perform laryngotracheal separation. The surgical procedure consisted in suturing the distal segment of the trachea to the cervical skin after complete closure of the larynx. RESULTS: After surgery, these children did not present any pulmonary infection and were allowed oral nutrition. However, oral communication was no longer possible. Although it is a theoretically reversible procedure, the decision is ethically difficult in children free of mental deficiency, because of the vocal loss and the unpredictable NBD outcome. CONCLUSION: Laryngotracheal separation may be recommended after multidisciplinary decision for severe chronic aspiration in the particular case of children presenting with NBD.

[Congenital laryngotracheo-esophageal cleft: diagnosis and surgical treatment by anterior, translaryngeal approach]. / Die kongenitale, laryngotracheo-ösophageale Spaltbildung: Diagnostik und operative Behandlung über einen anterioren, translaryngealen Zugang.

BACKGROUND: Laryngotracheoesophageal cleft is a rare but potentially life-threatening anomaly. Less than 200 cases have been published to date. Both the diagnostic and therapeutic recommendations are discussed controversially in the international literature. PATIENT: We report on the diagnostic and surgical management of a type III cleft larynx in a one month old male presenting with aspiration, pneumonia, and aphonia. Hypoplasia of the cricoarytenoid muscles was associated to the cleft. Rigid endoscopy was found to be the best tool for the diagnostic exploration of the cleft, whereas flexible endoscopy failed to detect the defect. The cleft was broadly exposed using a modified anterior translaryngeal approach that included a tracheostomy. After debriding the mucosal margins, the defect was closed in two layers, and a t-shaped Montgomery tube was implanted. Two further revisions using the mentioned translaryngeal approach and one endoscopic procedure were necessary to achieve complete and permanent closure of the cleft. RESULTS: Twenty months after birth the boy is able to swallow thick and liquid food without any problems. Stable scar tissue has grown within the former cleft region. The vocal cords are somewhat thickened but mobile in a reduced range. Both the trachea and the esophagus show quite normal diameters. CONCLUSION: Considering the fact that the arytenoid cartilages touch or overlap each other a congenital defect within the posterior midline of the larynx can only be diagnosed by rigid endoscopy that spreads the cleft apart. In addition to our positive experiences with traumatic fistulas and stenosis of the juvenile trachea we recommend now the anterior vertical laryngeal incision for the operative management of the congenital type III cleft larynx. This direct open approach provides excellent exposure of all components of the defect without the risk of recurrent laryngeal nerve injury. Subglottic stenosis or impaired stability of the larynx described by other authors did not occur in this case. However, the postoperative period is relatively short and careful follow-up for a period of several years is therefore required.

Aventriculy: a new entity?

In an 11-year-old girl who had repeated episodes of aspiration pneumonia, no lateral ventricles and no third or fourth ventricle could be identified on T1-, T2-, or proton density-weighted MR images. This condition was associated with failure of midline cleavage of the cerebral hemispheres, rhombencephalosynapsis, and complex migrational disorders.

Staphylectomy for treatment of dorsal displacement of the soft palate in two foals.

Dorsal displacement of the soft palate associated with dysphagia and aspiration pneumonia was diagnosed in 2 young foals. The displacement appeared to be congenital. Clinical signs associated with the condition were resolved after staphylectomy. Dorsal displacement of the soft palate is usually recognized in adult animals as an upper respiratory tract disease, but may be a contributing factor to dysphagia and lower respiratory tract disease in young animals.

Persistent fetal circulation: an evolving clinical and radiographic concept of pulmonary hypertension of the newborn.

The roentgenographic presentations of 11 newborn infants with hypoxemia secondary to pulmonary vasospasm and subsequent right-to-left shunting of blood through the foramen ovale and/or ductus arteriosus (persistent fetal circulation) are described (P. F. C. Syndrome). One infant had radiographically normal lungs, while ten had pulmonary parenchymal abnormalities including hyaline membrane disease [4], meconium aspiration syndrome [4], or an ill defined pattern of retained lung fluid [2]. The roentgenographic appearance of the lungs, however, was discordant with the severe hypoxemia observed in most. Heart size was variable but some degree of cardiomegaly was commonly present. Tolazoline, a potent vasodilator, was useful diagnostically and may have resulted in increased survival. An expanded clinical and roentgeonographic concept of the PFC syndrome is suggested.