[size=20px]A four-month old former term baby boy has had two episodes of presumed aspiration pneumonitis. He frequently coughs and sputters during feeding. There is no history of vomiting. Physical exam is normal. A video fluoroscopic swallow study shows a normal swallowing mechanism and coordination. A pull back esophagram and upper gastrointestinal series shows no anatomic abnormality of the esophagus, stomach or duodenum with a single episode of reflux to the mid esophagus. An esophageal pH probe is within normal limits.

 

In this infant with recurrent aspiration, the investigation most likely to yield a definitive diagnosis is

 

A high resolution computerized tomography scan of the neck and chest.

 

B esophageal manometry.

 

C oral administration of radiolabeled formula with nuclear scanning (including gastric emptying time).

 

D laryngoscopy and rigid bronchoscopy.

 

E flexible esophagogastroduodenoscopy.[/size]

D

(Untitled)

 

D

D

correct answer

D laryngoscopy and rigid bronchoscopy.

 

Recurrent aspiration in a baby suggests primary aspiration, secondary aspiration due to gastroesophageal reflux or more uncommon causes such as an H-type tracheoesophageal fistula (TEF). In the case described, primary aspiration was initially suspected because of the symptoms observed during feeding but a normal video fluoroscopic swallowing study makes primary aspiration unlikely. Gastroesophageal reflux is very common in infants but a normal esophageal pH probe makes severe reflux with aspiration pneumonia unlikely. The upper gastrointestinal (UGI) series findings of reflux are not diagnostic of clinically significant reflux.

 

Since the more common diagnoses seem unlikely, H-type TEF should be suspected and specifically investigated. While the unremarkable UGI reliably excludes most anatomic abnormalities it does not completely exclude H-type TEF since the accuracy of an UGI for this diagnosis is dependent upon the size and location of the fistula and the precise technique of the study. A dedicated pull back esophagram may identify a fistula not seen by an UGI but is not one hundred percent accurate so if TEF is still suspected the next investigation would be direct laryngoscopy and rigid bronchoscopy to specifically look for a laryngeal cleft (although a laryngeal cleft that was not associated with swallowing difficulty and primary aspiration would probably not need surgical intervention) and fistula in the posterior membranous trachea.

 

High resolution computerized tomography scanning of the neck and chest has been reported to identify primary and recurrent TEFs in older patients but it is not currently recommended for infants because of the radiation exposure and unclear efficacy in this age group. Esophageal manometry would be used to investigate unusual motility disorders such as achalasia. Nuclear medicine feeding study might show aspiration into the lungs but would not help pinpoint the cause. Esophagoscopy (flexible or rigid) is not as likely to identify a TEF as bronchoscopy.