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Introduction To Aero Digestive Tract Disorders In Children
Respiratory symptoms in children are very common issues faced by all pediatric physicians in daily practice. Many of them present with complex symptoms and needs special interest to assess evaluate and manage such cases. In such children, though the symptoms being primarily respiratory, evaluation of Aero-Digestive tract is mandatory to come to a definitive diagnosis.
Aero-digestive tract is common anatomical area further leading to both airway and upper digestive tracts separately. Evaluation of one cannot be complete without the other. Evaluation of airway, breathing and swallowing disorders caused by problems in the aero digestive tract (throat, esophagus ) is very important in such cases. These disorders pose a great challenge to diagnosis due to difficult, dynamic & constantly changing anatomy, overlapping areas of specialties, lack of proper knowledge of abnormalities, difficulties in evaluation and post operative care. It needs multidisciplinary efforts to yield good outcome.
This is an effort to create awareness about these overlooked abnormalities.
Symptoms that indicate an aerodigistive disorder, include:
- Chronic cough
- Chocking when eating,
- Feeding difficulties
- Noisy breathing
- Persistent Wheezing
- Persistent Pneumonia
- Persistent Stridor
- Hemoptysis
- Dysphagia
- In co-ordinated swallowing
- Recurrent croup
- Resistant asthma
- Recurrent respiratory infections
- Obstructive Sleep Apnea (OSA)
- Nighttime cough
- Exercise induced shortness of breath
- Sleep disordered breathing
Conditions affecting this area –
The Aero digestive disorders include the abnormalities of organs and tissues of the respiratory tract and the upper part of the digestive tract. Many uncommon abnormalities result, when the septum between esophagus and trachea fails to develop fully, both in larynogotracheal tree and pharyngoesophagus. Congenital abnormalities of the trachea and bronchi may create serious respiratory problems from birth. Such abnormalities are diagnosed with increasing frequency as a result of advances in the bronchoscopy and other imaging modalities. Examples of commonly seen conditions include:
- Laryngeal and tracheal stenosis (airways too small and narrow)
- Subglottic stenosis
- Tracheostomy dependence
- Vocal cord paralysis
- Lung hypoplasia / agenesis
- Laryngeal web / cyst
- Laryngomalacia (floppy airways)
- Tracheomalacia
- Bronchomalacia
- Laryngeal cleft
- Bronchiectasis
- Bronchial compression
- Gastro esophageal reflux disease with breathing problems
- Congenital esophageal disorders with airway or breathing problems (e.g. TEF: tracheoesophageal fistula)
- Intrluminal obstructions (Papilloma, FB)
- Bronchopulmonary dysplasia and premature lung disease
- Chronic lung disease
- CHARGE syndrome and other conditions that affect neurologic and muscular control
- Eosinophilic Esophagitis (EE)
- Intestinal motility disorders
- Food Allergies
Diagnosis & Evaluation
To evaluate the abnormalities of this region is a real challenge. Detailed clinical history about each symptom may give clue to a probable area of affection. Thorough clinical examination will help to decide further modality of evaluation. Radiological evaluation gives clue to some static anatomical abnormalities but due to continuous movements of multiple organs, static images may not help in all situations. After this comes the direct under vision examination of this area by various endoscopic methods. Examination in awake condition and under anesthesia or sedation is mandatory to see the real time changes happening during breathing. This helps a lot to detect the actual quantum of severity and is also helpful in making therapeutic decisions to fix the problem. For children this type of evaluation needs, special equipments, sound knowledge of anatomy, physiology and pathology of pediatric airway abnormalities, monitoring & care, expert anesthesiologist and foresight of complications are must. Special diligence is required to monitor the child before, during & after the procedure. Flexible Bronchoscopy is mainly useful for the evaluation of Vocal cords & subglottic areas. Despite the advent of flexible bronchoscope, rigid bronchoscopy is still widely used. Various procedures used in the diagnosis and treatments of children with aero digestive issues include:
- Plain radiological films
- High resolution Chest CT scan with 3D airway reconstruction/analysis
- Cardiopulmonary testing
- Full spectrum of pulmonary function testing
- Overnight oximetry
- High resolution esophageal manometry with impedance
- MR scanning of brain and chest
- Exercise induced asthma challenge study
- Polysomnography (sleep studies)
- Esophagogastroduodenoscopy
- Modified swallow studies
- Upper GI barium studies
- Direct laryngoscopy
- Flexible bronchoscopy
- Bronchoalveolar lavage
- Endobronchial biopsy
- Rigid bronchoscopy
DR AMIT SITAPARA
MCh (Pediatric Surgery)
DNB (Pediatric Surgery)
www.bestpediatricsurgeon.com
E-mail: laxmirajkot@yahoo.com