Tracheobronchomalacia in pediatric patients with esophageal atresia: comparison of diagnostic laryngoscopy/bronchoscopy and dynamic airway multidetector computed tomography.
OBJECTIVE
Diagnostic laryngoscopy and bronchoscopy (DLB) has been the traditional preoperative diagnostic modality for evaluating presence and severity of tracheobronchomalacia (TBM), and requires anesthesia. Alternatively, multidetector computed tomography (MDCT) is potentially a noninvasive modality that provides high-resolution, 3-dimensional (3D) imaging of the thorax providing preoperative guidance for pediatric surgeons. This study compares MDCT with intraoperative DLB in the assessment of TBM in symptomatic pediatric patients with esophageal atresia (EA).


METHODS
Following IRB approval all pediatric patients (≤18 years) who had EA and who underwent an MDCT study as a preoperative evaluation of TBM prior to aortopexy were retrospectively reviewed. Patients with incomplete reports on intraoperative DLB or MDCT studies were excluded. Two pediatric radiologists independently evaluated all MDCT studies in a blinded fashion. On both DLB and MDCT studies, TBM was scored as present or absent in five anatomic segments: upper, middle, and lower trachea, as well as right and left main stem bronchi. Operative reports including DLB findings were reviewed and compared to findings from MDCT study using the chance corrected kappa (κ) coefficient. Diagnostic accuracy of dynamic MDCT for detecting TBM was determined by sensitivity and specificity, and interobserver agreement between two radiology reviewers was measured by the kappa statistic.


RESULTS
The final study population included 18 patients (8 males and 10 females) with ages ranging from 1month to 11years (median: 7 months). Their presenting clinical symptoms included apneic spells (n=15, 83%) and failure to extubate (n=3, 17%). The overall diagnostic accuracy of dynamic airway MDCT compared to DLB was 91% (82/90 possible segments for TBM) with excellent overall agreement across all 5 anatomic segments (κ=0.82, p<0.001). The agreements for upper, mid, lower trachea, and right and left trachea were 89% (κ=0.73, p<0.001), 94% (κ=0.85, p<0.001), 89% (κ=0.76, p<0.001), 94% (κ=0.82, p<0.001), and 89% (κ=0.61, p=0.005); respectively. Interobserver agreement between two radiologists was excellent (κ=0.98, 95% confidence interval: 0.94-1.00, p<0.001) with only 1 disagreement between two radiologists that was found for the left main bronchus. Fifteen (83.3%) of the patients clinically improved after the aortopexy.


CONCLUSIONS
MDCT with 3D imaging is a highly accurate and reliable preoperative noninvasive imaging modality for evaluating TBM in pediatric patients with EA providing anatomic information consistent with and complimentary to bronchoscopy.
Department of Surgery, Faculty of Medicine Siriraj Hospital, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand.
Monawat
M
Ngerncham
Departments of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
Edward Y
EY
Lee
Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
David
D
Zurakowski
Department of Radiology, Tufts University School of Medicine, 750 Washington Street, Boston, MA 02111, USA.
Donald A
DA
Tracy
Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA. Electronic address: russell.jennings@childrens.harvard.edu.
Russell
R
Jennings
D001999:Bronchoscopy / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D004933:Esophageal Atresia / Q000150:complications* / Q000453:epidemiology; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007828:Laryngoscopy / Q000379:methods*; D008297:Male; D061330:Multidetector Computed Tomography / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D055089:Tracheobronchomalacia / Q000175:diagnosis / Q000453:epidemiology*; D014481:United States / Q000453:epidemiology
Bronchomalacia; Diagnostic laryngoscopy and bronchoscopy; Dynamic airway study; Esophageal atresia; Multidetector computed tomography; Pediatric patients; Tracheobronchomalacia; Tracheomalacia