Newborn with inability to pass nasogastric tube through the nose

CT of pyriform aperture stenosis — Axial CT without contrast of the face shows narrowing of the pyriform apertures bilaterally.

The diagnosis was pyriform aperture stenosis.

Our DDX For This Week Is

Starting a pediatric radiology rotation, preparing to take call, or in need of a pediatric radiology review?

Clicking on Intro/Review will take you to a course intended to provide:

An introduction to pediatric radiology for residents studying it for the first time
A focused review of pediatric radiology for residents preparing to take call
A practical review of pediatric radiology for the radiologist in practice

Try it at PediatricImaging.org/intro/

School ager with large soft tissue masses involving the right arm and chest

Clinical image of neurofibromatosis type 1 with chest wall and arm plexiform neurofibromas — Clinical image shows extensive, large soft tissue masses involving the right arm and chest wall.

The diagnosis was Neurofibromatosis type 1 with multiple plexiform neurofibromas of the right arm and chest wall.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Toddler with abdominal distension 2 days after gastrojejunostomy tube placement

AXR and gastrojejunostomy tube injection of pneumoperitoneum due to malposition of the gastrojejunostomy tube outside of the bowel — Supine (above left) and left lateral decubitus (above right) AXR show no evidence of air between the abdominal wall and the liver but on the decubitus view several concerning air bubbles project over the liver and appear extra-lumenal. The gastrojejunostomy tube was exchanged for a gastrostomy tube and AP image from a gastrostomy tube injection with water soluble contrast (below) shows contrast extravasating inferiorly out of the duodenum at the junction of the second and third parts of the duodenum.

The diagnosis was initial malposition of the gastrojejunostomy tube outside of the bowel. In the operating room a perforation was found in the 4th part of the duodenum.

Infant with hemodynamic instability after gastrojejunostomy tube placement

AXR of pneumoperitoneum due to malposition of gastrojejunostomy tube outside of bowel — Supine AXR (above) shows the tip of the gastrojejunostomy tube extending deep into the pelvis. Left lateral decubitus AXR (below) shows air between the abdominal wall and the liver.

The diagnosis was initial malposition of the gastrojejunostomy tube outside of the bowel. In the operating room a perforation was found in the 4th part of the duodenum.

School ager not tolerating their jejunostomy tube feeds well

Gastrojejunostomy tube injection showing appropriate position of the tube tip — AP image from a jejunostomy tube injection shows the tip of the jejunostomy tube in the jejunum. Subsequent image showed no evidence of downstream small bowel obstruction.

The diagnosis was normal position of the tip of the gastrojejunostomy tube.

School ager status post gastrojejunostomy placement

AXR showing gastrojejunostomy tube in appropriate position — AXR shows the tip of the gastrostomy tube projecting over the stomach and the tip of the gastrojejunostomy tube projecting near the duodenal-jejunal junction.

The diagnosis was normal position of the tip of the gastrojejunostomy tube.

Teenager vomiting after gastrostomy tube feedings

Gastrostomy tube injection showing gastric outlet obstruction from gastrostomy balloon — AP image from a gastrostomy tube injection shows a round filling defect in the antrum of the stomach. Only an extremely small amount of contrast was seen to empty out of the stomach after 30 minutes.

The diagnosis was gastric outlet obstruction caused by the gastrostomy tube balloon

Infant who has just undergone a gastrostomy tube replacement which was technically difficult

Gastrostomy tube injection of gastromy tube malposition outside of stomach — AP image from a gastrostomy tube injection done with water soluble contrast (left) shows none of the injected contrast conforming to the lumenal contour of the stomach. AXR taken 15 minutes later (right) shows the extravasated contrast diffusing throughout the peritoneum and outlining loops of bowel and being excreted in the bladder.

The diagnosis was malposition of the gastrostomy tube replacement outside of the stomach.

Infant with vomiting after gastrostomy tube placement a week ago

Enema and gastrostomy tube injection showing gastrostomy tube that was placed through colon into stomach — AP image during an enema shows a fixed lumenal caliber change or filling defect caused by the gastrostomy tube balloon in the mid transverse colon. Early lateral image during gastrostomy tube injection with water soluble contrast (above right) shows the gastrostomy balloon and tip within the stomach. Later lateral image during gastrostomy tube injection (below right) shows contrast refluxing back from the stomach along the gastrostomy tube tract into the colon which is anterior to the stomach.

The diagnosis was initial malposition of the gastrostomy tube through the colon and then into the stomach.

Newborn with esophageal atresia with abdominal distension after gastrostomy tube placement 1 week ago

AXR of pneumoperitoneum due gastrostomy tube malposition causing gastric perforation — Supine AXR (left) shows a gastrostomy tube projecting appropriately over the stomach with a triangular lucency superior to the stomach. Left lateral decubitus AXR (above right) again shows the triangular lucency superior to the stomach but does not show air between the abdominal wall and liver. Cross-lateral AXR (below right) shows air between the anterior abdominal wall and liver.

The diagnosis was pneumoperitoneum due to gastric perforation after gastrostomy placement. In the operating room the patient was found to have ischemic necrosis of the greater curvature of the stomach.

Our DDX For This Week Is

Infant with abnormal facies and congenital heart disease

Surgical image of absent thymus in DiGeorge syndrome — Pathologic image shows near-complete absence of the thymus.

The diagnosis was DiGeorge syndrome

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Toddler with respiratory distress

CXR and CT of lymphatic malformation of the thymus — CXR AP obtained intially (left) shows a normal appearing exam with a normal appearing thymus. CXR AP obtained 10 days later for continued respiratory distress (right) showed interval development of an anterior mediastinal mass. Axial+coronal CT with contrast of the chest shows a large low density anterior mediastinal mass with multiple thin septations.

The diagnosis was lymphatic malformation of the thymus which had bled in the interval between the two exams.

School ager who fell on to her right shoulder

CXR and CT of teratoma of thymus — CXR AP+lateral shows a large anterior mediastinal mass. Axial CT with contrast of the chest shows a heterogenous mass containing low density fat and high density calcium.

The diagnosis was teratoma of the thymus.

School ager with respiratory distress

CXR and CT of thymic cyst — CXR AP shows an abnormal contour to the left superior mediastinum in the region of the aortic arch which is too prominent for the patient’s age. Axial CT with contrast of the chest shows a low density lesion within the thymus compressing the brachiocephalic vein.

The diagnosis was thymic cyst.

School ager with respiratory distress

CXR and CT of Hodgkins lymphoma with infiltration of the thymus — CXR AP+lateral shows a large mass filling the anterior mediastinum which is seen to be homogeneous in appearance on the axial CT with contrast of the chest.

The diagnosis was Hodgkins lymphoma with infiltration of the thymus.

School ager with malaise

CXR of acute lymphocytic leukemia with infiltration of the thymus — CXR AP+lateral shows a large anterior mediastinal mass centered in the region of the thymus.

The diagnosis was acute lymphocytic leukemia with infiltration of the thymus.

Infant who was ill one month ago and now has recovered and presents for followup

CXR of thymic rebound — CXR AP from one month ago (left) shows evidence of a right lower lobe infiltrate and right pleural effusion due to bacterial pneumonia. The superior mediastinum is narrow. CXR AP taken today (right) shows resolution of the pneumonia and interval reappearance of the thymus.

The diagnosis was thymic rebound.

Newborn with abnormal facies and respiratory distress

CXR of absent thymus in DiGeorge Syndrome — CXR AP shows a very narrow superior mediastinum while on the lateral view the anterior mediastinum appears empty.

The diagnosis was an absent thymus due to DiGeorge syndrome

Preschooler with left neck mass

US and CT of cervical thymus — Transverse+sagittal US of the neck (above) shows the mass to have a starry sky appearance. Axial+coronal CT with contrast of the neck shows the mass to be inferior to the thyroid and contiguous with the thymus.

The diagnosis was cervical thymus.

Newborn with respiratory distress

CXR of a prominent thymus — CXR AP+lateral shows an anterior mediastinal mass without a thymic wave or thymic sail sign that was confirmed on US to be normal thymic tissue.

The diagnosis was prominent thymus.