Pediatr Radiol (1992) 22:522-524
Pediatric Radiology 9 Springer-Verlag 1992
Balloon dilatation of cricopharyngeal achalasia T. Mihailovic, V.N. Perisic Mother and Child Health Institute of Serbia, Beograd, Yugoslavia Received: 17 October 1990; accepted: 8 April 1992
Abstract. A 6-month-old male infant with difficulty swallowing, recurrent aspiration p n e u m o n i a and failure to thrive was diagnosed with cricopharyngeal achalasia. N o r m a l oral feeding and no further aspirations followed a single c a t h e t e r balloon dilatation.
Cricopharyngeal dysfunction (CD) is a cause of orop a h r y n g e a l dysphagia in infancy [1, 2]. It results f r o m two conditions: cricopharyngeal achalasia (CA), the failure of relaxation of the u p p e r esophageal sphincter (UES), and/or cricopharyngeal incoordination, the lack of coordination b e t w e e n the contraction of the p h a r y n g e a l contractors and the U E S relaxation [3, 4]. C r i c o p h a r y n g e a l dysfunction is usually m a n i f e s t e d by swallowing difficulties, n a s o p h a r y n g e a l regurgitation, choking, coughing and aspiration p n e u m o n i a [5, 6]. T h e diagnosis is usually m a d e by r a d i o g r a p h y [7, 8] and the standard t r e a t m e n t consists of cricopharyngeal m y o t o m y [8, 9] and forceful dilatations [10, 11]. We report the successful t r e a t m e n t of C A with a single balloon c a t h e t e r dilatation.
Case report A 6-month-old male infant was referred for evaluation of his swallowing difficulties, nasal regurgitation, choking and repeated aspiration pneumonia since the age of 6weeks. On several occasions he has been fed via nasogastric tube with improvement of his respiratory illness. At admission he weighed below the third percentile and his length was on the 50th percentile. Auscultation of the chest revealed diminished breath sounds and rales bilaterally. Laryngotracheobronchoscopy excluded palsy of the soft palate and/or vocal cord, and laryngotracheoesophageal cleft as possible causes of repeated aspiration pneumonia. Radiography of the pharyngeal phase of swallowing revealed dilatation of the hypopharynx while the epiglottis remained in the transverse position. The upper esophageal sphincter was constricted and during the examination did not relax (Fig. 1.). The posterior cricopharyngeal indentation was seen. As an initial therapeutic procedure UES balloon catheter dilatation was performed. Balloon catheter dilatation has previously been used in the treatment of esophageal stenosis [12, 13]. The pro-
cedure was done under general anesthesia in an intubated patient. A catheter was introduced through the mouth and positioned within the UES under fluoroscopic control. A soft tip angiographic guide wire was introduced across the constricted UES. After catheter removal, a 20mm deflated Polystan balloon dilator was advanced over the wire and positioned within the UES, then it was filled with dilated contrast (Renografin) and left in place for 3 min (Fig. 2). The size of the dilating balloon was chosen on the basis of the estimated caliber of the esophagus determined by the initial barium swallow. After dilatation, a small amount of barium was introduced into the hypopharynx to exclude a tear, and the patient was NPO for 24 h. Follow-up radiography done on the next day demonstrated normal passage of the barium through the pharynx and esophagus. However, the hypopharynx was still dilated and epiglottic dysfunction persisted (Fig.3). Follow-up examination at 6 months demonstrated no further swallowing difficulties nor aspirations.
Discussion In children i n c o m p l e t e relaxation, p r e m a t u r e closure or delayed relaxation (incoordination) of the U E S , epiglottic dysfunction, and paresis of p h a r y n g e a l constrictor musculature and of the soft palate are the principal causes of o r o p h a r y n g e a l dysphagia [6, 7, 14]. Cricop h a r y n g e a l dysfunction m a y be caused by either p r i m a r y U E S motility disorder or it m a y be associated with central n e r v o u s system diseases [15]. O t h e r diseases such as m y a s t h e n i a gravis and thyroid disease m a y be complicated with C D [3] and a transient f o r m of C D was r e p o r t e d in n e w b o r n s [5]. T h e diagnosis of C D is usually m a d e by r a d i o g r a p h y [7] and e s o p h a g e a l motility studies [14, 16]. Radiologic e x a m i n a t i o n of C A characteristically shows a p r o m i n e n t posterior horizontal indentation at the phar y n g o - e s o p h a g e a l junction [17]. H o w e v e r , in s o m e children with n o r m a l swallowing and e s o p h a g e a l motility such a cricopharyngeal bar m a y be an incidental transient X-ray finding. In some patients with n o r m a l peristaltic contraction of the p h a r y n x and an isolated cricopharyngeal bar, U E S m a n o m e t r i c studies m a y be n o r m a l [11, 15, 18]. T h e m a j o r
523
Fig. 1. Detail from the cine-radiographic examination of the pharynx during deglutition (oblique projection): the epiglottis (triangle) is tilted down to the transverse position. Contrast reaches into the trachea (t). A prominent cricopharyngeal bar (c) at the level of the UES limits normal opening of the UES Fig.2 Balloon dilatation of UES: fluoroscopically directed central constriction of balloon catheters dilatator in the area of UES (argo WS)
Fig.3. Detail from follow-up cineradiographic examination of the pharynx during deglutition 6 month after balloon dilatation of CA (oblique projection): continuous column of barium at the pharyngoesophageal junction (c-arrow), the epiglottis (triangle) is tilted down to the transverse position and contrast medium does not reach into the vestibule and trachea
abnormalities in the patients with cricopharyngeal bars were reduced maximal dimensions of U E S during the trans-sphincteric flow of barium and increased intra-bolus pressure upstream to U E S [18]. This m a y indicate that a prominent cricopharyngeal bar may be caused by impaired muscle compliance wherein the relaxed cricopharyngeus muscle did not expand normally during swallowing [18]. While standard m a n a g e m e n t of CA, U E S m y o t o m y and forceful dilatations in adult patients m a y provide relief [8, 15]. In infants and children this operation has been less rewarding [19]. L e r n a u and Dinari reported 3 infants successfully treated by repeated forceful dilatations with mercury bougies [10,11]. In our patient we report successful p e r f o r m e d balloon dilatation of the U E S in children. In CD this method increases the effectiveness of dilatation, because of applied axial forces. Fluoroscopically directed central constriction of the balloon catheter allows precise topography of the U E S and its successful dilatation. However, this procedure did not improve the dysfunction of the epiglottis nor did it normalize the hypopharyngeal caliber. T h e simple, quick and safe procedure enabled us to provide our patient with p r o m p t and long lasting relief of swallowing difficulties and repeated aspirations. In children with C A associated with tracheal aspiration we reco m m e n d balloon catheter dilatation of U E S as the initial therapeutic procedure.
References
Acknowledgement. The authors are thankful to Prof. Dr. J. A. Kirkpatrick Jr., for his great contribution to this paper.
1. Reichert TJ, Bluestone CD, Stool SE, Siber VK, Sieber AM (1977) Congenital cricopharyngeal achalasia. Ann Otol Rhinol Laryngo186:603 2. Utian HL, Thomas RG (1969) Cricopharyngeal incoordination in infancy. Pediatrics 43:402 3. Palmer ED (1976) Disorders of the cricopharyngeal muscle: a review. Gastroenterology 71:510 4. Hutwitz AL, Durabceau A (1978) Upper oesophageal sphincter dysfunction. Digest Dis 23:275 5. Frank MM, Baghadassarian, Gatewood O (1966) Transient pharyngeal incoordination in the newborn. Am J Dis Child 111: 178 6. Fisher SE, Paonter M, Milmoe G (1981) Swallowing disorders in infancy. Pediatr Clin North Am 28:845 7. Ekberg O, Nylander G (1982) Cineradiography of the pharyngeal stage of deglutition in 250 patients with dysphagia. Br J Radio155: 258 8. Ekberg O, Lindgren S (1987) Effect of cricopharyngeal myotomy on pharyngoesophageal function: pre and postoperative cineradiographic findings. Gastrointest Radiol 12:1 9. Helsper JT, Lance JS, Baldfidge ET, Vap JG (1974) Cricopharyngeal achalasia. Am J Surg 128:521 10. Lernau OZ, Sherzer E, Mogle R Nissan S (1984) Congenital cricopharyngeal achalasia treatment by dilatations. J Pediatr Surg 19:202 11. Dinari G, Danziger Y, Mimouni M, Rosenbach Y, Zahavi I, Grunebaum M (1987) Cricopharyngeal dysfunction in childhood; treatment by dilatations. J Pediatr Gastroenterol Nutr 6: 212 12. Hoffer FA, Winter HS, Fellows KE, Folkman J (1987) The treatment of postoperative and peptic esophageal strictures after esophageal atresia repair. A program including dilatation with balloon catheters. Pediatr Radio112:1
524 13. Sato Y, Frey EE, Smith WL, Pringle KC, Soper RT, Frangen E A JR (1988) Balloon dilatation of esophageal stenosis in children. A J R 150:639 14. Kramer SS (1985) Special swallowing problems in children. A J R 150:639 15. Malik MI, Schwarz KB, Kotagal S (1990) Syringomyelia presenting as cricopharyngeal pseudostricture. J Pediatr Gastroenterol Nutr 11:115 16. Hellemans J, Agg HO, Pelemans W, Vantrapen G (1981) Pharyngeal swallowing disorders and the pharyngeal sphincter. Med Clin North A M 65:114
17. Chriclow T V L (1956) The cricopharingeus in radiography and cineradiography. B r J Radio129:546 18. Dontas OR, Cook I J, Doods WJ, Kern MK, Lang IM, Brassur JG (1990) Biomechanics of cricopharyngeal achalasia and childhood. J Pediatr Surg 9:775 Dr. T. Mihailovic Mother and Child Health Institute of Serbia, St. Radoja Dakica 6-8 11070 Novi B eograd, Yugoslavia
Literature in pediatric radiology
Continued from p. 518
EuropeanJournalof Pediatrics (Berlin)
Neuroradiology(Berlin)
McKusick-Kaufman syndrome: the diagnostic challenge of abdominal distension in the neonatal period. Schaap, C. et al. (Dept. of Clinical Genetics, Academie Hosp., E O.Box 1475, NL-6201 BL Maastricht, The Netherlands) 151: 583 (1992) Robinow syndrome in two siblings from consanguineous parents. Schorderet, D. E et al. (Dept. of Microbiol. and Genetics, Univ. and H6pital cantonal Univ., 9, av. de Chm-npel,CH-1211 Geneva, Switzerland) 151:586 (1992) Convulsions, hemiparesis and central retinal artery occlusion due to left atrial myxoma in child.T6nz, M. et al. (Chnic for Cardiovascular Surg., Univ. Hosp., Ramistr 100, CH-8091 Ziirieh, Switzerland) 151:652 (1992) The role of sonography in the evaluation of gastrooesophageal reflux-correlation to pH-metry. Riccabona, M. et al. (Dept. of Paed., Univ., Auenbruggerplatz, A-g036 Graz, Austria) 151:655 (1992) Diagnosis of intralobar lung sequestration by colour-coded Doppler sonography. Deeg, K.H. et al. (Paed. Clinic, Bugerstr.80, W-8600 Barnberg, FRG) 151:710 (1992)
CT detection of basal ganglion lesions in neurofibromatosis type 1: correlation with MRI. Menor, E, Marti-Bonmati, L. (Serv. de Radiodiagn., Hosp. Infantil "La Fe", Av. Campanar, 21, E-46009 Valencia, Spain) 34:305 (1992) MRI ofaveryrarehereditaryectodermaldysplasia: PIBI(D)S. Peserico, A. et al. (Battistella, EA., Dept. of Ped., Univ., Via Giustiniani 3, 1-35128 Padova, Italy) 34:316 (1992) Childhood moyamoya disease before and after encephalo-duro-arterio-synangiosis: an augiographic study. Yamada, I. et al. (Dept. of Rad., School ofMed.,Med, and Dental Univ., 1-5-45 Yushima, Bunkyo-ku, Tokyo 113, Japan) 34:318 (1992) Cerebellopontine angle ganglioneuroblastoma. Sohma, T. et al. (Dept. of Neurosurg., City General Hosp., Kita-1, Nishi 9, Chuoku, Sapporo 060, Japan) 34:334 (1992)
EuropeanRadiology (Berlin) Juvenile intervertebral disc calcification. Rosenkrantz Grage, L., Egeblad, M. (Dept. of Orthop. and Rad., Hosp., Univ., Ndr. Ringvey, DK-2600 Glostrup, Denmark) 2:377 (1992)
Gyniikologe(Berlin) Perinatale Hirnsch~iden. Rtickschliisse zur A_tiologie. Schulte, EJ. (Kinderklinik, Univ.-Krankenhaus Eppendorf, Martinistr.52, W-2000Hamburg 20, FRG) 25:169 (1992)
Piidiatrische Praxis (Manchen) M6glichkeiten der farbkodierten Dopplersonographie im Kindesalter (2). Deeg, K.H. (Kinderklinik, Buger Str.80, W-8600 Bamberg, FRG) 44: 181 (1992) Das stumpfe Bauchtrauma im Kindesalter. Hasse, W. et al. (Eitel Fritz Str.35, W-1000 Berlin 38, FRG) 44:269 (1992) Rationelles diagnostisches Vorgehen und Therapie bei Coxitis fugax. Sennhauser, EH. et al. (Ostschweizerisches Kinderspital, Claudiusstr. 6, CH-9006 St. Gallen, Switzerland) 44:283 (1992)
Radiologe (Berlin) Integrated imaging of head and neck tumors in children. [In Germ.] Reither, M. et al. (Rad. Zentrum/Diagn., St~idt. Klinikum, Flurstr.17, W-8500 Niirnberg 91, FRG) 32:309 (1992) Indications for magnetic resonance tomography in the examination of space-occupying abdominal
lesions in children. [In Germ.] St6ver, B. et al. (Rad. Klinik, Albert-Ludwigs-Univ., Hugstetter Str.55, W-7800Freiburg i.Br., FRG) 32:314 (1992) Special features of sonographic findings in the thyroid in babies and children. [In Germ.] Klingmiiller, V. et al. (R6ntgenabt. Pfid., Klinikmla der JLU, Feulgenstr. 12, W-6300 Giegen, FRG) 32: 320 (1992) Aluminium intoxication in a non-dialysed infant treated with oral aluminium hydroxide. [In Germ.] Feldmann, B. et al. (F~irber, D., R6ntgenabt, der Kinderklinik der Techn. Univ., K/3Inerplatz 1, W-8000 Miinchen 40, FRG) 32:327 (1992) Diagnosis of complicationsinventriculo-peritone al and ventriculo-atrial shunts. [In Germ.] Langen, H.-J. et al. (Klinik fiir Rad. Diagn., Klinikum der RWTH, Pauwelsstr.30, W-5100 Aachen, FRG) 32:333 (1992) Digital luminescence radiography in prematures and term newborns-possibilities andlimitations. [In Germ.] B artsch, M., Richter, E. (R6ntgenabt. der Univ.-Kinderklinik Eppendorf, Martinistr.52, W-2000 Hamburg 20, FRG) 32:340 (1992)
Skeletal Radiology (Berlin) The periphysis and its effect on the metaphysis: 1.Definition and normal radiographic pattern. Oestreich, A. E. et al. (Dept. of Rad., Children's Hosp. Med. Center, Elland & Bethesda Av., Cincinnati, OH 45229-2899, USA) 21:283 (1992) Plain radiographic predictors of survival in treated Ewing's sarcoma. Reinus, W.R. et al. (Jewish Hosp. of Washington Univ. Med. Center, 216S Kingshighway, RO.Box 14109, St.Louis, MO 63178, USA) 21:287 (1992) continued on p. 526
Pediatric Radiology 9 Springer-Verlag 1992
Balloon dilatation of cricopharyngeal achalasia T. Mihailovic, V.N. Perisic Mother and Child Health Institute of Serbia, Beograd, Yugoslavia Received: 17 October 1990; accepted: 8 April 1992
Abstract. A 6-month-old male infant with difficulty swallowing, recurrent aspiration p n e u m o n i a and failure to thrive was diagnosed with cricopharyngeal achalasia. N o r m a l oral feeding and no further aspirations followed a single c a t h e t e r balloon dilatation.
Cricopharyngeal dysfunction (CD) is a cause of orop a h r y n g e a l dysphagia in infancy [1, 2]. It results f r o m two conditions: cricopharyngeal achalasia (CA), the failure of relaxation of the u p p e r esophageal sphincter (UES), and/or cricopharyngeal incoordination, the lack of coordination b e t w e e n the contraction of the p h a r y n g e a l contractors and the U E S relaxation [3, 4]. C r i c o p h a r y n g e a l dysfunction is usually m a n i f e s t e d by swallowing difficulties, n a s o p h a r y n g e a l regurgitation, choking, coughing and aspiration p n e u m o n i a [5, 6]. T h e diagnosis is usually m a d e by r a d i o g r a p h y [7, 8] and the standard t r e a t m e n t consists of cricopharyngeal m y o t o m y [8, 9] and forceful dilatations [10, 11]. We report the successful t r e a t m e n t of C A with a single balloon c a t h e t e r dilatation.
Case report A 6-month-old male infant was referred for evaluation of his swallowing difficulties, nasal regurgitation, choking and repeated aspiration pneumonia since the age of 6weeks. On several occasions he has been fed via nasogastric tube with improvement of his respiratory illness. At admission he weighed below the third percentile and his length was on the 50th percentile. Auscultation of the chest revealed diminished breath sounds and rales bilaterally. Laryngotracheobronchoscopy excluded palsy of the soft palate and/or vocal cord, and laryngotracheoesophageal cleft as possible causes of repeated aspiration pneumonia. Radiography of the pharyngeal phase of swallowing revealed dilatation of the hypopharynx while the epiglottis remained in the transverse position. The upper esophageal sphincter was constricted and during the examination did not relax (Fig. 1.). The posterior cricopharyngeal indentation was seen. As an initial therapeutic procedure UES balloon catheter dilatation was performed. Balloon catheter dilatation has previously been used in the treatment of esophageal stenosis [12, 13]. The pro-
cedure was done under general anesthesia in an intubated patient. A catheter was introduced through the mouth and positioned within the UES under fluoroscopic control. A soft tip angiographic guide wire was introduced across the constricted UES. After catheter removal, a 20mm deflated Polystan balloon dilator was advanced over the wire and positioned within the UES, then it was filled with dilated contrast (Renografin) and left in place for 3 min (Fig. 2). The size of the dilating balloon was chosen on the basis of the estimated caliber of the esophagus determined by the initial barium swallow. After dilatation, a small amount of barium was introduced into the hypopharynx to exclude a tear, and the patient was NPO for 24 h. Follow-up radiography done on the next day demonstrated normal passage of the barium through the pharynx and esophagus. However, the hypopharynx was still dilated and epiglottic dysfunction persisted (Fig.3). Follow-up examination at 6 months demonstrated no further swallowing difficulties nor aspirations.
Discussion In children i n c o m p l e t e relaxation, p r e m a t u r e closure or delayed relaxation (incoordination) of the U E S , epiglottic dysfunction, and paresis of p h a r y n g e a l constrictor musculature and of the soft palate are the principal causes of o r o p h a r y n g e a l dysphagia [6, 7, 14]. Cricop h a r y n g e a l dysfunction m a y be caused by either p r i m a r y U E S motility disorder or it m a y be associated with central n e r v o u s system diseases [15]. O t h e r diseases such as m y a s t h e n i a gravis and thyroid disease m a y be complicated with C D [3] and a transient f o r m of C D was r e p o r t e d in n e w b o r n s [5]. T h e diagnosis of C D is usually m a d e by r a d i o g r a p h y [7] and e s o p h a g e a l motility studies [14, 16]. Radiologic e x a m i n a t i o n of C A characteristically shows a p r o m i n e n t posterior horizontal indentation at the phar y n g o - e s o p h a g e a l junction [17]. H o w e v e r , in s o m e children with n o r m a l swallowing and e s o p h a g e a l motility such a cricopharyngeal bar m a y be an incidental transient X-ray finding. In some patients with n o r m a l peristaltic contraction of the p h a r y n x and an isolated cricopharyngeal bar, U E S m a n o m e t r i c studies m a y be n o r m a l [11, 15, 18]. T h e m a j o r
523
Fig. 1. Detail from the cine-radiographic examination of the pharynx during deglutition (oblique projection): the epiglottis (triangle) is tilted down to the transverse position. Contrast reaches into the trachea (t). A prominent cricopharyngeal bar (c) at the level of the UES limits normal opening of the UES Fig.2 Balloon dilatation of UES: fluoroscopically directed central constriction of balloon catheters dilatator in the area of UES (argo WS)
Fig.3. Detail from follow-up cineradiographic examination of the pharynx during deglutition 6 month after balloon dilatation of CA (oblique projection): continuous column of barium at the pharyngoesophageal junction (c-arrow), the epiglottis (triangle) is tilted down to the transverse position and contrast medium does not reach into the vestibule and trachea
abnormalities in the patients with cricopharyngeal bars were reduced maximal dimensions of U E S during the trans-sphincteric flow of barium and increased intra-bolus pressure upstream to U E S [18]. This m a y indicate that a prominent cricopharyngeal bar may be caused by impaired muscle compliance wherein the relaxed cricopharyngeus muscle did not expand normally during swallowing [18]. While standard m a n a g e m e n t of CA, U E S m y o t o m y and forceful dilatations in adult patients m a y provide relief [8, 15]. In infants and children this operation has been less rewarding [19]. L e r n a u and Dinari reported 3 infants successfully treated by repeated forceful dilatations with mercury bougies [10,11]. In our patient we report successful p e r f o r m e d balloon dilatation of the U E S in children. In CD this method increases the effectiveness of dilatation, because of applied axial forces. Fluoroscopically directed central constriction of the balloon catheter allows precise topography of the U E S and its successful dilatation. However, this procedure did not improve the dysfunction of the epiglottis nor did it normalize the hypopharyngeal caliber. T h e simple, quick and safe procedure enabled us to provide our patient with p r o m p t and long lasting relief of swallowing difficulties and repeated aspirations. In children with C A associated with tracheal aspiration we reco m m e n d balloon catheter dilatation of U E S as the initial therapeutic procedure.
References
Acknowledgement. The authors are thankful to Prof. Dr. J. A. Kirkpatrick Jr., for his great contribution to this paper.
1. Reichert TJ, Bluestone CD, Stool SE, Siber VK, Sieber AM (1977) Congenital cricopharyngeal achalasia. Ann Otol Rhinol Laryngo186:603 2. Utian HL, Thomas RG (1969) Cricopharyngeal incoordination in infancy. Pediatrics 43:402 3. Palmer ED (1976) Disorders of the cricopharyngeal muscle: a review. Gastroenterology 71:510 4. Hutwitz AL, Durabceau A (1978) Upper oesophageal sphincter dysfunction. Digest Dis 23:275 5. Frank MM, Baghadassarian, Gatewood O (1966) Transient pharyngeal incoordination in the newborn. Am J Dis Child 111: 178 6. Fisher SE, Paonter M, Milmoe G (1981) Swallowing disorders in infancy. Pediatr Clin North Am 28:845 7. Ekberg O, Nylander G (1982) Cineradiography of the pharyngeal stage of deglutition in 250 patients with dysphagia. Br J Radio155: 258 8. Ekberg O, Lindgren S (1987) Effect of cricopharyngeal myotomy on pharyngoesophageal function: pre and postoperative cineradiographic findings. Gastrointest Radiol 12:1 9. Helsper JT, Lance JS, Baldfidge ET, Vap JG (1974) Cricopharyngeal achalasia. Am J Surg 128:521 10. Lernau OZ, Sherzer E, Mogle R Nissan S (1984) Congenital cricopharyngeal achalasia treatment by dilatations. J Pediatr Surg 19:202 11. Dinari G, Danziger Y, Mimouni M, Rosenbach Y, Zahavi I, Grunebaum M (1987) Cricopharyngeal dysfunction in childhood; treatment by dilatations. J Pediatr Gastroenterol Nutr 6: 212 12. Hoffer FA, Winter HS, Fellows KE, Folkman J (1987) The treatment of postoperative and peptic esophageal strictures after esophageal atresia repair. A program including dilatation with balloon catheters. Pediatr Radio112:1
524 13. Sato Y, Frey EE, Smith WL, Pringle KC, Soper RT, Frangen E A JR (1988) Balloon dilatation of esophageal stenosis in children. A J R 150:639 14. Kramer SS (1985) Special swallowing problems in children. A J R 150:639 15. Malik MI, Schwarz KB, Kotagal S (1990) Syringomyelia presenting as cricopharyngeal pseudostricture. J Pediatr Gastroenterol Nutr 11:115 16. Hellemans J, Agg HO, Pelemans W, Vantrapen G (1981) Pharyngeal swallowing disorders and the pharyngeal sphincter. Med Clin North A M 65:114
17. Chriclow T V L (1956) The cricopharingeus in radiography and cineradiography. B r J Radio129:546 18. Dontas OR, Cook I J, Doods WJ, Kern MK, Lang IM, Brassur JG (1990) Biomechanics of cricopharyngeal achalasia and childhood. J Pediatr Surg 9:775 Dr. T. Mihailovic Mother and Child Health Institute of Serbia, St. Radoja Dakica 6-8 11070 Novi B eograd, Yugoslavia
Literature in pediatric radiology
Continued from p. 518
EuropeanJournalof Pediatrics (Berlin)
Neuroradiology(Berlin)
McKusick-Kaufman syndrome: the diagnostic challenge of abdominal distension in the neonatal period. Schaap, C. et al. (Dept. of Clinical Genetics, Academie Hosp., E O.Box 1475, NL-6201 BL Maastricht, The Netherlands) 151: 583 (1992) Robinow syndrome in two siblings from consanguineous parents. Schorderet, D. E et al. (Dept. of Microbiol. and Genetics, Univ. and H6pital cantonal Univ., 9, av. de Chm-npel,CH-1211 Geneva, Switzerland) 151:586 (1992) Convulsions, hemiparesis and central retinal artery occlusion due to left atrial myxoma in child.T6nz, M. et al. (Chnic for Cardiovascular Surg., Univ. Hosp., Ramistr 100, CH-8091 Ziirieh, Switzerland) 151:652 (1992) The role of sonography in the evaluation of gastrooesophageal reflux-correlation to pH-metry. Riccabona, M. et al. (Dept. of Paed., Univ., Auenbruggerplatz, A-g036 Graz, Austria) 151:655 (1992) Diagnosis of intralobar lung sequestration by colour-coded Doppler sonography. Deeg, K.H. et al. (Paed. Clinic, Bugerstr.80, W-8600 Barnberg, FRG) 151:710 (1992)
CT detection of basal ganglion lesions in neurofibromatosis type 1: correlation with MRI. Menor, E, Marti-Bonmati, L. (Serv. de Radiodiagn., Hosp. Infantil "La Fe", Av. Campanar, 21, E-46009 Valencia, Spain) 34:305 (1992) MRI ofaveryrarehereditaryectodermaldysplasia: PIBI(D)S. Peserico, A. et al. (Battistella, EA., Dept. of Ped., Univ., Via Giustiniani 3, 1-35128 Padova, Italy) 34:316 (1992) Childhood moyamoya disease before and after encephalo-duro-arterio-synangiosis: an augiographic study. Yamada, I. et al. (Dept. of Rad., School ofMed.,Med, and Dental Univ., 1-5-45 Yushima, Bunkyo-ku, Tokyo 113, Japan) 34:318 (1992) Cerebellopontine angle ganglioneuroblastoma. Sohma, T. et al. (Dept. of Neurosurg., City General Hosp., Kita-1, Nishi 9, Chuoku, Sapporo 060, Japan) 34:334 (1992)
EuropeanRadiology (Berlin) Juvenile intervertebral disc calcification. Rosenkrantz Grage, L., Egeblad, M. (Dept. of Orthop. and Rad., Hosp., Univ., Ndr. Ringvey, DK-2600 Glostrup, Denmark) 2:377 (1992)
Gyniikologe(Berlin) Perinatale Hirnsch~iden. Rtickschliisse zur A_tiologie. Schulte, EJ. (Kinderklinik, Univ.-Krankenhaus Eppendorf, Martinistr.52, W-2000Hamburg 20, FRG) 25:169 (1992)
Piidiatrische Praxis (Manchen) M6glichkeiten der farbkodierten Dopplersonographie im Kindesalter (2). Deeg, K.H. (Kinderklinik, Buger Str.80, W-8600 Bamberg, FRG) 44: 181 (1992) Das stumpfe Bauchtrauma im Kindesalter. Hasse, W. et al. (Eitel Fritz Str.35, W-1000 Berlin 38, FRG) 44:269 (1992) Rationelles diagnostisches Vorgehen und Therapie bei Coxitis fugax. Sennhauser, EH. et al. (Ostschweizerisches Kinderspital, Claudiusstr. 6, CH-9006 St. Gallen, Switzerland) 44:283 (1992)
Radiologe (Berlin) Integrated imaging of head and neck tumors in children. [In Germ.] Reither, M. et al. (Rad. Zentrum/Diagn., St~idt. Klinikum, Flurstr.17, W-8500 Niirnberg 91, FRG) 32:309 (1992) Indications for magnetic resonance tomography in the examination of space-occupying abdominal
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Skeletal Radiology (Berlin) The periphysis and its effect on the metaphysis: 1.Definition and normal radiographic pattern. Oestreich, A. E. et al. (Dept. of Rad., Children's Hosp. Med. Center, Elland & Bethesda Av., Cincinnati, OH 45229-2899, USA) 21:283 (1992) Plain radiographic predictors of survival in treated Ewing's sarcoma. Reinus, W.R. et al. (Jewish Hosp. of Washington Univ. Med. Center, 216S Kingshighway, RO.Box 14109, St.Louis, MO 63178, USA) 21:287 (1992) continued on p. 526
