VOL.

No.

109,

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UPPER

RESPIRATORY
IN INFANTS

TRACT
OBSTRUCTION
AND
CHILDREN*

By J. SCOTT

M.D.,

DUNBAR,

CALDWELL

LECTURE,

HE feelings
experienced
when
one is
asked to give the Ca/dwell
Lecture
can be
better imagined
than described.
I am pleased,
honored,
and thrilled.
May I, in presenting
this lecture
in honor
of a great physician
and pioneer
in radiology,
also pay tribute
to The American
Roentgen
Ray Society?
For many years
the Society
has
had my loyalty,
admiration,
and respect.
To
our President,
Dr. James
Cook,
who has
honored
me by the invitation
to present
todays
lecture,
I would
particularly
like to express
my gratitude,
and my feelings
of admiration
for
the splendid
work
he has done
in the
Society
and elsewhere,
and of warm and lasting friendship.
This is not the first time that a Canadian
has been asked
to give the Ca/dwell
Lecture,
and in reflecting
upon this, one is struck
by
the thought
that although
the border that separates
our two countries
is a geographic
and
Radiologic
respiratory
grams

examination

barium,

and

copy,

is

which

age
follows,

choanae,
trachea

the
will

their

diatri
*

number
group.

by

they

should

The

at the
Montreal

diseases
the

simple

often

upper

Seventieth
Childrens

Annual
Hospital,

and
on

lateral
importance

of normal
will
be pre-

sagittal
visualization,

Meeting
and

the

pe-

of the American
the Department

of Diagnostic

227

Ray

dysphagia

be

or

noted

and
since

Radiology,

and
lateral
about

coronal
can
the

on

outset

that

axis
also

that
position;
either
can
cause

structures

they
a
the

impair
false
may

be

airway.

Washington,
McGill

the

function,
choking

are
of particular
respiratory
tract

upper

normal
on

infras-

abnormality

or
at

children,
in true
rotation

the

Society,

and
the

or esophageal

be

superimposed
Roentgen

When

and
made
of

diagnosis,

indicates

suprasternal

roentgenograms
in the

of infants
should
be
few
degrees

in

the
tissues.

pharyngeal

there
may
feeding.
It should

radiologic

to

presence

soft

impairs

the

errors

of

ternal

respiratory

familiar

their

in
the
discussion

cause

of

drawing

of

larynx
emphasis

a number
variants

be

of

affecting

this

that
an obstruction
must
exist
and should
be radiologically
demonstrable.
The
signs
are inspiratorv
stridor
and
inspiratory
in-

fluoros-

diagnosis

the
with

signs

c radiologist;

Presented

1969.
From

of
In

however,
normal

clinical

obstruction

the

pharvnx,
be described,

since

diagnosis.
The

utilizing

1969

political
phenomenon
which cannot
be denied,
nonetheless
as we address
ourselves
to the
problems,
the duties,
and the pleasures
we
share as physicians
and as radiologists,
that
boundary
fades
and blurs to become
what we
diagnostic
radiologists
would
call an indistinct linear shadow
of no clinical
significance.
As one reads about Eugene
Ca/dwell,
ones
admiration
increases
for the man, his accomplishments,
and his character.
In him were
surely present
the ingredients
of greatness-a
brilliant
mind,
tremendous
energy
and stainma, a lively
imagination
which
gave rise to
numerous
innovations,
tenacity
of purpose,
a
wide
variety
of interests,
profound
understanding
of electricity
and engineering
as well
as of clinical
medicine,
and,
with
all this,
warmth
of personality
and great charm.
It is
fitting
that we are inspired
by and pay hoi,iage to the memory
of Eugene
Ca/dwell.

upper

roentgenoaddition

abnormalities

First,
and

sented,

with
to

recognition

means.
findings

the

plain
the

occasionally

applicable

considerable
pediatric

of

by

tract
sometimes

(C)

l.R.C.P.

University,

D.C.,

September
Montreal,Quebec,

30-October
Canada.

3,

J.Scott

228

Dunbar

JUNE,

1970

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The
normal
soft
tissues
of the posterior
pharvngeal
wall,
particularl\
in the
age
group
from
about
3 to 9 months,
is remarkably

mobile,

bulges
stri

into

the

kingly

equall

this

Rounded

simulating

end

posterior

a soft

tissue

mass

of

inferior

in

the

however,

turbinates

grams

nasopharynx.

addition,

it is of great

inspiration
of the upper

and
expi
respiratory

suflcient

ration

or

utes

to

roen
tract,

mobility

stancy

value

in

this

in

inconstancy

of

recognition

and

tgenograms
since
there
that

findings

is
con-

with

contrib-

evaluation

of

nor-

structures,
and of abnormalities.
The
an teroposteri
or
roen tgenogram
also
important,
although
sometimes

posterior

but

We

not

A high
filtration
airway

in

emphasize

the

is
not

kv.

technique
adds
to the
in the antero-

lateral

projection.

examination

without

or

appreciate

the

tion
phv

made
by positive
in the
elucidation

level
the

in the
childs

adult,
upper

of

even

material

is

hazardous,

we would
a primary

small

amounts
and

consider
step

when
the

of
such

as a second
in diagnostic

foreign

The
nates,
almost

posterior
particularly
exactl\

VARIATIONS

ends
on

the mandibles,
sometimes
pharyngeal
mass
(Fig.
The
ear lobe,
when
shown
simulate

in

true

lateral

a pharyngeal

of

the

inferior

since
the\
the coronoid

turbi-

superimpose
processes

simulate

of

a naso-

i).

the

pharvnx

projection,
mass.

solve
the
mobility

is
also

fills

not
can

the

b\

happens

exposure

of the
much

tonsil,
larger

child

such

monest

single

infants

and

our
cause

sometimes

sim-

thyroglossal
it partially

of

the

the

trachea

aperture,
or antero-

chest

experience,
for

or

chest

the

com-

overdiagnosis

children.

The

early
in life is a soft,
relativel
fixed
at its

flaccid
upper

structure.
and lower

but

this

mobile

young

between;

allows

of the head
and
shortening

throughout
The infants

the complete
respiratory
trachea,
particularly

and

since

and

the
head
straight,
displaced
awa
from
the

aortic

arch

in
trachea

for

ing positions
lengthening

tion
with
variably

in

4).

of

in

is

obvious

superior
thoracic
posteroanterior

projection
is,

can

(Fig.
deviation

the
the

curiously
more

as so-called
thyroid,
when

valleculae
lateral

neck,

is
of

adenoids

which
and

or adult,

a lesion
or ectopic

just
below
as seen
in

enlarged

of
naso-

B).

lingual

older

in

since
the
visualized

displaces

relatively

the
Right

be

if necessary
television
tape)

problem,
is easily

with

If,

expirato

the upper
oropharynx
and
This
normal
phenomenon
misinterpreted
as occlusion

nasophar\nx
3, A and

ulate
cyst

true

techniques.
sometimes

which

in

and

rather
investi-

(recorded
or by

the air
phar\nx.
frequently

posterior

interven-

gation.
NORMAL

and

exactly

The

and

roentgeno-

appears

roentgenogram,

the

contribu-

because
obstructed,

to obtain

diagnosis

intensification
Swallowing,

often

This
recog-

contrast
lar\rngograof lesions
at this

but rather
tract
is

addition
tion
than

enormous

easil
marked

the
(Fig.

an

thinning

inspiration

the

lateral

the

use
of
positive
contrast
medium.
policy
is not
because
of a failure
to
nize

if

to coincide

mal

essential,
in diagnosis.
with
increased
beam
visibility
of the upper

will
very

of

inspiration
show

this
normal
mobile
posterior
soft tissue
(Fig.
2, A and
B).

true

or

which

space-occupying

degree

doubt,
fluoroscop
by cinefluorographv

to obtain

area

it is difficult

tion,
In

of

expiration

happens,
the
will
generally

striking

flattening
pharyngeal
1.

during

in a manner

resembles

lesion.
When
roentgenogram

11G.

and
phar\nx

neck,
of the

It is
ends,
changand
for
trachea

cycle.
in expira-

is almost
inthe mid-line,

normally

lies

on

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\OL.

11G.

No.

109,

2.

(4)

Upper

A normally

thin

Respira

3.

(4)

1)uring

sw
tissue

ving,

is shown

Tract

Obstruction

pharyngeal
wall during
wall bulges
forward

posterior

pharyngeal

lic.

tory

adenoid
to

be

tissue
small

and

appears
the

inspiration.
the

into

to

11 the

nasopharyngeal

229

(B)
pharynx.

nasopharvnx.
airway

l)uring

expiration

(1)
patent.

At

the

rest,

the

posterior

ad

j.

230

Scott

Dunbar

JUNE,

u nnecessar

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made
show
the

mass

the

prominent

in the

left

side,

lingual

oropharynx,

the

tonsil

filling

may

the

displacement

simulate

valleculae.

is ordinaril\

to the right.
It is the degree
of this buckling
of the trachea
to the right
in the normal
infant
in expiration
which
is so marked
as to
be startling
(Fig.
SB), and
to give
rise
to

IIG.

5. (4)

The

normal

trachea

during

inspiration.

(B)

a few

roen

tgenogram

BA),

(Fig.
during

cycle,

toward-but
if the trachea

or only

inspiration
trachea,

respiratory

back
Indeed,

lic.

concern.

during
that
the

this

tends

millimeters

it should
aortic

enlarged

tracheobronchial

to

will
of

phase

to

not
to-the
is completely

mid-line,
right-sided

1970

displace
mid-line.
straight

the

left

of

the

arouse
the suspicion
arch
(Fig.
i6, A and
lymph

of a

B),

nodes,

or

some
other
mass
lesion
in or impinging
the right
superior
mediastinum.
The thymus
gland
can present
roentgeno-

on

logically
frequenthr

to
It

in

such
a
be
the

should
be
all practical

emphasized,
purposes

no

how

matter

displace

large,

normal

variety
cause

of ways
of concern.

however,
the
thymus
does

structures,

not
and

as

that

for
gland,

compress
thus

or
con-

stitutes
a hazard
only
inasmuch
as it may
be wrongly
diagnosed
as representing
a
lesion-a
superior
mediastinal
mass,
or col-

During

expiration,

the

trachea

is buckled

to the

right.

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\OL.

No.

109,

Upper

Respira

ton-

thymus

simulating

Tract

Obstruction

___

Fic.

6. (4

and

B) The

normal

lapse

or

consolidation

6, A and

(Fig.

DISEASES

of

upper

lobe

B).

TRACT

upper
the

UPPER

RESPIRATORY

minutes

duced
posterior

OBSTRUCTION

CHOAXAL

choanal

ATRESIA

atresia

in

can

be

a threat

examine
cause

feeding.

ob-

roen

or

half

acquired
and aspirate
in

nasal

an
the

respiration
be

cause
newborn

each

clinical
from

when

suspected

ability
nares
Since,

to

ma

infant

time

he drinks,

tracheoesophageal

The
pected

is

it congenital
choke
as occurs

nasal
be

often
discharge,

be

susand

confirmed

in-

pass
a catheter
through
the
into
the nasopharvnx
and esophagus.
however,
a nasal
tube
is sometimes

difficult
since

in the

to pass
roentgen

posterior

choanae

ways

is

and

the
diagnosis
roentgenologi

normal
of

the

value

in

display

of
in

exam

infant,
and
occluded

planning

i nation

is

to gently
shrinking
per

aspirate
solution
cent

in the
medium,

the
such

phenslephrine

as

the
the

An

be

the

introanteromade

B).

and
other

not

to

At

side

is

try

to

same
time,
beon
the
lateral

exaggerated
is

brow-up

and

7,

both
sides
at
superimposition
projection

in

shown

if the

or

Waters

particularl

valu-

anteroposterior
but
all should

position

secretions

from
the nose.
It has been
can sometimes
level

treatment,

have

HC1

to

to

avoid

and
be

loss

of

the
contrast
medium
from
the
choanae
before
the films
are exposed.
The
level
of obstruction
will
be reliably

the

a few

(Fig.
best

axial

confirming

then

dis-

is then

session,
is

tgenogram.

of

bone

been

stated
that
be recognized
which

can

the

ptersgoid

of

had

not

have

this

be

removed

choanal
because

atresia
of

demonstrated
plates,

a
at

but

we

experience.

al-

nose
can imso it is best

and

nose,

not

is

of the nose,
roentgenograms

It

tHE

secretions
of contrast

examination

position

performed.

Excessive
pair the flow

It does

of lipiodol

one side
and lateral
or a later

of

bar

almost

amount

into

examined.

done
can

can

then

the

able
in addition
to
lateral
roentgenograms,

fistula.
diagnosis
bilateral

or consolidation.

before

same

life
in the
neonatal
period.
This
is
because
the
newborn
infant
depends
to a
high
degree
on
nasal
respiration
when
\Vhen

mass

brow-up

the

to

structed

lobe

trachea.

performed.
A small

CAUSING

Bilateral

an

a right

or narrow

place

0.5

23!

instill

drops
a

The
threat

to

in the
of

few

can
of

PIERRE-ROBIN

Pierre-Robin
the

newborn
readily

the

obvious

patenc
period

be

SYNDROME
syndrome

of
and

recognized
micrognathia,

the

is

upper

infanc-.
cli ni call

real

airway
While
because

retrognathia,

it

j.

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232

lic.

7. (4

and

B) Bilateral
contrast

and

cleft

being
inspiratory

produ

palate,
ced,

and

the
parti
expirator

choanal
medium

degree

atresia.
in the

of

cularlv

Scott

obstruction
of

JUNE,

Brow-up
(4) anteroposterior
nares
show complete
choanal

between
phases

Dunbar

the
respir-

and (B)
obstruction.

ation,
can
sometimes
b\? roentgenologic

and

11G. . (4 and
B) lateral
roentgenograms
of the pharynx
Robin
syndrome.
The pharvngeal
airway
is compromised
tongue,
although
less on inspiration
(4) than on expiration

lateral

best
examination

projections

be

appreciated
(Fig.
8,

1970

with

B).

and upper
trachea
by the small
and

(B).

of an infant
retrodisplaced

with the Pierremandible

and

\OL.

No.

109,

ECIOPIC

THYROID

Ectopic
occur
at

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Upper

or

airway.

Usually
in

placement

The

region
of the
radiologic

least

not
File

means

or

of

in

the
di s-

posterior

trachea.

changes

serious

diagnosis.
is by

is
in

displacing

thus

produced,

pathognomonic,

cause

to

either
9)

cau Sing

233

or

th-roid

mid-line,
area,
(Fig.

Obstruction

maxneck

give
rise
the
tracheal

ectopic

tile

anteriorly

although

the

1w its presence
alteration
of

or near
the
retropharvngeal

trachea

tissue
in

Tract

CYSt

tii-roid

locations

and
or

situated
the lower
su bsternal

IHYROGLOSSAL

aberrant

various

the chest,
obstruction

the

AND

Respirator

silould

consideration
diagnosis

definitive
radioisotope

at

of

this

of cou

rse

of

the

scanning

thyroid.
of

Throglossal
the tongue

lowing,

cs-st

can

gagging,

or

cause
choking

remnant
(lifllcuitv

at

and

tile

base

in

swal-

cyanosis,
to. A

1i;.
filling

cyst in the base

and displacing

mid-line

the

valleculae

of the tongue
the epiglottis

I)oSteriorl.

and

indeed

to life.
recognize
the

if large

upper
is,

filling
tilts

thus

hvpopharvngeal
Tile
assessment
first
on its being
mass

at the
its possible

An

and

and
the

tion
for

tion
tongue,
11G.
and

airway

A severe
obstructing
in

a young

retropharvogeal

the

pharvngeal
infant.

goiter
anti

upper

distorting
tracheal

partiali
c\stic
in

interfering

gland

before

and
nature,

throglossal

Tile

valleculae,

epiglottis

it

posterowith

can

normal

an

b-

thyroid
thus

su rgi cal

Conversely,
situated
at the

are

not

of

throid
and

gland,
although

csts,

max

gland.
such

examina-

scanning
of prime

is
-

second

produce

physical

a search

or

be

to
of

10).

base of the tongue,

and
relation
to the thyroid

is undertaken.
which
are

sions

a threat

acti vi tv and
coordi
nation.
of sucil
a lesion
depends
recognized
as a mid-line

if necessarnormal
tilyroid

importance

be

(Fig.

tue

the

thyroid

ectopic

a mass,

tract

over
and

inferiorlv,

can

is Ilot
difficult
roentgenograms

the
more
likely
it is to cause
and respirator
difficulties;
this
at least
partially
so because,
ill

and

displaces

On

lesion
lateral

respiratory

larger
it
swallowing
is probably
filling

enough,

Such
a
in true

composed

i nterven-

those
base
of

lethe

completely

are
often
assumed
to
ill

fact

not

be

j. Scott

234

Dunbar

swallowing
spirator\

or

breathing,

often

stridor,

andor

ciloking

UNE,

1970

with

in-

on

feed-

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ing.
The

radiologic

identification

epiglottic
cyst
roentgenogranis

is not
of

obtained

inspiration

ill

(Fig.
II).
The
to be enlarged
proxi

matel-

a simple

and

this

and

spherical

ar\_

lateral
are
is

silown
an ap_

tissue

(water

such
an appearance
it is at least
suggestive

of

the

suggestion

endoscopic

fold

soft

\Vhile

cs-st

an

expiration

arvepiglottic
and
deformed

density)
mass.
not pathognomonic,
of

of

difficult,
if true
the
hpopharvnx

ar-epiglottic

can

be

exploration

is
fold,

confirmed

and

by

removal

or

drainage.
I.ARYN(EAI.

Chronic
tosis
is an

Fic.
it.
An
aryepiglottic
torting
one arvepiglottic
popharvnx.

iliStologicallv
more

recognizable

specific

tilan

as

lesion.
If tile thyroid
gland
in its normal
position,

has
and

covered
roentgenologically
the
tongue
can
be seen
be cystic,
treatment
a part
of the cyst
ation
of

of
tile

tom

the

1)een
the

base
ciently

of

such
called

confirmed
lesion
disbase

of
to

and
collapse
signs
and
symp-

a thvroglossal
mid-line
cyst

nosis
is
hoarseness
confirmed
illoniata

usually

signs

or

is

it

found
does

symptoms,

it

will

l)e
not

and

conservatively,
that

to

witil

bat

however,

the

graduall\

The
mass
recognize,

then
expec-

in

diminisil

The
usually

taming

and

genograms

size.
RVEIIGI.O1FIC

histology

of

nonspecific,

symptoms

are

and
the

CYSTS

an arepiglottic
and
tile
resulting
those

of

difficulty

cyst

is

tracilea

in

gioma
small,

signs

causing
in infants
itself
because

expiration,
contour

is

which

the
and

con-

symptoms,
will silow

examination

of
masses.

the

of

the

trachea

of

subglottic

upper
and

vocal

tile

tile

soft

respirators
tract
\-oung
children.

true
area

and the
density

produces.
The
s-mptom-producing

is

sometimes
difficult
of the
problem
of

interpreting
of

is hot
and

HEMANGIOMA

cause

tissue
mass
obstruction

progressive
child,
and
of typical
papOccasionally,

signs

deformity
nodular

stop
Diag-

by

diagnosis

hemangioma

commonest

of

mucosa
of
reaclles
adoles-

patient

correct

enlargement
and
cords
by irregular

An
the

sufficause

can
tile

child.
spite

of the

suggested
a preadolescent
demonstration
larvngoscopv.

ill

sidered
from
pil\-sical
and
then
radiologic

cyst,

at

preadolescent
recur,
in

(stripping
tile

papillomarare
condi-

cence,
when
the papillomata
ordinaril
recurring
or regress
spontaneously.

is usually
excision
of
wall,
which
allows
evacu-

the
tongue,
small
so that

treated

tation

laryngeal
but
not

TRACHEAL

alarming

and

surgical
removal
the lar-nx)
until

s.

Occasionally,
perhaps
better

be

hy-

c\stic

at the
endoscopicallv

liquid
contents,
with
relief
of

cst,

dis-

an\tlling

fluid-containing

infectious
uncommon

tion
occurring
in the
Laryngeal
papillomata

enlarging
and
and filling
the

cyst
fold

IA1ILLOMATOSIS

ill

lateral

both

sul)tle

upper

presence

of

to
ob-

roent-

inspiration
alteration

tile

tracileal

in

subglottic
heman-

of a localized,
soft
tissue
mass

sOL.

in

the

subglottic
child
is,

young

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monic

of an
be

must

this

trachea

hemangioma

suggested

most
or

A and
The

and

or

nature

endoscop--

must

tile

tilis

the

mass

have
to be
to relieve

viate

complications

at

least

by

radiation

all

is

sufficient

the

that

is

is

Congenital
other
hand,
or

therapy,

i nspi

of
signs

treatment,

a tracheostom

(lone
below
the s-mptoms,

the

ill

tile

level
and

size

of

of

and
Before
of the
to ob-

course

ble.

of

its

Congenital

tion,
signs

lar-ngeal

stenosis

a radiologicallbecause
it
and
symptoms

Fic.

1 2.

(4

and

SFENOSIS

raton-

tends

to

or

atresia

condi-

produce

immediateI

B) A subglottic

if

at

tract

i hldrawi

more

cords

tile

to

remain

is

therefore

moment

demonstra-

severe,

if bilateral,

tend

and

stridor

birth,
is roentgenologically
It is of course
much
threatening,

on the
signs
and

obstruction(weak

inspiratorfrom

since
in

indeed
the

vocal

adduction,

and

severeR-

compro-

mi sect

Ci nefluorographic
small
roentgen-ray

such
the

birtil,

pediatrician

trachea
airway.

is

pilenomenon

posterolaterally,

the

of
that
since

be recognized

it is extremely
and

or

appear

superfluous,

can

reso-

movement

might

it

a high

unilaterally

silow,

While

cords.

and

of normal

demonstration

same

lar\-ngoscop\-,

of the
the

will
absence

vocal

with

examination

beam,

system,

acute

hemangioma
compromising

PARALYSIS

ng)

life

tile

recognizable

CORI)

voice,

bilaterally,
LARYNGEAL

and
tiObl

is to survive.2

of upper

absent

lution
CONGENItAL

identified
i nterven

vocal
cord
paralysis,
wilile
it also produces

inspiration

management.

not

baby

newborn

VOCAL

primar\necessary

cause
tile
or (lisappear.

immediately
larngoscopic

be
(Fig.

diminution

the
hemangioma
to
ss-mptoms
to subside

is

be
b

s-mptoms
or

is usually

undertaking

and

235

-but

and can
the mass

when

Obstruction

treated

B).

produce

may

infant

roentgenologicall-

sometimes

to

Tract

pathogno-

exact

diagnosis,

considered

treatment

treatment,

its

b-

demonstrated

12,

an
not

likel-

Respirators-

of

course,

of

determined

is the

first

Upper

No.

109,

helpful

otolan-ngologist

bulging

into

bto

the
to

and

j. Scott

236

Dunbar

JUNE,

(Fig.

13,

monly

seen

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marked

B).

alld

in

of

the

In
is

trachea

cheal

mild

so

far

as

B.
operation

Fic.
i.
(4)
There
is subglottic
swelling
causing
tracheal
obstruction,
but
the tracheal
lumen
is
otherwise
normal
on expiration.
(B) (in inspiration,
the
pharynx
dilates
above
the subglottic
obstruction
caused
b- croup,
and
the
trachea
below
the level of the obstruction
shows
marked
narrowing.

have

the

ciency
possible.

cause

of

localized
If the

require

the

and

insuffi-

identified
as
is bilateral,

condition

tracileostom

respiratory

soon

as

it may

and

barking

time.

This
if,

longed

fore

A. Primary.
is exceedinglseen,

witil

case

in

sis.

However,

which

which

the

the

SFENOSIS

Congenital
rare,2

traclleal
and
we

exception

noted

we

are

certain

there

entire

occurs
an

larynx

is tile

(luring
severe

or

one

trachea,

tion,
appears
to be and
genologi
c exami
nation,
ulate
tracheal
collapse
This

of

is

narrowing

inspiration
obstruction

immediately

ilave

not

below,
the

any
diagno-

condition

or

cervical

por-

is narrow
on roentand
this
ni av si mor
stenosis.
of

the trachea
wllicil
in the course
of
at

the

below

level
tile

of
larynx

the

course

flattening

to

a cilrOnic

continue

for

the

pro-

anastomosis,

operation

proximal

some

and

accentuated
surgical

the

site,

and

segment

there-

persists.

direct
eration
max-

tracileal
stenosis
is an uncondition
secondary
to

serious

trauma
to the airwa.
of the
trachea
or

cartilaginous
in

max-

at

of

of
tile

cough,

recurs

the
level
the tra-

the

flattening

operation,

following

Post-traumatic
common
but

stenosis

after
had

and

above

a tendency

is of

dilatation

IRACHEAL

nar-

time
have

esophagus

and

trachea

stellosis

v.

after

harsh

tile

secretions

causes

Even

of the

some
who

patients

of

atresia,

tile

are

tracheal
for

of

accumulation
cilea.

even

pathogenesis

present

discontinuit

of

and

atresi
a treated
su rgi
calls-.
The
esophageal
segment,
which
before
birth
has been
dilated
because
of

after

the

nar-

prognosis,
the roent-

pathognomonic,
and

those

tra-

associated

tracheal

Secondary
be

in

esophageal
proximal

is

The

is good,

etiolog\-

max-

caliber.
whicil

it

B).

are

Secondary.

expira-

of

diffuse

known,

thougil
the
not understood.

on

normal

and

A and

findings

tra-

roentgenfltioroscop

calcification

moderate
14,

is

genologic

rowing

to

stridor
nlade

calcification,

occurs,

to

is

diffuse

tilat

idiopathic

(Fig.

rowing

subglottic

the

show

widens

cartilage

with

tilere

of

expiration
recorded

cartilage

rare,

com-

which

demonstrate

tracheal

ver

will
The
(or

will

quite

i nspi
ratora roentgenogram

onl-

Ilowever,

tion

in

and

narrowihlg.

if desired)

thus

edema

resultant

inspiration

cheal
ogram,

is

croup,

degree

trachea,
wi tii
and indrawing,
on

It

1970

of

and

scarring

fibrosis

rings,

cause

Following
fracture

significant

narrowing

of

lacthe

the

lu-

men.
FOREIGN

loreign

mon

but

1)OdV

of

readily

nonopaque,

can

the

the

in

obvious

recognized
al

contained

phaiynx

is

importance.
if

It

opaque,

but

be delineated

roentgenograms

air

BODIES

of

in

the

tile

on
area

pilarvnx.

uncom-

can

true
because

be
if

even

laterof

Downloaded from www.ajronline.org by 173.255.203.142 on 08/07/16 from IP address 173.255.203.142. Copyright ARRS. For personal use only; all rights reserved

sOL.

lIG.

(4

14.

Foreign
child

Upper

No.

109,

both

into

point,

ognized

in

a linear

tilat

body

max-

sible)

to

tenor
shadow

projection
the
is characteristic.

trated
both-

by
was

shown

in

Foreign
natel\eign
lower

in

be

lateral

difficult

gets

both

is

of

at

tile

par-

level

increased
of
foreign

able,

impos-

of

In

A and
of

case

the

plastic

in childhood.

body
which
trachea
is

becomes
one

trachea

of

nonopaque

arrested
the most

i.e.,
and

foreign

difficult

inspiration

fortufor-

in the
difficult

a possible

ing,

should

tive

of

lower

a dvi sect

just

the

signs

upper

and

lodges

at

above

the

and

symp-

lower

inspiratory

tract

stridor,

It

is

in-

understand-

diagnosis
Radiologibe

cannot

satisfac-

bplain
noentgenosilows
prolonged
and

and

expiration,

if it can

in an\-

episode

of

be

and

be related
while
eat-

highly
foreign

immediate

this

and

way

choking

considered

nonopaque

trachea,

invariand
be-

usuall-

abnormality

demonstrated
Fluoroscop-

combination,

it is not

that
an incorrect
be entertained.

may
the

but

is almost
distress,

trachea

wheezing.

therefore,
asthma

cartilages.

know,

bothlower

tonil\grams.

material,
are

foreign

curved
illus-

to

the

we

of its bifurcation,
are tllose
of both

call\-,

anteropos-

tile

B,

diagnoses

of the

drawing,

not

in

of tracheal

obstruction;

cases,

tile

slightl-

calcification

the
level

toms

(although

while

in

cause

projection

thin,

with

237

impossible.
Sucll
a child
ably
in severe
respirators-

rec-

projections.

bodies
rare

by

projection

Obstruction

radiologic

and

be

Tract

associated

stuck
can

shadow

demonstrate,

Figure
15,
a fragment

trachea

caused
egg-silell

density.
\Ve
have
seen
several
such
and
have
confirmed.
the
observations
others

tory

infant

it is thin,

anteroposterior

as

in

always
Tile

lar\-nx,

since

of the

stenosis

larynx

tile

the

and

ticularlv,

Mild

almost
egg-shell.

of

aspirated
this

in

is, curiousl-,

fragment

B)

and

Respira

sugges-

body

in

endoscopy

the

j. Scott

Downloaded from www.ajronline.org by 173.255.203.142 on 08/07/16 from IP address 173.255.203.142. Copyright ARRS. For personal use only; all rights reserved

238

1-ic.

15.

a linear

(4 and
shadow

B)

A thin fragment
in the anteroposterior

VASCULAR

This

subject

the literature,
orated
at length
ever,
First,

F;:-

RING

at least
described

and
thus
ilere.
\Ve

will
not
be
would
like,

aspects
can

JUNE,

of plastic
arrested
at and just
below the
projection
(4) but also demonstrated

is extensivel-

to stress
two
the condition

Dunbar

in
elabilOw-

of the problem.
almost
alwa-s

be

of

suspected

standard

infant
should

of the vocal
in the lateral

from
chest

or child.
and
can

rarer
vascular
A vascular

level

careful

cords,
shown
as
projection
(B).

examination

roentgenograms
Second,
the
be distinguished

sling.
ring is usuall\

1970

of
vascular
from

associated

the
ring
the
with

sW.

a right-sided
posteroan

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Upper

No.

109,

trachea
placed

tenor

there
tion

aontic
arcil,
and
thus
chest
roen tgenognam,

will be slightl
and
to the left,
whether

projection
(Fig.
i6d).
is
of

it

posteroanterior
ognized
displacement
on narrowing

the
the

Ofl

abnormally
or not

invariably

trachea

at

some
its

lower

displacement
(Fig.

Tract

(usthis

in

can
be recognized
as narrow
On tile lateral
roentgenogram

almost
tile

Respirators-

i6B).

Thus,

constricend,

maxhaving

and

be

rec-

identified

(on the posteroanterior)

(on the lateral
roentgenogram)

and,

a vascular
ring
can
be strongly
suspected.
It remains
olll\
to give
tile patient
tilin
barium
paste
b
mouth,
and
make
spot

drawn

e patient
as in I together
and narrowed

6.
h

Obstruction

239

roentgenograms
passes

of

through

that
esophagus

the

and

impingement
can
be

SO

;1-D).

Further,

area

(listends

as

the

tile

esophagus,

on 1)0th
demonstrated

the

barium

trachea
(Fig.

diagnosis

of

ing

are

squeezed

togetiler.
if

investigation,

giographic.
means
clear
or
aortograph

It

is

to

(IS

angiocardiographrequired.

usuall-

ring.

n barium
paste
extrinsic
compression

Its

shows
caused

b-

the
b

ananThe

the
procedures
althe presence
of a vasand

exploration

that

be
b

tilat

is

i.e.,

remain-

will

necessary,
ilowever,

evidence
displa\-ed
ready
noted
indicates
cular

The

not,

17,

vascular

ring is evident
if the tracilea
and esopilagus
are approxi
mated
b the abnormalit
;
if the\

and

trachea

a vascular

and
ring.

surgical

esophagus

con-

are

j. Scott

240

Dunbar
unless

studies

Downloaded from www.ajronline.org by 173.255.203.142 on 08/07/16 from IP address 173.255.203.142. Copyright ARRS. For personal use only; all rights reserved

ditional
cileSt.

the

surgeon

information

If

lie

may

dealing

witil

variants

is

chea

and

rated

whichever

of
the
constriction

the

causing

Ilie

iS.

with

vascular

the

sling

viewed
from
aorta
removed.

ascending

the

i.e.,

rection

tilen

tile

surgeon.

sum

cannot
and
arcil,

dium,

aortic
be

contributing

duced
not

1I(i.

b
to

1 1).

Inain
mass

become

the

Since
be

responsibility

a ligamentum

opacified

b-

to

the vascular
investigate

tile
ring,
b\-

of
artenio-

contrast

since
in addition
to a
a ligamentum
arteriosum

me-

double
may

constriction
we feel
contrast

prosatisfied
vascular

(4) The left lung is overintlated,

and
bronchus.
(B) The esophagus
is separated
which
compresses
both structures.

esophagus
each

this

tile

or

pressing
of tile
maxand
with
igin

them

the

trachea
This

because
left

pu1monan-

is caused
by compression
from the distal
trachea
and

the

tra-

sepawhich

B).

and

level
sling;
from

distal

tra-

and

com-

or one on
condition

both
also

angiocardiographv,
can
be established
the

anomalous

anten-

of the lower
bifurcation

its

be

arising

the

bifurcation,

be investigated
bhere
the diagnosis
certainty

trachea.

arten-

tracheal

suspinarHow-

and

slightly
lower
the vascular

behind

eitllen
the
main
bronchi.

of the

initial

19,

the
(Fig.
and

esophagus,

(Fig.

plus
the
identifies

the left pulmonary

right,
crossing

chea

in

are shown
to
by a structure

other

between

Tilis
finding,
of the lesion,

front

tile

be
of

numerous

of vascular
sling
a problem
of tracheal

opacif-ing

from

passes

the
tile

witil

esophageal
constriction,
and
cion
is aroused
by displacement
rowing
of tile lower
end of the
on

ad-

vascular
ring
will
feel himself
capable

then

particular
case.
In the condition
I 8),
there
is also

ever,

tllis

exploring

a thoracotomv

tilat

Ile

found,

wishes

before

does

knowledge

11G.

1970

JUNE,

can

orcleanly

trachea
and left
by a soft tissue

Downloaded from www.ajronline.org by 173.255.203.142 on 08/07/16 from IP address 173.255.203.142. Copyright ARRS. For personal use only; all rights reserved

No.

\OL.

109,

Fic.

20.

be shown.
essential
rection

\\iletilen

in our

surgeon

who

degree

ring.
circled

Tile
by

nosis

is

fected,
at

some

for
from

Gradual
contour

may

having
ring

surgical

for
to

some

and

the

time,

clinical

and

restitution
of the trachea

of

situation

tion

or

occur

tilese
picture
sternal

eflumen
is there-

and

to

s-mpring

cause

roentgen
normal
does,
how

to

evidence.

LARYNGOMALACIA*

Laryngomalacia

is

common

in

few
months
of life,
is cilaractenized
inspiratory
stnidor,
and
caused
by
glottic
laxit
612 The
condition
should
be called
ars-epiglottic
h-permobilitv,
*

A i6

mm.

teaching

subject
Laryngomalacia
The
American
College
Chicago,
Ill. 6o6o6.

cine

of

film,

with

is available
Radiology,

optical

sound

tile

variant

the

first

by
arvepineallbetract,

on the

for loan or purchase

20
North
Wacker

from
I)rive,

of

lower

are
child
tend

is
to

cited

or

cries.

This

at-pica1
This

goscop\,
ar-epiglottic

when

is

it

as

unlike
ced

harder.

the
by

in-

organic

Tile

clinical
condition
sometimes
is

voice

aperture

of

the

be

causing
(Fig.

narrowed

is now

fluoroscopy

sees

an-epiglot-

inspiration,
to

diagnosis

direct
lan-n-

otolanngologist
and
displacement

medially

is

is very
sufflcientl

to warrant
more
can
be (lone
by

tile
laxity

by

and
relaxed,
becomes
ex-

he

is quite

during

made

inwhen

sighls
and
smptoms
beas the patient
becomes

severe
or
confirmation.

and

in
supra-

marked

pnodu

tile

and

of
clinical

inspinatorsquiet

breathes

structures

relaxation

associated

relatively
disappear

normal.
Altilough
characteristic,

the glottic
A and B).
Radiologic

nor-

life.
The
cilaractenistic,

most

when
the
more
severe

downward

normal

sternal

obstruction

and

oI)struction.

is structurally

tile

usuall-

the
and

tic

tile

and

and

lesions,
come

(B),

inspiration

causing

in early
patient
is

stnidor

drawing

excited

and
occur.

itself

and

inspinatorv
difficulty
is caused
of tile supraglottic
structures;
in
turhl
is only
an exaggera-

structures
of tile

spi raton-

con-

caliber
ever,

tile

relaxation

been
enuntil
(hag-

vascular
and

by

larynx

and

that

it

signs

the

mal,

of vascular

normal

the

cause

larynx

treat-

treatnlent
its

months,

attributable

cern

stenosis

regain

uncommon

continue

the

to

expiration
(4)
on inspiration,

during

the

tilis

belongs

condition

and
not

least

not

toms

decision

distal
trachea,
the abnormal
made

is
corOpin-

241

Obstruction

of laryngomalacia
drawn
toward

and

is to undertake

in the

does

fore

the

tracheal

to some

Tract

angiocandiogram
exploration
of individual

view

ment.
Secondary

for

tile

for surgical
is also a matter

and

the

Respiratory

(4 and B) Endoscopic
photographs
the hypermobile
supraglottic
structures

showing

ion,

Upper

also
and/or

20,

possible,
spot

j. Scott

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242

lic.

21. (4-D)
roentgenograms
and anterior

In

an infant
with severe
made
while
the stridor
buckling
and displacement

Dunbar

laryngomalacia
shown
by
is occurring
show marked
of the aryepiglottic
folds.

JUNE,

inspiratory
posterior

stridor
bending

and indrawing,
of the epiglottic

1970

spot
tip

Vot..

roentgenognaphv

witil

lateral

and

position,
If

occurring.

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Upper

No.

109,

no

stnidon

will

be

cop,

tile

Respi

the

patient

wilile

the

examination

can

1)e

shown

no

The

recorded

b-

Obstru

ctiohl

.,

-43

true

abnormalit\-

radiologicall-.

usually

in

Tract

stnidor
is
(lone
when

is

hear(l,

rator-

cine

fluorosor

video-

tape,
shows
striking
an(l
characteristic
(lownward
and
anterior
displacement
and
buckling
of the
aryepiglottic
folds
in inspiration.
loose
sails

Tile
appearance
flapping
in

noentgenograms

show

same

buckling

ment

of

the

varying
tip

an(l

Croup

an(1

age group,
very
high

AND

are

are

peculiar

and which
reliability
This

scopically

is

loosely

tion

occurs

currently

ticus.
Radiologic
genograms
and
lateral

used

caused

to

the

i cm.
and

trachea,
producing
level
only-the

sometimes

called

trachea

usually
is replaced

that

the

the larynx
inflamma-

conus

includes
in
in

elasroent-

anteropostenior
inspiration

expiration-4
roentgenograms
these
roentgenograms,
one can
ing
degrees
that
the
shoulder-like
convexity

it

is stripped
off
a slit-like
narpart
of the

examination
of the
neck
projections,

22.

trachea
projections

(4
in

and
B) Severe
croup.
anteroposterior
(4)
shows marked
narrowing

The
subglottic
and
lateral
(B)
due to mucosal

edema.

trachea.
fact

the

I-ic.

endo-

below
when

the

in

by

because

subglottic

is due

for

it is a common
the
upper
resin temperate

of

of the

about
attached,

coIl-

pediatric

invariably
is recognizable

It

the
submucosa,
rowing
at this
trachea

acute

tile

radiologically

narrowing
for

two

to

term

almost

and

mucosa

a
tile

can be diagnosed
with
b- roentgen
methods.4

is the

narrowing

This

to
of

EPIGLOTTITIS

epiglottitis

and
is
infection.

causes

and,

postenionl-

larngo-tracheo-bronchitis;
inflammatorcondition
piratory
tract
encountered
zones
virus

the

displace-

epiglottis.

wilich

Croup.

zl-D)

2!,

folds,

bending

CROUI

ditions

(Fig.

resembles
The
spot

anteroinfenior

anepiglottic

degree,

of tile

thus
breeze.

present

in

the

in

anteroposterior

and

in all.
In
see in varylateral
subglottic
pro-

jection
(Fig.
22B)
by narrowing,
the curve
of the
subglottic
trachea
being
reversed,
with
convexity
now medial.
Also
typical
is
the slit-like
narrowing
of the lumen
shown

immediately

below

In

anteropostenior

the

larynx

the

distal

tile

level

of

tile

projection,

can

usually

end

be identified

of the

has a cilaractenistic
side,
terminates

at

of the larynx
(Fig.
jection
(Fig.
221),
radiolucent
subglottic

the

p\nifonm
tapered
almost
23).

the

tion

to

and

sinus,

contour
exactly

In the
normally
tracileal

sometimes
more
are constant

expiration.

The

of

because

which
on each
the level

lateral
clear
lumen

tered
by increase
in density
and
of definition
for approximately
to the level
of the vocal
cords.
ings are sometimes
more
obvious
teropostenior,
projection,

larynx.
level

proan(l
is al-

diminution
cm. distal
These
findin tile an-

in the lateral
from
inspira-

structures

above

the

larynx
are clear
and well defined.
Croup
is not only
very
common,
but usually
mild.
Those
cases
which
are
severe
enough

to warrant

roentgenologic

examina-

-,

j.

244

Scott

Dunbar

Juxe,

Epiglottitis.

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more
ous

3 to

imately
throat,

an(l

progress

to

not

and
Its

It is
which

tient.

enzae,
from
from

the
the

Treatment,

begins

caused
can

therefore,

Clinical
edge
of the

diagnosis
con(lition,

may

saliva.

it

of

the

by

culture

Haemophi/us

and
culture

usually

FIG.

23.

The

the

infants

The

distal

normal
end

proximately

tion

ma

anteroposterior

neck

with
of

the

each

level

have

the

projection

vocal

cords

pyriform

of the

marked

true

fnequentl\is done.

includes

both

tracheostomv.

by looking
in
the enormousl\-

depends
on a knowlan(l where
possible
is
the
throat
and
recogred, swollen
cherry-

is

at

ap-

dvspnea

with

in-

the cases,
by moist

are adequately
or without
added

The
about

t\pical
1-

casionally
of

12

upper

however,
air with
age
to

occur
years
limit.

distribution
although

being

in
for

older
practical

treated
oxygen.

of cnoup
it does

3 years,

on

lateral

cords.

Occasionally
tile
tion
sufficiently
rary
tnacheostomy.

stridor

a single

of

and
a
croupv
cough.
condition
causes
obstrucsevere
to require
tempoThe
great
majonitof

spiratorv

roentgenograms-on

pro-

adducted.

sinus
vocal

painftu_

recovered

like
tip of the
inflammed
epiglottis
truding
into
the hypophan-nx.
Radiologic
diagnosis
depends
only
lateral

If

treated,

demise

bbe

a sore

hours

promptl-

supraglottic
area,
blood,
if a blood
an(I

with
of

swallow

produces

antibiotics

made
nizing

to

and

always

is

a matter

inability

dangerapprox-

more

range
It

years.

10

is a much

much

age

witilin

recognized

almost

epiglottitis

Acute

uncommon
condition.

1970

children,
purposes

the

is
ocage
the

Fic.

24.
Acute
epiglottitis.
The
aryepiglottic
folds are enormously
the hypopharynx.

epiglottis

swollen

and

and

fill

No.

sOL.

109,

roen

tgenogram-of

tract.

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are

The
so

Upper

Respiratory

the

upper

respiratory

and

arvepiglottic

epiglottis
swollen

ilugelv

(Fig.

fill the entire

roentgenologic

il\-pophar\-nx,
appearance

nomonic.

structures

The

Tract

Obstruction

245

folds

24),

that

and
wilicil

the-

present
is patilog-

1)elow

the

lar-nx,

contrary
to the findings
ill
crOup,
are
clean.
It must
strollglV
be empilasized
that
tile
patient
Witil
acute
epiglottitis
is ill mortal
(langen,
wilich
He

iio pil\sical

examination
makes

on roentgeno-

shouki

telldS

to

it harder
assunie

the

ilead

forward,

witil
tile
ing

that

alld

logic

be
for

the

(1n(Iertaken

hinl
upright

the

to

breathe.
position,

tongue

out

and

neck

slightly
flexed,
and may
be droolbecause
he cannot
swallow
saliva
(Fig.
If he is forced
to submit
to pilanvilgeal

25).

examination,

on

lie

to

(lown

for

logic
examinaton,
he may
(lie.
minimum
examination
should
(lone

to establish

is not

clean1-

evident

ination,
the neck

from

a single
leaves

tile

varied
ever,

should

a so-called
cs-st.

The

rentenic

cyst,
may
or

esophagus
and/or
nlent
is by surgical

nature

an(l

trachea.
excision,

s-mptoms

1S t temporary

discovere(I
rentenic

a posterior
and

or

anchentenic,

for

a duplication

domen,
ciated

an important
anomaly.

because

the

is

markedly

and
child

The

saliva

head

drools

cannot

is

from

and

swallow

obstructed.

mediastinal
likely
a search

of the
and

tance

which
is
be either

witil

embryo-

clinon the

gut

common1-

in tile

neube
abasso-

of

regard
of

techniques,

will

lead

localization
respirators-

of many
of tile
tract
obstruction

children,

an(1,

the

exact

diagnosis.

The

Montreal

Childrens

2300

lupper

Street
io8, Quebec,

s-er\\.

j.

the

causes

pital,
Chicago,
The
author

ng

and
of

upper

in infants

and

number,

to

Hospital

Canada

valuable

help

Alexander,

and

who

cooperation

prepared

this material,
is acknowle(lged
ticular
gratitude.
Figure
20 was
kindly
supplied
Hollinger,

the

necon(li

of

Paul

an(1
in

recognition

a considerable

ill

impor-

barium

fluoroscopi

to

chest

the

expiration,

addition
or

the

for

versus

inspiration

and;

The
is

due

esophagus,

of 1)r.

cyst
to be
should

of

with

occasional

Montreal

Finally,

noentgenograms

neck,

be drawn

of the cs-st
and
relieve

measure.

is thought

nlade

lip

lower

Standard

Definitive
treatbut sometimes

needle
aspiration
reduce
its
volume

such

the

and

is usually
associated

Tile
immediate
impingement

transthoracic
serves
to
when

epiglottitis.

open,

SUMMARY

archentenic

of such
a lesion
tile discovery
of

spinal
malformations.
ical importance
is the

acute

mouth

breathing

how-

in particular

congenital

logic
significance
established
b-

with

tile

treat-

Attention,

mediastinal
anomaly
and

neu

A child

25.

forward,

and

indivi(lual

article.

perhaps

to the posterior
a congenital

of
doubt.

so numerous

their

present

I-ic.

exam-

CYSTS

are

as to preclude
in the

if it

physical

lateral
noentgenogram
tile situation
in no

masses

ment

diagnosis;

gentle

NEURENTERIC

Mediastinal

noentgeno-

The
absolute
therefore
be

Childrens
Illinois.
gratefully

Memorial
acknowledges

mucil
with
1w

parDr.
Hosthe

J.

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246

Scott

assistance
of Mrs.
L. C. Hebert
and Mrs.
Sandy
Harnity,
of the Department
of Photography,
and of Miss
Isabel!
Webb
and
Mrs.
C. E. Emery
of the secretarial
staff,
Department
of Radiology,
of the Montreal
Childrens
Hospital.

Dunbar

JUNE,

responsible
for
fants. 7.4.M.4.,
9. HOLINGER,
P. H.,
aspects

Dis.

genital

cysts

REFERENCES

J.

AM.
I.

2.

3.

BATES,

D.,

Ruiz,

0.,

and

Studies
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the
lateral
Bi-it. 7. Radiol.,
1957,30,
BEAL,
H. A. Stenosis
of
Laryngoscope,
1930,
40,
CAPITANIo,

M.

A.,

and

A.

BACHMAN,

neck
298.
larynx

L.

radiograph.
and

trachea.

J.

A.

Upper
fants

4.

6.

respiratory
tract
obstruction
in inand children.
Radiol.
C/in. North
America,
1968, 6, 265-277.
DUN BAR, J. S. Epiglottitis
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1961,
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86.
GOLDBLoOM,
R. B., and DUNBAR,
J. S. Calcification
of cartilage
in trachea
and larynx
in
infancy
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with
congenital
stridor.
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1960,
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P. H.,

HOLINGER,

with

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HOLINGER,

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JOHNSTON,

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K. C. Factors

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in

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SANCHEZ,

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F. R.,

MURPHY,

D. W.,

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sling.

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compression

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MACEWAN,

D. Y. E.

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572-

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J. R.,
J. E. An Atlas

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and
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Springfield,
Ill., 1964.
Radiotherapeutic
management
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hemangioma
in children.
Radiology,

STEWART,

Malformations

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TEFFT,
M.
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anomalies

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hemangioma
1965,

Company,

J. F. M.,

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K. C. Infant
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MED.,

JACKSON,
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lateral

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HOLINGER,

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and JOHNSTON,
stridor.
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MCALISTER,

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KIRKPATRICK,

Otol.,

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NUCLEAR
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and

tracheal

E. P. Con-

STEINMANN,

larynx.

9,

L.,

of trachea

i#{231},jz, 613.

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structing

in-

K. C. Clinical
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JoHNsToN,

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of

H.

HUDSON,

in

1229.

anomalies

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and

P. H.,

HOLINGER,

obstruction

1950,

of congenital

bronchi.
JO.

laryngeal

1970

1966,

17.

WOLMAN,

Am.

86,

KINCAID,

0.

of Vascular

207-214.

T.
7. Dis.

J.

Congenital

Child.,

1941,

stenosis

6i,

of

1263-1271.

trachea.