AN INFANT was born by spontaneous vaginal delivery after an uneventful pregnancy. Maternal serology screening was nonreactive for syphilis, negative for hepatitis B surface antigen, and showed immunity for rubella. Maternal rectovaginal culture grew group B streptococcus, and the mother received 2 doses of antibiotics before delivery. Labor and delivery were uncomplicated, and his birth weight was 3.5 kg. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Initial vital signs and physical examination findings were normal. With the first bottle feeding, he regurgitated all the formula through his nostrils. Despite suctioning of the nasopharynx, his airway remained congested, and he had difficulty clearing nasal secretions. Sterile water feeding was attempted, but instant reflux of water occurred through the nostrils.
Findings from complete blood cell count, C-reactive protein, and chest radiograph were normal. He received a sepsis workup and antibiotics for 3 days until blood culture had negative findings. Investigation for nasopharyngeal reflux was initiated with barium esophagram, which showed reflux of contrast from the oropharynx into the nasopharynx and through the nostrils (Figure 1). Some contrast passed down the esophagus into the stomach, and an aspiration episode into the trachea was visualized (Figure 2). The infant underwent direct laryngoscopy, esophagoscopy, and bronchoscopy. No structural anomalies of nasopharynx, larynx, esophagus, or bronchi were present. Computed tomographic scans of the brain, neck, and chest were normal, showing no intrinsic or extrinsic structural obstruction to the esophagus or trachea. A 2-dimensional echocardiogram with Doppler flow study of the heart and major blood vessels did not reveal abnormal vessels or structural anomalies.
Itani O, Prophit C, May D, Shekhawat P. Radiological Case of the Month. Arch Pediatr Adolesc Med. 2000;154(11):1167. doi:10.1001/archpedi.154.11.1167