A Rare case of Swallowing Incoordination; Difficulties In Diagnosis And Its Management
Jan 07 2023 | Medicover Hospitals
A 4 months male infant (born prematurely) was admitted to the emergency room (ER) with fever, persistent crying, vomiting, distension of abdomen, and rapid breathing for the last 4 days. After examination, it was found the baby had a high-grade fever; the respiratory rate was at 45 breaths per minute, and abdominal distension with absent bowel sounds and swelling in the right scrotum. Further radiological and blood tests revealed bilateral pneumonia in the upper lobes of both lungs, increased CRP /WBC count along with right obstructed inguinal hernia. After initial resuscitation and with high-risk consent, the sick baby was taken for emergency surgery. Right inguinal exploration was done, small bowel intestinal contents were reduced, and a herniotomy was completed. The baby was put on mechanical ventilation for two days and extubated once the general condition got improved. Lung condition started improving, and slowly over the period of 10 days, the consolidation of the lungs got much better.
From day 5 following surgery, bowels started functioning, and feeds were initiated slowly, and the baby was on full feeds by day 10 post-surgery and got discharged.
Within 2 days of discharge from the hospital, the baby came back to ER with similar complaints of high-grade fever, respiratory distress, and refusal to feed. The baby was resuscitated and radiological and blood workup revealed Bilateral Pneumonia involving the upper lobe with raised CRP and WBC count. In view of the second episode of pneumonia extensive workup was done, which included a Neurosonogram, 2d Echo, upper GI contrast study of the stomach, and followed through and diagnostic bronchoscopy to rule out H type esophageal fistula / foreign body in the upper airway/tracheomalacia. Diagnostic bronchoscopy was normal, ruling out all airway anomalies, and an upper GI contrast study revealed GRADE III GERD. The baby was put on antireflux measures like 45-degree elevation while feeding and medication (oral anti reflux drugs like Pantaprozole and Domperidone). The baby started to do better and was discharged.
Within 3 days of discharge the baby came back to ER with similar complaints; we were left out with no further investigation. After much deliberation, we got a SWAT (Swallowing assessment test) by a Neurodevelopmental physiotherapist, and it revealed swallowing incoordination and deglutition difficulties. In view of the above findings along with GERD (Grade III), we decided to go ahead and perform laparotomy- Nissen’s partial Fundoplication along with Feeding gastrostomy. The post-surgery baby started doing extremely well, and all the lung opacities completely disappeared. Presently the baby is asymptomatic, and the growth chart shows an upswing following 2 months of follow-up with normal development.