Mediastinoscopy or thoracotomy is often pursued for diagnostic evaluation of mediastinal lesions in children, both of which carry an associated risk of morbidity and mortality.1 Convex probe endobronchial ultrasound (EBUS) bronchoscope has an ultrasound transducer at its tip, which provides high-quality images of structures at the point of contact and allows a minimally invasive approach to real-time sampling of mediastinal lymph nodes.2 Only 2 case reports and 1 small case series have described the utilization of EBUS transbronchial needle aspiration (TBNA) for pediatric patients.1,3,4 Performing pediatric EBUS-TBNA usually requires general anesthesia (GA) or deep sedation [owing to the large diameter of the EBUS scope (6.8 to 7.4 mm) compared with pediatric trachea] and consequently is rarely performed and reported.1 Transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) using the EBUS bronchoscope has been described as a safe, efficacious, and potentially advantageous approach for mediastinal lymph node sampling in adults.5,6 Utilization of the EBUS bronchoscope for transesophageal ultrasonography evaluation and fine-needle aspiration has also been described in certain special situations in adults, wherein any obstructing pathology of the oropharynx or esophagus (like esophageal stricture) prevents the introduction of the larger-diameter EUS-FNA scope.7–9 For these reasons, we hypothesized that the pediatric esophagus should be able to accommodate the EBUS bronchoscope without risk of significant airway compromise. Herein, we report the successful and safe use of EUS-B-FNA for sampling of the subcarinal lymph nodes in a 3-year-old child.
A 3-year-old child presented with a history of fever and dry cough for 3 months. There was no history of chest pain, wheezing, hemoptysis, or contact with a tuberculosis (TB) patient. The child had normal development. His weight and height were 9.2 kg and 82 cm, respectively, and both were less than third centile for his age. Past history was not significant. On examination, the respiratory rate was 24/min, pulse rate 120/min, and saturation while breathing room air was 95%. General physical examination, examination of the respiratory system, and other systems were unremarkable. Chest radiograph demonstrated mediastinal widening (Fig. 1, left panel). Induced sputum smear examinations and gastric aspirates for acid-fast bacilli were negative and tuberculin skin test was negative (0 mm induration). Computed tomography scan of the thorax (Fig. 1, right panel) demonstrated multiple enlarged mediastinal lymph nodes at the lower right paratracheal and subcarinal lymph node stations. A clinical possibility of lymphoma was considered.
Oxygen was administered by nasal prongs, and the patient was positioned in slight lateral decubitus position. Under conscious sedation (intravenous midazolam), EUS-B-FNA was performed with the patient (fasting for 8 h) breathing spontaneously. Olympus BF-UC180F convex probe (6.8 mm diameter) EBUS scope was used. Topical spray of lignocaine was applied. The EBUS scope was advanced into the esophagus and enlarged lymph nodes were visualized at the subcarinal station. An EBUS-TBNA needle of 21 G (Olympus) was used for aspiration (3 aspirates obtained) and rapid onsite evaluation was performed. No other station was sampled as sampling adequacy by rapid onsite evaluation was confirmed after 3 aspirates from the subcarinal station. The patient remained hemodynamically stable throughout and there were no episodes of desaturation. Procedure duration was 15 minutes.
Cytopathologic examination demonstrated granulomatous inflammation compatible with TB. Stain for acid-fast bacilli was positive. In addition, the Xpert MTB/RIF test detected Mycobacterium tuberculosis, while rifampicin resistance was not detected. The child was initiated on antitubercular treatment with 4 first-line drugs and improved.
We herein describe the feasibility of safe mediastinal lymph node sampling in a 3-year-old child using EUS-B-FNA, under moderate conscious sedation.
In the first description of pediatric EBUS-TBNA, Wurzel et al4 reported the case of a 13-year-old with hilar mass, diagnosed as sarcoidosis. Siemsen et al3 described successful utilization of EBUS-TBNA for sampling hilar and subcarinal lymph nodes in a 6-year-old without any complications.3 Gilbert et al1 described performance characteristics of EBUS-TBNA in 21 children (age 13.7±4.1 y). Only a single patient younger than 5 years of age (GA was required) was reported. The larger external diameter of the EBUS scope limits its endotracheal introduction (EBUS-TBNA) in the very young pediatric population and, if so, usually requires GA or deep sedation. Of the 21 patients in the series reported by Gilbert et al,1 81% (17 patients) required GA (9 patients) or deep sedation (8 patients). Our report highlights that this difficulty can be circumvented by utilizing a transesophageal approach to the mediastinum (EUS-B-FNA) under moderate sedation thereby expanding the benefits of convex probe EBUS for the pediatric patients.
Diagnostic esophagogastroduodenoscopy examination in children weighing <10 kg is preferably performed using a <6 mm gastroscope. A standard adult gastroscope can be considered for use in children weighing 10 kg or more, but still most gastroenterologists prefer the smaller caliber instrument (ultrathin endoscope) for initial evaluation.10 Apart from limitations like difficulty in negotiating the upper esophageal sphincter, pylorus, and esophagus per se due to compression from endotracheal tube (if performed with the patient intubated), larger scopes also carry an associated risk for esophageal injury, perforation, or airway compromise. There are no pediatric-specific EUS-FNA scopes available. The standard adult linear EUS (FNA) scopes have an outer diameter of 12.1 to 14.6 mm, and it has been advised that their use may be considered only in patients weighing 15 kg or more.10 Therefore in light of these considerations, the EBUS bronchoscope (6 to 7.4 mm diameter) is an ideally suited instrument for endosonographic examination of the upper gastrointestinal tract and the surrounding structures in most of the pediatric population.
The average anteroposterior and transverse tracheal diameters in a 3-year-old boy are reported to be 7.4 (0.8) and 8.1 (0.7) mm, respectively, and the tracheal dimensions in our patient were quite similar.11 A detailed discussion was undertaken before the procedure by the multidisciplinary clinical team and it was decided that in view of the tracheal size and the most prominently enlarged lymph node being the subcarinal (ease of sampling it using the esophageal approach), the safest approach under the circumstances would be to perform EUS-B-FNA, and an endotracheal approach was deemed risky.
It has been highlighted in the last few years that EBUS has immense potential for utilization in the pediatric population.12 Despite this, there is scant literature on pediatric EBUS. Because of the large size of the EBUS scope it was proposed that children above 12 years of age or weighing >50 kg could safely undergo this procedure.12 Of the previous 23 reported cases of pediatric EBUS-TBNA, all except 2 patients were 9 years of age or older.1,3,4 Transesophageal approach as highlighted in our report can enable the expansion of the limits of utilization of EBUS for pediatric patients under moderate sedation.
Upper gastrointestinal endoscopic examinations are performed at our center in the lateral decubitus position, and this position also offers an advantage in terms of prevention of backward fall of the tongue to impinge on the upper airway. During the procedure, a complete team including the bronchoscopist, endoscopist, assistant, nurse, treating pediatrician, and 2 pediatric fellow residents were present to supervise the entire procedure. An anesthesiologist was available on standby. Although this technique is potentially better due to the need for lesser anesthesia and performance in the endoscopy suite, we suggest that a trained doctor (pediatrician/anesthesiologist) with familiarity in administering pediatric sedation and management of pediatric airway be present during the procedure in addition to the bronchoscopist, assistant, and the nurse.
Conventional TBNA has also been reported in pediatric patients with large subcarinal lymphadenopathy. Goussard and colleagues described performance of TBNA in 28 children with large subcarinal lymphadenopathy, wherein the diagnosis was unclear despite thoracic computed tomography scan and mostly patients with treatment failure. TBNA provided diagnosis in 15 of 28 patients as was the sole diagnostic modality in 7 patients. There were no serious procedure-related complications.13 Certain issues regarding safety of TBNA/EUS-B-FNA/EUS-FNA, such as the risk for mediastinitis and bacteremia, need to be considered, especially in pediatric patients. Although EUS-FNA is usually safe, infection can develop in necrotic lesions such as TB lymphadenopathy. Infectious complications were also reported with EBUS-TBNA in patients with TB lymphadenopathy. Development of serious infectious complications like pericarditis after EBUS-TBNA has also been reported.14 For EUS-FNA of solid-appearing lesions along the upper or gastrointestinal tract (like lymph nodes), routine use of prophylactic antibiotics for prevention of local infectious complications is not recommended. For EUS-FNA of cystic-appearing lesions (mediastinum), antibiotic prophylaxis for prevention of cyst infection is recommended.15 Therefore, antibiotic prophylaxis during EUS-B-FNA of solid lesions in pediatric patients may not be warranted. No serious infectious complications have been reported in previous reports of pediatric EBUS-TBNA.1,3,4
Despite the potential advantages of the transesophageal approach, there are limitations that it provides limited access to some mediastinal stations as compared with EBUS-TBNA. Advantages over EBUS-TBNA include improved access to the stations 5, 8, and 9 nodes and the obvious advantages of minimal anesthesia. It has also been highlighted that in certain situations EUS-B-FNA can provide technically easier sampling of nodes already visible by EBUS.6 Pediatric EUS-B-FNA needs further evaluation in larger studies.
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