The role of computerised tomographic angiograms (CTA) and lateral neck radiographs in penetrating neck oesophageal injuries

Oompie, Ferdinand Musawenkosi

The role of computerised tomographic angiograms (CTA) and lateral neck radiographs in penetrating neck oesophageal injuries

Master Thesis

2019

Abstract

Background South Africa has a high rate of injuries related to violence which includes penetrating neck injuries (PNI’s). Of the 163 patients that are annually referred for contrast swallow studies to exclude associated pharyngo-oesophageal injuries (PPOI’s), only 0-14% contrast studies confirm injury. The contrast swallow is still viewed as the ‘gold standard’ for oesophageal pathology even in the modern era of digital general radiography and Multidetector Computerized Tomographic Angiogram (MDCTA). This procedure is however time consuming and requires good cooperation, sometimes from acutely ill patients which is not always possible. This contributes to delay in final management of the patient which is the most significant contributor to associated complications. The study reviewed whether the less time-consuming MDCTA’s and lateral soft tissue radiographs usually performed before the contrast swallow studies can also be used to diagnose POI’s. This will reduce dependence and possibly exclude the contrast swallow study, thus reducing the time delay in POI pre-operative investigations. Methods A retrospective review was undertaken of the radiological findings of all patients who presented at Groote Schuur Hospital over a 28-month period with suspected penetrating neck injuries and were investigated with a contrast swallow, MDCTA and lateral soft tissue radiograph. The time interval between request of the contrast swallow study and the final report was calculated as the difference in the time indicated on the Groote Schuur Hospital Philips Extended Internet Radiology Information System (XIRIS) by the requesting clinician and the time indicated on the radiology report after completion of the study on the Philips Picture Archiving and Communicating System (PACS). Results Of the 389 patients referred, 153 patients met the study criteria. Fourteen patients (9%) had PPOI’s on contrast swallow. The majority of the patients with PPOI’s had prevertebral air (12; sensitivity of 85.7%), however a majority of patients with prevertebral air had no POI’s (90; specificity of 35.3%). In 28 MDCTA’s where there was suspicion of PPOI’s, six contrast swallows confirmed oesophageal leaks (42.9% sensitivity). Although there was no suspicion of PPOI’S in 125 patients undergoing MDCTA’s, eight were found to be positive for leaks on contrast swallow (84.2% specificity). The mean time interval between request of the contrast swallow study and final report was 586 minutes. Conclusion Contrast swallow remains the gold ‘standard’ for diagnosing PPOI’s in patients with PNI’s. The lateral soft tissue radiograph was unreliable in predicting POI’s with a low specificity of 35%. MDCTA’s was also not contributory in assisting diagnoses of PPOI’s with a low sensitivity of 43%. The two modalities can thus not be considered as augmentation or alternative diagnostic modalities. The time delay between the request and reporting of the contrast swallow is longer than that in literature and needs improvement.

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