right middle lobe syndrome in children
Introduction
Brief introduction of right middle lobe syndrome in children Middle right lobe syndrome in children is Middlelobesyndrome, also known as middle lobe-tongue syndrome in children, middle right lobe syndrome in children, acute temporary mid-leaf disease in children, chronic atelectasis in children with right middle lobe , Brock syndrome in children, Graham-Burford-Mayer syndrome in children. In 1937, it was first reported by Brock. Later generations called pediatric Brock syndrome. In 1948, Graham further studied that the enlarged lymph nodes were non-specific inflammation and were named as right middle lobe syndrome in children. In a narrow sense, it refers to obstructive pneumonia caused by the swelling of the bronchus, which causes the atelectasis of the middle lobe due to the swelling of the parabronchial lymph nodes belonging to the middle lobe of the right lung. Broadly speaking, any atelectasis or chronic inflammation limited to the middle lobe, regardless of its etiology, whether it is accompanied by parabronchial lymphadenopathy or bronchial lumen stenosis, can belong to the category of middle lobe syndrome. basic knowledge The proportion of illness: 0.15% Susceptible people: children Mode of infection: non-infectious Complications: bronchiectasis, lung abscess, empyema, anemia
Cause
The cause of right middle lobe syndrome in children
Primary factor (30%):
This symptom is not caused by a single factor. Any inflammatory lesion that can cause hilar lymphadenopathy and oppression of the right middle lobe or left lung lingual bronchus can cause pneumonia and atelectasis. The cause of this disease can be non-specific pneumonia. And lymphadenitis, causing swelling of the surrounding lymph nodes, compression of the bronchial obstruction, causing atelectasis, or inflammation of the middle lobe itself, severe cases may involve the pleura, bronchial lymphatic tuberculosis, sarcoidosis, etc. can cause this disease.
Secondary factors (35%):
There are three types of causes of middle lobe syndrome: tuberculosis (such as primary tuberculosis), inflammatory lesions in the right middle lobe and other (tissue cytoplasmosis, sarcoidosis, etc.), pediatric mid-leaf syndrome often associated with asthma Especially in the persistent state of asthma, it may have a certain relationship with the lack of alveolar surface tension factor, and the cause of deficiency is related to changes in pH and oxygen tension.
Congenital factors (35%):
Pediatric middle lobe syndrome may be related to genetic factors, as Hartl reported that 5 children in a family, 3 of them had middle lobe syndrome, and Dees reported 30 children with pulmonary middle lobe syndrome, 9 males, female 21 For example, boys with asthma are different from boys. At the same time, 1 case of middle lobe syndrome occurred 2 weeks after birth, and her sister also had difficulty breathing and wheezing in the first month after birth. Both sisters had IgA deficiency, which may be related to genetic factors.
Pathogenesis
1. Anatomical features: The right middle lobe is prone to atelectasis because the middle lobe is relatively slender compared to other bronchi. The opening is located at the junction of the upper and lower lobe lymphatic drainage, surrounded by lymph nodes, and is therefore susceptible to compression of swollen lymph nodes. Erosion, formation of stenosis and obstruction, the middle bronchus is not only slender, and intersects with the right common bronchus at an acute angle, so the drainage is not smooth, easily blocked by congenital secretions and mucosal edema, and because the middle lobe is small, located between the upper and lower leaves , anatomically relative independence, but lack of collateral ventilation, more prone to atelectasis.
2. Inflammation: In children with primary pulmonary tuberculosis, swollen lymph nodes compress the middle lobe bronchus and cause middle lobe syndrome. In addition, swollen lymph nodes corrode the bronchus to cause bronchial perforation, and cheese-like tissue and granules can block the middle lobe bronchus, causing middle lobe syndrome. Inflammatory lesions caused by the right middle lobe itself, bronchial mucosal inflammation in the middle lobe, edema narrows the lumen, the lumen is filled with mucus, white blood cells and debris, obstructing bronchial drainage, and the lymph nodes surrounding the drain are swollen. The bronchus can be compressed, and it is more likely to cause obstruction. The obstruction aggravates the infection and makes the lymph nodes more swollen, forming a vicious circle of mutual causality. Dees reported that among the 30 children with right middle lobe syndrome, 23 were of a reactive physique. Laboratory findings also indicate the presence of an infection.
3. Pathological staging
(1) The first phase (lung atelectasis): This period has symptoms of acute lymphadenitis and middle lobe atelectasis, but no symptoms of obstructive pneumonia.
(2) The second phase (obstructive pneumonia phase): There is obstructive pneumonia, which forms the initial clinical symptoms of this disease. During this period, X-ray findings are difficult to distinguish from general pneumonia.
(3) The third stage (restoration or progression): If the treatment is proper, the lymph nodes shrink, the circulation is smooth, the inflammation subsides, the obstruction disappears, and the atelectasis is opened. If the treatment is not proper, the obstruction lasts and the lungs are substantially inflamed, which will form. Bronchiectasis and chronic fibrosis of the lung tissue may even form a lung abscess or empyema.
Prevention
Prevention of right middle lobe syndrome in children
For non-specific pneumonia and/or allergic reactions, treatment with antibiotics, sputum, anti-allergy, etc. during acute attack will completely cure infection and inflammation; it can prevent middle lobe syndrome.
Complication
Complications of right middle lobe syndrome in children Complications, bronchiectasis, lung abscess, empyema, anemia
Repeated pneumonia or asthmatic bronchitis can cause bronchiectasis, chronic fibrosis of the lung tissue, and even form a lung abscess or empyema. Can cause anemia and nutritional deficiencies.
Symptom
Symptoms of right middle lobe syndrome in children Common symptoms Repeated pneumonia, atelectasis, swollen lymph nodes, chronic cough, weight loss, fatigue, purulent sputum, blood, weakened breath sounds
Children often have repeated pneumonia from 1 to 2 years old, generally diagnosed with middle lobe syndrome in 4 to 8 years old, children with long-term cough, school children can cough mucus, late purulent, occasional hemoptysis and cough stones, repeated children Suffering from pneumonia or asthmatic bronchitis, have difficulty breathing, fever, severe bruising, signs of wheezing, wet voice, dry voice, right lung can have a weakened breath sound, a few can be heard in the right middle lobe area Breathing sound is weakened, percussion is dull, the disease is long, the weight is reduced, the anteroposterior diameter of the thorax is widened, and a few can have clubbing (toe). This symptom can be seen in children and any other age, often acute onset, fever, repeated Hemoptysis and pneumonia, intermittent cough and fatigue in the intermittent period, pneumonia signs in acute attacks, intermittent bronchiectasis or chronic lung suppuration signs, acute inflammation or foreign body caused by acute onset, tuberculosis caused by slow onset, The chest X-ray has a triangular shadow on the anterior arch, the base is fused to the heart, the tip is toward the lung field, and in the right anterior position, the middle lobe is a dense shadow with uniformity or unevenness, and the edge is blurred. Like inflammatory lesions.
The middle lobe syndrome should have the following three conditions:
1 middle lobe bronchial lymph node enlargement.
2 bronchoconstriction.
3 middle lobe atelectasis and obstructive pneumonia.
Examine
Examination of right middle lobe syndrome in children
1. White blood cell count: The total number of children with some diseases increased, and neutrophils increased.
2. ESR increases.
3. Pathogen examination: The bacterial culture of the secretion is mostly hemolytic streptococcus, pneumococci, staphylococcus aureus, gram-negative bacilli, etc. In the later stage of tuberculosis, tubercle bacilli can be found, and only non-specific bacteria can be found.
4. Tuberculin test: mostly negative.
5. Immunity test: Pay attention to the exclusion of Ig deficiency.
6. X-ray examination: great help for diagnosis.
(1) posterior anterior position: visible in the lower part of the right hilum, with a shadow of increased density next to the right heart edge into a triangular shadow. Its size, shape, position and density may vary depending on the degree of atelectasis and the severity of inflammation. The upper boundary of the shadow is clearer, and does not exceed the median position of the hilar shadow. The edges of other parts are unclear, and the horizontal leaf gap is shifted downward.
(2) anterior arch position: a typical triangular shadow is visible, the base is mediastinum, the tip is toward the lung field, and the edges on both sides are sharp.
(3) Right side: A fusiform shadow can be seen in the middle lobe, and the lumps or lymph node calcification can be observed in the hilar area. According to the change of the leaf space, the degree of atelectasis and pleural adhesion can be easily seen in the lateral position. In the case of the disease, the lateral position is more important in the diagnosis of this condition.
7. Bronchial angiography: It has certain value for the diagnosis of this disease. It can show the middle bronchus and its branches. If the middle bronchus and its branches can not be filled or poorly filled, the area of the middle bronchus is obviously reduced, indicating the middle lobe. Atelectasis, angiography has a certain value for the diagnosis of this disease.
8. Bronchoscopy: It can be found that the bronchial mouth of the middle lobe is compressed, the mucous membrane is red and swollen or the secretion is blocked. Sometimes the X-ray examination changes slightly and the bronchoscopy can find obvious abnormalities. The foreign body can be found and removed, and the secretion is identified and sucked out. The middle leaves have the possibility of re-expansion.
9. Pulmonary function test: In patients who need to cooperate with surgery in children over 6 years old, the lung capacity can be measured, and the amount of exhaled force is used in 1 second.
Diagnosis
Diagnosis and diagnosis of right middle lobe syndrome in children
The clinical manifestations of this disease are non-specific. The clinical symptoms and signs are not easy to be diagnosed. According to the clinical symptoms, X-ray chest X-ray and other auxiliary examinations are needed for diagnosis. The angiography can show the middle bronchus and its branches. The diagnosis needs to be carried out at the same time, so that reasonable treatment can be carried out as soon as possible.
The disease should be differentiated from the inter-leaf pleural effusion, the latter is more ambiguous in the anterior arch position, often bulging in a full state; and accompanied by adjacent pleural changes between the leaves, while the former in the anterior arch position as a sharp edge triangle shadow.
