This morning while we were visiting the pulmonologist, of all people, we got some interesting news! We were discussing Ian’s habit of retching and all of the mucus he has. Not only does he think Ian has chronic sinusitis, which is creating LOTS of mucus drainage that is unable to flow past the Nissen, causing it to backflow and causing him to retch, cough, gag, and spit it up........... but........... he would like Ian to have a head MRI. While at the appointment, he mentioned that there can be some neurological reasons for Ian’s symptoms in reflux. He thinks there might be a second reason for the reflux, other than the prematurity and underdeveloped lower-esophageal sphincter muscles at the base of the esophagus.
He asked if Ian had a sacral dimple..... which he does! A sacral dimple is literally a depression, or dimple, at the base of the spinal cord... right above little baby Ian’ butt crack. This is an area where there was some type of discrepancy in the formation of the spinal cord. Ian’s was discovered in the hospital NICU. They are often associated with spina bifida. Ian had an ultrasound in the NICU and the dimple is “closed.” There is no exposure to outside access, hence, no spina bifida and no need for surgical repair. We have known this since Ian was born.
Now, for the interesting part! The reason he was asking if Ian had one of those is it can go hand in hand with what he is looking for in the MRI that could be causing so many problems.......... an Arnold-Chiari Malformation! This is a malformation of the brain where it is “downplaced” into the opening of the base of the skull. This opening is called the foramen magnum, and the spinal cord travels from the brain, through the foramen (hole) and down through the vertebrae. In this malformation, a portion of the base of the brain, such as the cerebellum and brain stem are forced down through this foramen. This can cause all types of issues with the vagus nerve, which is a cranial nerve. Nausea, reflux, mucus, and all sorts of things. This malformation is formed during the early stages of embryonic development and is in no way associated with his prematurity.
There are three types of malformations depending on the degree of the placement. Various symptoms may or may not occur. Many are asymptotic until adulthood and it is not discovered until the condition worsens. The pulmonologist believes this is more common than realized. He has mentioned previously that Ian has a large head, and he does, in relation to proportional growth percentiles. He would like Ian to have a head MRI done. The frequency of the malformation in the population is debatable since many with a “I” classification never have symptoms or do not well into adulthood.
The treatment for this is surgery. Surgery is the only way to *permanently* fixed the malformation. We have a call in to the hospital to get the MRI scheduled. The idea is out there, but not too far out there. It may help us gather another piece of the puzzle.
Ian's vagus nerve, as shown above, is the one affected if this is the case.
Ian is also now taking Nasonex to help with the chronic mucus produced by the aggravated goblet cells in the glands over all the months of reflux irritation. This should help less *drain* into the esophagus and less *trying* to get past the Nissen. When it cannot pass through the Nissen, and backs up, it creates coughing and retching, and snoring!! He also gave us an antibiotic for the chronic sinusitis infection he believes is present. This 20 day medication will help him calm and clear his sinuses.
When we hear more about the MRI, we will follow up. We are looking forward to seeing if there are any neurological reasons for Ian’s current issues.