Lateral Neck XRay Soft Tissues Mark Bromley PGY

Lateral Neck X-Ray Soft Tissues Mark Bromley PGY 4 November 19, 2009

Outline Relevant Anatomy Cases Epiglottitis Retropharyngeal Abscess Bacterial Tracheitis Croup FB Test Characteristics

Case 1 4 year old male Inspiratory stridor Unwell for past 24 hours Mom found him in his room with increased work of breathing

When to order films… Sub-acute presentation Diagnosis is unclear Impending airway embarrassment something else

Epiglottitis Enlarged epiglottis Loss of valecular airspace Thickened aryepiglotic folds Distended hypopharynx Straightening of the cervical spine Sensitivity (38 -88%) Specificity (78%) Croup and epiglottitis: a radiologic study. AU Stankiewicz JA; Bowes AK SO Laryngoscope 1985 Oct; 95(10): 1159 -60. Epiglottitis and croup. AU Sobol SE; Zapata S SO Otolaryngol Clin North Am. 2008 Jun; 41(3): 551 -66, ix. Adult epiglottitis: the Toronto Hospital experience. AU Solomon P; Weisbrod M; Irish JC; Gullane PJ SO J Otolaryngol. 1998 Dec; 27(6): 332 -6.

Case 1 4 year old male Inspiratory stridor Unwell for past 24 hours Mom found him in his room with increased work of breathing

Retropharyngeal Infection Widened retropharyngeal space C 2 – 7 mm or C 6 – 14 mm (kids) C 6 – 22 mm (adults) Reversal of normal cervical lordosis Foreign body Air-fluid level Gas

False Pre-vertebral Swelling Oblique lateral Neck flexion Crying

Case 1 4 year old male Inspiratory stridor Unwell for past 24 hours Mom found him in his room with increased work of breathing

Case 1 3 year old male Inspiratory stridor Unwell for past 24 hours Mom found him in his room with increased work of breathing

Case 1 4 year old male Inspiratory stridor Unwell for past 24 hours Mom found him in his room with increased work of breathing

Foreign Body Visualization of radiopaque FB Widened pre-vertebral shadow Loss of lordosis Location Esophagus – coronal plane Trachea – sagittal plane (best seen on lateral)

Test Characteristics Sensitivity Specificity Epiglottitis 33 -88% 78% Retropharyngeal abscess 80% 100% Croup Foreign Body 84%

Questions? Thank You!

Triple blinded prospective study 100 elective surgery patients Lateral neck x-ray compared with Mallampati Anesthesiologist gold standard (grade III or IV) Results Mallampati sens: 26% spec: 100% Lateral neck film: sens: 100% spec: 100%

Adult Epiglottitis Radiographic Criteria Epiglottic height-to-width ratio >0. 6 Epiglottic to C 4 vertebral body width ratio >0. 33 Aryepiglottic fold to C 3 vertebral body width ratio >0. 35 Prevertebral soft-tissue to C 4 vertebral body width ratio >0. 25 Hypopharyngeal airway to C 4 vertebral body width ratio >1. 5