1. Soft Tissues Mark Bromley PGY4 November 19, 2009
Lateral Neck X-Ray
Soft Tissues
Mark Bromley PGY4
November 19, 2009

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

3. Enlarged epiglottis
Loss of valecular airspace
Thickened aryepiglotic folds
Distended hypopharynx
Straightening of the cervical spine

4. Normal sagittal MR of an adult and lateral soft
tissue neck radiograph of a child showing normal
upper airway structures.
Adenoids (none in adult)
1. Adenoids
2. Vallecula
3. Epiglottis
4. Aryepiglottic folds
5. Subglottic trachea
6. Retropharyngeal soft tissues

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

6. When to order films… Sub-acute presentation Diagnosis is unclear
Impending airway embarrassment
 something else
Friend in the or
Triple set-up
Value judgement – you should be ashamed of your airway right now

7. Enlarged epiglottis
Loss of valecular airspace
Thickened aryepiglotic folds
Distended hypopharynx
Straightening of the cervical spine

9. Normal on left
Distended hypopharynx
Straightening spine
Lulu

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

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

13. Lateral neck radiograph demonstrating widening of the retropharyngeal space and reversal of the normal cervical spine curvature. The retropharyngeal space is considered widened if it is greater than 7 mm at C2 or 14 mm at C6. The epiglottis and sub-glottic area in this radiograph are normal
Longus colli

14. Widened retropharyngeal space
C2 – 7mm or C6 – 14mm (kids)
C6 – 22mm (adults)
Reversal of normal cervical lordosis
Foreign body
Air-fluid level
Gas

15. Retropharyngeal Infection
Widened retropharyngeal space
C2 – 7mm or C6 – 14mm (kids)
C6 – 22mm (adults)
Reversal of normal cervical lordosis
Foreign body
Air-fluid level
Gas
Give me 5 signs of retropharyngeal infection on lateral XR
Longus colli

17. False Pre-vertebral Swelling
Oblique lateral
Neck flexion
Crying
Give me 2 false positive scenarios
True lateral
Neck in slight extension – neutral
expiration

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

20. Tracheal membranes  irregularity, clouding
Clinical: toxic fevor stridor
Staph aureus

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

22. Barky cough
Croup – subglottic narrowing and distended hypopharynx
“ballooning” of pharynx
Subglottic edema

23. Steeple sign

24. Clinical: 6-24 months
Influenza, parainfluenza

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

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

28. Chickenbone  air

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

32. Questions?
Thank You!

34. 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%

35. h – middle of hyoid bone
e – highest point of epiglottis
t – thyroid cartilage
a – posterior surface of arytenoid bone
A line from point h and parallel to TA was drawn (HE) and the angle formed between HE and HE’ was called B’. HEE’ is triangle of safety.

37. Chicken bone at c7 – retropharyngeal air

39. Croup – steeple sign …may vary with respiration even in normal kids

40. Enlarged epiglottis
Loss of valecular airspace
Thickened aryepiglotic folds
Distended hypopharynx
Straightening of the cervical spine

41. Adult Epiglottitis Radiographic Criteria
Epiglottic height-to-width ratio >0.6
Epiglottic to C4 vertebral body width ratio >0.33
Aryepiglottic fold to C3 vertebral body width ratio >0.35
Prevertebral soft-tissue to C4 vertebral body width ratio >0.25
Hypopharyngeal airway to C4 vertebral body width ratio >1.5