Lateral Neck Radiograph Research Articles

Evaluation of Dentofacial Angles in Children with Severe Adenoid Hypertrophy.

Hypertrophy of adenoids is a common condition in childhood, resulting in obstructive symptoms such as sleep apnea, snoring, and rhinosinusitis. Adenotonsillectomy is recommended to improve prognosis and quality of life. This case-control study compared facial angles and lip position related to dentofacial and mouth growth in symptomatic children with adenoid hypertrophy and asymptomatic control groups. The study included children aged 5 to 7 who presented with obstructive symptoms and confirmed severe adenoid hypertrophy in lateral neck radiography. Standard lateral photography was taken. The Nasofacial and Nasomental angles, and upper and lower lip positions and their distance behind the Ricketts line, were measured and compared with the normal control group. This study included 54 children with severe adenoid hypertrophy and 66 normal children. Facial angles were not significantly different between the two groups, but the mean horizontal position of the upper and lower lip in children with adenoid hypertrophy was significantly lower than in the control group (P value = 0.05). The lips were too close to the Ricketts line compared with the control group. This research demonstrates that children with severe adenoid hypertrophy have more dentofacial disorders than others. Adenotonsillectomy surgery is necessary for children with obstructive symptoms caused by tonsil enlargement, and if symptoms like snoring persist post-surgery, complementary orthodontic treatments should be considered.

Successful Management of Retropharyngeal Lymphangioma with Stridor Using Sirolimus: A Case Report.

Lymphatic malformations (LMs) are one of the congenital malformations of the lymphatic system in the body. The patient usually presents with head and neck swelling, airway compression, and/or airway obstruction. The diagnosis of retropharyngeal LMs can be challenging due to their rare occurrence. We report a case of a five-month-old boy diagnosed with retropharyngeal LMs. He presented with a three-day history of fever, cough, and stridor and was initially treated for acute bronchiolitis. A lateral neck radiograph revealed prevertebral widening, suggesting retropharyngeal collection. The patient's condition worsened, requiring intubation in the operating room and proceeding with aspirations and drainage. However, the symptoms recurred after a few days, necessitating re-intubation, repeated aspirations and drainage procedures. The patient was intubated, and the neck's magnetic resonance imaging (MRI) confirmed retropharyngeal LMs. An elective tracheostomy was performed and was treated with sirolimus. The patient had a successful tracheostomy decannulation and showed no recurrence during follow-up.

Lateral neck radiography: the case is not closed.

Lateral neck radiography: the case is not closed.

Improving detection of impacted animal bones on lateral neck radiograph using a deep learning artificial intelligence algorithm

ObjectiveWe aimed to develop a deep learning artificial intelligence (AI) algorithm to detect impacted animal bones on lateral neck radiographs and to assess its effectiveness for improving the interpretation of lateral neck radiographs.MethodsLateral neck radiographs were retrospectively collected for patients with animal bone impaction between January 2010 and March 2020. Radiographs were then separated into training, validation, and testing sets. A total of 1733 lateral neck radiographs were used to develop the deep learning algorithm. The testing set was assessed for the stand-alone deep learning AI algorithm and for human readers (radiologists, radiology residents, emergency physicians, ENT physicians) with and without the aid of the AI algorithm. Another radiograph cohort, collected from April 1, 2020, to June 30, 2020, was analyzed to simulate clinical application by comparing the deep learning AI algorithm with radiologists’ reports.ResultsIn the testing set, the sensitivity, specificity, and accuracy of the AI model were 96%, 90%, and 93% respectively. Among the human readers, all physicians of different subspecialties achieved a higher accuracy with AI-assisted reading than without. In the simulation set, among the 20 cases positive for animal bones, the AI model accurately identified 3 more cases than the radiologists’ reports.ConclusionOur deep learning AI model demonstrated a higher sensitivity for detection of animal bone impaction on lateral neck radiographs without an increased false positive rate. The application of this model in a clinical setting may effectively reduce time to diagnosis, accelerate workflow, and decrease the use of CT.

Using Transfer Learning of Convolutional Neural Network on Neck Radiographs to Identify Acute Epiglottitis.

Acute epiglottitis (AE) is a life-threatening condition and needs to be recognized timely. Diagnosis of AE with a lateral neck radiograph yields poor reliability and sensitivity. Convolutional neural networks (CNN) are powerful tools to assist the analysis of medical images. This study aimed to develop an artificial intelligence model using CNN-based transfer learning to identify AE in lateral neck radiographs. All cases in this study are from two hospitals, a medical center, and a local teaching hospital in Taiwan. In this retrospective study, we collected 251 lateral neck radiographs of patients with AE and 936 individuals without AE. Neck radiographs obtained from patients without and with AE were used as the input for model transfer learning in a pre-trained CNN including Inception V3, Densenet201, Resnet101, VGG19, and Inception V2 to select the optimal model. We used five-fold cross-validation to estimate the performance of the selected model. The confusion matrix of the final model was analyzed. We found that Inception V3 yielded the best results as the optimal model among all pre-train models. Based on the average value of the fivefold cross-validation, the confusion metrics were obtained: accuracy = 0.92, precision = 0.94, recall = 0.90, and area under the curve (AUC) = 0.96. Using the Inception V3-based model can provide an excellent performance to identify AE based on radiographic images. We suggest using the CNN-based model which can offer a non-invasive, accurate, and fast diagnostic method for AE in the future.

Effect of adenoidal enlargement on development of otitis media with effusion

Background Adenoid hypertrophy has a major effect on development of middle ear effusion not due to the large volume but through combination of factors including local immune regulation, biofilm, and immunoglobulin E allergic reaction. Aim To assess the correlation between adenoid tissue volume and development of middle ear effusion. Patients and methods This was a sequential analysis study including a sample size of 195 patients from 4 to 12 years. They were diagnosed with adenoid hypertrophy, confirmed by flexible nasopharyngeal endoscopy (FNE) and lateral neck radiographs. They were evaluated by tympanometry to assess otitis media with effusion. Results We found that 59 (29.2%) patients had FNE grade 1, 68 (35.4%) patients had FNE grade 2, 68 (35.4%) patients had FNE grade 3, and no patients had grade 4. A total of 101 (52.6%) patients had a tympanogram type A and 94 (47.4%) patients had a tympanogram type B. There was no statistically significant correlation between tympanogram groups in relation to the FNE (P=0.762). Conclusion We suggested that there was no valuable correlation between change in size or volume of adenoid tissue and development of middle ear effusion.

RELATIONSHIP BETWEEN CLINICAL SYMPTOM SEVERITY SCORE AND ADENOID-NASOPHARYNX RATIO IN PAEDIATRIC PATIENTS WITH ADENOID HYPERTROPHY

Objective: The aim of the study was to assess the clinical symptoms severity score of adenoid hypertrophy in paediatric patients, to determine the relation between the clinical symptoms severity score and Adenoid-nasopharynx ratio and to determine the adenoid nasopharynx ratio in relation to the age of the patient. Methodology It is an Observational, prospective based study. The chart of 41 patients who presented to GMCH, ENT OPD with complaint of nasopharyngeal obstruction due to the adenoid. All the children were clinically and radiologically assessed between (JAN 2020 to JUNE 2021). ResultsAmong 41 patients, female preponderance was observed. Majority of the patients were in the age group of 11-15 years. Snoring were observed to be the commonest type of lesions in both male and female. Mouth breathing was equally common in either sex. In our study, Apnea was seen in one patient each of male and female. The diagnosis based on clinical and radiological assessment were highly accurate. Conclusion: The A/N ratio has a strong relationship with actual adenoid measurement. Lateral neck radiography is a low-cost, readily available procedure with few side effects that could be used to treat adenoid hypertrophy.

Diagnostic accuracy of deep learning for evaluation of C-spine injury from lateral neck radiographs

BackgroundTraumatic spinal cord injury (TSI) is a leading cause of morbidity and mortality worldwide, with the cervical spine being the most affected. Delayed diagnosis carries a risk of morbidity and mortality. However, cervical spine CT scans are time-consuming, costly, and not always available in general care. In this study, deep learning was used to assess and improve the detection of cervical spine injuries on lateral radiographs, the most widely used screening method to help physicians triage patients quickly and avoid unnecessary CT scans. Materials and methodsLateral neck or lateral cervical spine radiographs were obtained for patients who underwent CT scan of cervical spine. Ground truth was determined based on CT reports. CiRA CORE, a codeless deep learning program, was used as a training and testing platform. YOLO network models, including V2, V3, and V4, were trained to detect cervical spine injury. The diagnostic accuracy, sensitivity, and specificity of the model were calculated. ResultsA total of 229 radiographs (129 negative and 100 positive) were selected for inclusion in our study from a list of 625 patients with cervical spine CT scans, 181 (28.9%) of whom had cervical spine injury. The YOLO V4 model performed better than the V2 or V3 (AUC = 0.743), with sensitivity, specificity, and accuracy of 80%, 72% and 75% respectively. ConclusionDeep learning can improve the accuracy of lateral c-spine or neck radiographs. We anticipate that this will assist clinicians in quickly triaging patients and help to minimize the number of unnecessary CT scans.

Correlation of Rhinomanometry Measurement and True Lateral Radiography towards the Degree of Upper Airway Obstruction in Patients with Adenoid Hypertrophy

Background: Adenoid hypertrophy is one of the most common disorders in children which may lead to upper airway obstruction. Various modalities to measure airway obstruction in patients with adenoid hypertrophy, including true lateral radiographs, nasoendoscopy, and rhinomanometry are available; however, the results from different studies are still controversial. This study aimed to determine the relationship between the results of rhinomanometry and the true lateral radiographs to the degree of upper airway obstruction in patients with adenoid hypertrophy. Methods: This cross-sectional study included a total of 33 patients with adenoid hypertrophy aged 5-18 years using a purposive sampling technique. Patients diagnosed with adenoid hypertrophy were subjected to a true lateral examination using lateral neck radiographs to measure the degree of airway obstruction. Subsequently, an active anterior rhinomanometry was performed by measuring resistance and nasal airflow and then measuring the degree of airway obstruction. Data analysis was done using Chi-Square test. Results: The rhinomanometric nasal resistance in the inspiratory phase was 0.4159 ± 0.15201 Pa/cm3/s and 0.3694 ± 0.13717 Pa/cm3/s in the expiration phase. The results showed a significant relationship between the true lateral radiographs and both nasal inspiratory (p=0.005) and expiratory resistance (p=0.004). Similarly, the relationship between the true lateral radiographs and nasal airflow on both inspiratory and expiratory rhinomanometry was significant (p<0.05). Conclusion: Rhinomanometric measurements can be used as an additional objective examination in assessing the degree of upper airway obstruction in patients with adenoid hypertrophy prior to surgery.

Updates in Diagnosis and Management of Croup

Croup is a common respiratory disease that affects 3% of children aged six months to three years. It represents 7% of annual hospital admissions for fever and/or acute respiratory disease in children under the age of five. Boys are more susceptible than girls to the condition, with an overall male/female predominance of 1.4/1. Viruses are detected in up to 80% of patients with croup with identifiable pathogens. The onset of symptoms is usually sudden and usually occurs at night: stridor, hoarse voice and respiratory distress are often seen due to upper airway obstruction. Croup is a clinical diagnosis, children with an uncertain diagnosis, anterior and lateral soft-tissue neck radiographs may be useful to support an alternative diagnosis. Management includes: general care, humidified air, heliox, corticosteroids, and epinephrine, Objective: This study aimed to discuss croup in terms of its etiology, pathogenesis, clinical features, diagnosis, assessment, and finally management.

Case report of acute epiglottitis in a 44-year-old man: a rare case

Background: Acute epiglottitis, also known as supraglottitis or supraglottic laryngitis, is an acute inflammation of the supraglottic area of the larynx. The diagnosis can be made based on clinical signs and symptoms as well as several investigations.Case Description: We reported a case of a 44-year-old man who presented to our emergency department and whose condition was ultimately diagnosed as epiglottitis. Indirect laryngoscopy and lateral soft tissue neck radiograph had an important role in determining the diagnosis. The patient was treated conservatively by giving a high dosed antibiotic, anti-inflammatory, and analgesic drugs.Conclusion: Acute epiglottitis can be a life-threatening condition because it can cause sudden upper airway obstruction. Therefore, management must be given quickly and precisely so as not to fall into a life-threatening condition.

Migrated Foreign Body of Upper Digestive Tract-A Ten-Year Institutional Experience.

The ingested foreign body is one of the commonest emergencies encountered by otolaryngologists Depending on the shape and duration of impaction, a small number of foreign bodies (1-2%) can perforate the wall of the gastrointestinal Tract. A migrated foreign body may remain quiescent or cause life-threatening suppurative and vascular complications. Data were collected retrospectively from the hospital records in a tertiary care hospital in South India from 2010 to 2020. Fifteen patients diagnosed with migrated foreign body and who underwent neck exploration were included in the study. Demographic details, mode of presentation, clinical and radiological findings, rigid esophagoscopy findings, neck exploration techniques employed were noted. The mean age of the patients was 37.66years. All patients had a history of dysphagia, odynophagia, and point tenderness. All the patients underwent a lateral neck radiograph, and it was positive in 12 patients (80%), while in 3 patients (20%), it was negative. All the patients had a positive finding in Contrast-Enhanced Computed Tomography. Esophagoscopy was done prior to neck exploration to identify the site of injury and the probable site of migration. All the patients underwent lateral neck exploration, and foreign body was removed. Migrated foreign body can cause significant morbidity and mortality if not diagnosed and managed early. Strong suspicion and a systematic approach are needed for the diagnosis and management.

Advantages of Cold-knife Dissection with Adjunctive Suction Cauterization Adenotonsillectomy: A Useful and Safe Surgical Technique for Pediatric Patients

Background and Objectives To introduce cold-knife dissection with adjunctive suction cauterization (CDASC) technique for pediatric adenotonsillectomy and to evaluate the advantages of this technique through short and long-term follow-up results.Subjects and Method Enrolled in the study were 492 subjects with a mean age of 6.5 years, who underwent adenotonsillectomy via the CDASC technique. Surgical outcomes were evaluated through the postoperative bleeding rate, days of normal diet (as a measure of pain), and improvement of obstructive symptoms at regular follow-up visits. Intraoral photography and lateral neck radiography were analyzed for long-term surgical outcomes.Results None of the enrolled patients revisited the hospital due to hemorrhage, indicating 0% immediate and delayed postoperative bleeding with this surgical technique. Most of the patients showed normal diet consumption and activity within 3 days. Postoperative intraoral photography after 6 and 12 months were graded as normal (grade 0) in 77.5% and 79.7% of the enrolled patients, respectively. Postoperative adenoid to nasopharyngeal ratios were significantly reduced (p<0.05) and no recurrence of snoring and adenoid regrowth were demonstrated during the follow-up period of 12 months.Conclusion Our CDASC technique seems to have several advantages including less postoperative pain, no postoperative bleeding, less scarring, and no recurrence of preoperative symptoms. We suggest that our CDASC technique is a very useful, safe, and effective method of surgery for pediatric adenotonsillectomy.

Early recognition and critical management of adult epiglottitis in the emergency department: a case report and review of the literature

Background: Acute epiglottitis was considered a disease of the pediatric population. However, it has constantly been a report of a certain number of adult cases. Death by airway obstruction is caused by delayed diagnosis and untimely invasive airway management contributing to the higher mortality rate in adults. Case presentation: We presented a case of a 24-year-old male patient without significant underlying condition, who presented at our emergency department with a progressive sore throat and high-graded fever for one day. After a set of investigations, the patient was diagnosed with acute epiglottitis, and airway management was managed accordingly. His conditions improved after a course of antibiotic treatment during hospital admission. Conclusion: Acute epiglottitis in adults is not frequently encountered in the emergency department. This case underlines the importance of clinical suspicions in cases with consistent symptoms as well as the excellent utility of lateral neck radiography for the diagnosis of this life-threatening entity.

Automatic Detection of Inadequate Pediatric Lateral Neck Radiographs of the Airway and Soft Tissues using Deep Learning.

To develop and validate a deep learning (DL) algorithm to identify poor-quality lateral airway radiographs. A total of 1200 lateral airway radiographs obtained in emergency department patients between January 1, 2000, and July 1, 2019, were retrospectively queried from the picture archiving and communication system. Two radiologists classified each radiograph as adequate or inadequate. Disagreements were adjudicated by a third radiologist. The radiographs were used to train and test the DL classifiers. Three technologists and three different radiologists classified the images in the test dataset, and their performance was compared with that of the DL classifiers. The training set had 961 radiographs and the test set had 239. The best DL classifier (ResNet-50) achieved sensitivity, specificity, and area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI]: 0.86, 0.94), 0.82 (95% CI: 0.76, 0.90), and 0.86 (95% CI: 0.81, 0.91), respectively. Interrater agreement for technologists was fair (Fleiss κ, 0.36 [95% CI: 0.29, 0.43]), while that for radiologists was moderate (Fleiss κ, 0.59 [95% CI: 0.52, 0.66]). Cohen κ value comparing the consensus rating of ResNet-50 iterations from fivefold cross-validation, consensus technologists' rating, and consensus radiologists' rating to the ground truth were 0.76 (95% CI: 0.63, 0.89), 0.49 (95% CI: 0.37, 0.61), and 0.66 (95% CI: 0.54, 0.78), respectively. The development and validation of DL classifiers to distinguish between adequate and inadequate lateral airway radiographs is reported. The classifiers performed significantly better than a group of technologists and as well as the radiologists.© RSNA, 2020.

Diagnostic Accuracy of Lateral Neck Radiography for Esophageal Foreign Bodies in Adults.

OBJECTIVE. The objective of our study was to evaluate the accuracy of signs on lateral neck radiography for the assessment of patients with suspected esophageal foreign bodies (FBs). MATERIALS AND METHODS. This retrospective study was conducted of 235 adult patients between January 2012 and December 2017. Group 1 was composed of 95 patients with esophageal FBs, and group 2 was composed of 140 patients without esophageal FBs. Four signs on lateral neck radiography were recorded in both groups: presence of abnormal radiopaque density, presence of abnormal air column lucency, loss of cervical lordosis, and increased prevertebral soft-tissue thickness. The prevertebral thickness was also evaluated in three groups of patients categorized by patient age: 19-29 years old, 30-59 years old, and 60 years old or older. RESULTS. The accuracy of the presence of abnormal radiopaque density, presence of abnormal air column lucency, loss of cervical lordosis, and increased prevertebral soft-tissue thickness was 84.3%, 66.8%, 54.0%, and 60.9%, respectively. Combined two signs of presence of radiopaque density with air column lucency provided the highest accuracy, 90.6%. The prevertebral thickness at C6 of group 1 was 14.28 ± 3.19 mm (mean ± SD), and the prevertebral thickness at C6 of group 2 was 13.34 ± 2.54 mm (p = 0.018). CONCLUSION. Lateral neck radiography is helpful for the initial evaluation of patients with suspected esophageal FBs. The presence of radiopaque density or air column lucency provided the highest practical diagnostic value. Loss of cervical lordosis, as a single diagnostic sign, did not seem to provide a diagnostic advantage. Despite the variations in values for the three age groups, clinicians should be alert regarding increased prevertebral thickness at C6 especially when it is more than 20 mm.

Case report of a piece of dishwashing steel wool in a child’s pharynx

Objective: Foreign body swallowing is a common pediatric problem. A foreign body in the pharynx is a medical emergency that requires urgent intervention. Evaluation and treatment of pharyngeal foreign bodies is much more difficult in children than in adults and sometimes requires hospitalization and removal of the foreign bodies under general anesthesia due to children’s lack of cooperation. Fish and chicken bones are the most common swallowed foreign bodies, but an interesting case of a piece of dishwashing steel wool stuck in a child’s pharynx is reported in this article. Case Presentation: A 10-year old boy was presented with a history of dysphagia from five weeks ago. Oral examination did not reveal anything significant. In lateral neck radiographs of the patient, a metal wire was observed in the hypopharyngeal region opposite the 4th and 5th cervical vertebrae. Endoscopic attempts to remove the foreign body were not successful. Therefore, the foreign body was removed from the patient’s pharynx in the operating room under general anesthesia. No complications were observed. Conclusion: Despite the prevalence of swallowing foreign bodies in children, ingestion of a piece of dishwashing steel wool not diagnosed for three weeks was considered interesting to report. Pharyngeal foreign bodies are medical emergencies; therefore, it is particularly important to suspect the presence of a foreign body and perform diagnostic procedures.

Lateral Neck Radiography in Preoperative Evaluation of Adenoid Hypertrophy

To assess the value of lateral neck radiographs in quantifying adenoid hypertrophy to help guide treatment decisions in patients with symptoms of nasal obstruction. Retrospective review. Quantitative radiologic grading of adenoids was correlated with the intraoperative grading to select cases in agreement between the two methods. The percent airway obstruction was calculated as a ratio of adenoid size to the size of the nasopharyngeal airway near the level of the choanae on the lateral neck radiographs for adenoidectomy cases in which radiographic and intraoperative grading of adenoid size were in agreement. A total of 426 adenoidectomy cases with preoperative lateral neck radiographs were reviewed (M:F = 254:172 for age range 9 months to 16 years), and only cases in agreement between radiographic and intraoperative adenoid grading were included in radiographic analysis (N = 234). The percent airway obstruction values were significantly different between "severely obstructive" (N = 137, mean = 94.71, SD = 6.55, range [72.00; 100.00]) and "moderately obstructive" adenoid categories (N = 97, mean = 78.53, SD = 6.91, range [63.67; 98.08]), not only within clinically relevant age groups (1-3 years, 4-7 years, 8-15 years), but also for the entire data set (95% CI [14.41; 17.95], P < .0001). "Mildly obstructive" category was omitted due to small sample size (N = 4). Lateral neck radiographs can provide useful supplemental information on the degree of nasopharyngeal airway obstruction when other clinical findings do not clearly point toward adenoid hypertrophy as a primary cause of nasal obstruction. In our data set, a 65% nasopharyngeal airway obstruction represents a value two standard deviations below the mean for "moderately" obstructive adenoid category, and can be viewed as a simplified cut-off to indicate that the degree of adenoid enlargement is clinically relevant. This cut-off value can assist in evaluation of patients with symptoms of nasal obstruction. 4.

Age-stratified sex differences in polysomnographic findings and pharyngeal morphology among children with obstructive sleep apnea

Background: Childhood obstructive sleep apnea (OSA) has important implications for growth, learning, behavior, cognition and cardiovascular health as well as snoring and OSA in adulthood. In this study, we elucidated the sex differences in polysomnographic (PSG) findings and pharyngeal radiographic data in pediatric OSA patients. Methods: Sixty three children (age between 3 and 15 years old) with OSA [defined as apnea-hypopnea index (AHI) ≥1/h by polysomnography] were enrolled. Lateral neck radiographs were obtained from the patients. All subjects were separated by age: pre-adolescent group (3–8 years old) and adolescent group (9–15 years old). Results: Overall, 45 patients in the pre-adolescent group (33 boys and 12 girls) and 18 patients in the adolescent group (10 boys and 8 girls) were enrolled, and sex differences were compared in each group. We found sex differences in craniofacial features and severity of OSA in the adolescent group, in which girls with OSA had more upper airway space, in addition to lower AHI, lower 3% oxygen desaturation index (ODI), higher minimum SO 2 and better sleep efficiency than the boys. Conclusions: The present study found revealed sex differences in pediatric OSA patients in the adolescent group. Girls in the adolescent group had more upper airway space in addition to lower AHI, lower 3% ODI, higher minimum SO 2 and better sleep efficiency than boys.

The Runaway Croup Train: Off the Pathway and Through the Woods

A previously healthy, fully immunized 23-month-old girl presented to the emergency department (ED) with 1 day of fever, cough, hoarseness, stridor only with agitation, and no drooling or retractions. She was given acetaminophen and dexamethasone 0.6 mg/kg orally. After these interventions, she improved and took a Popsicle. A chest radiograph and lateral neck radiograph were read as “prevertebral soft tissue thickening at the level of C5-C7, which can be seen with retropharyngeal infection versus projection or positioning.” This prompted an otolaryngology consult. Bedside flexible fiber-optic nasolaryngoscopy in the ED revealed mild to moderate swelling of the epiglottis with scattered foci of edema and erythema on the laryngeal surface of the epiglottis, mobile and moderately edematous vocal folds bilaterally, and moderate to severe subglottic stenosis, which are all findings typical of viral croup. Laboratory studies revealed a normal white blood cell count of 10.1 k/μL (reference range: 6–17.5), elevated C-reactive protein of 8.0 mg/dL (reference range: <0.9), elevated procalcitonin of 1.08 ng/mL (reference range: <0.5), and a normal chemistry. A nasal swab for respiratory pathogen polymerase chain reaction (PCR) was obtained. A diagnosis of epiglottitis was made, the patient was made NPO, maintenance intravenous fluids were started, intravenous ampicillin-sulbactam and intravenous dexamethasone were given and scheduled every 6 hours, and admission to the PICU was arranged. Three hours after admission to the PICU, the respiratory pathogen panel was reported as positive for parainfluenza virus 3, and 12 hours after admission, the patient was transferred from the ICU to the inpatient ward. The patient did not require any additional interventions in the ICU other than scheduled intravenous antibiotics and steroids. The next morning, 9 hours after transfer …