Lateral Neck Radiograph Research Articles

Schematic interpretation of lateral neck radiographs of adults in the emergency department: a pictorial review.

The lateral neck radiograph is widely utilized for the evaluation of common neck conditions in the emergency department. The anatomy of the neck is complex and it can be difficult to differentiate between soft tissue structures on a lateral radiograph. We suggest a schematic pattern of interpreting the lateral neck radiograph with case images of various pathologies that can present in the emergency setting.

A case of foreign body inhalation

A 55-year-old man, having consumed a bottle of wine, presented having swallowed his denture. He had painful swallowing, was not managing his secretion load, and had moderate respiratory distress. A lateral neck radiograph was taken in the emergency department (Fig. 1), which confirmed the presence of a denture lodged within the pharynx at level C4–6 and partially overlying the laryngeal inlet. On review, some remaining anterior air space was seen that was thought to be passable from above. He had no other airway risk factors with the exception of now being edentulous! Aspiration risk dictated a preference to carry out airway management awake. Discussion was had with surgical colleagues that if the denture was dislodged by fibreoscopy and worsening airway obstruction ensued, then an awake surgical cricothyroidotomy would be required. The patient was prepared for this, and marked utilizing ultrasound before operation. Flexible fibreoscopy confirmed that the obstruction was negotiable and an awake fibreoptic intubation was carried out uneventfully with passage of a 5.5 reinforced tube. Subsequent management was uneventful. Extubation concern centred on the potential for trauma related airway swelling following removal of the dentures. A dose of 8 mg dexamethasone was given and the patient extubated without any issues. One further dose was prescribed prophylactically after operation and he was observed closely for 24 h. The associated MCQs (to support CME/CPD activity) can be accessed at www.access.oxfordjournals.org by subscribers to BJA Education. Predicting the difficult airwayBJA EducationVol. 15Issue 5PreviewThe difficult airway (DA) has been defined as ‘the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both’.1 A more complete definition would include airway instrumentation (e.g. with supraglottic airway devices), direct tracheal access, and consideration of the airway at extubation. Full-Text PDF Open Archive

Characteristic thumb sign in epiglottitis

Thumb sign is detected in simple lateral neck radiograph (preferably in upright view with neck in extension). Diagnosis can be confirmed by direct examination of pharynx, which reveal swollen epiglottis and can be confirmed by direct naso-pharyngo-laryngoscope. However this should be performed in an operating room where facilities to secure air way are available. Diagnostic investigations like CT can reveal other findings like thickening of epiglottis, thickening of ari-epiglottic fold and prevertebral fascia. Suspicion of an abscess may be deduced from evidence of multiloculated density collections in the neck.

Near-complete Upper Airway Obstruction from a Grape

A 3-YR-OLD boy presented to our facility for evaluation of inspiratory stridor and respiratory distress. Lateral neck radiograph revealed a foreign body posterior to the aryepiglottic folds causing severe narrowing of the glottic inlet (fig., arrow indicates epiglottis and star indicates aryepiglottic folds). The child was transferred to the operating room and positioned to comfort, which was slight left lateral recumbent with head elevated. Spo2 ranged from 88 to 92% at initial evaluation on room air and greater than 98% through transfer to the operating room on 100% oxygen by facemask. Inhalational anesthesia was induced with 8% sevoflurane in oxygen. Spontaneous breathing was maintained and Spo2 remained greater than 98%. Direct laryngoscopy was performed and a grape was removed from the upper airway using Magill forceps.There is no consensus on optimal technique for an airway foreign body removal with regard to spontaneous versus controlled ventilation, intravenous versus inhalational induction, and use versus avoidance of muscle relaxants.1 Maintenance of spontaneous ventilation is commonly used for foreign bodies proximal to the carina due to the risk of converting a partial obstruction into a complete obstruction.2 Deep levels of anesthesia or muscle relaxants can be beneficial for foreign bodies distal to the carina for rigid bronchoscopy1; however, ablation of spontaneous ventilation for proximal foreign bodies risks dislodgement and complete airway obstruction. The narrow pediatric glottis and cricoid ring structures are anatomical landmarks at which foreign bodies can be trapped proximally.3 Positive-pressure ventilation can potentially cause worsening of the airway obstruction via a ball-valve phenomenon and lead to tension pneumothorax. Avoidance of nitrous oxide is reasonable as it decreases Fio2 and can increase gas volume if air trapping is present.The authors declare no competing interests.

Diagnostic accuracy of lateral neck radiography in ruling out supraglottitis: a prospective observational study.

To assess the diagnostic accuracy of lateral neck radiographs (LNR) for acute supraglottitis in adults. A single centre prospective observational study. Emergency department at Kurashiki Central Hospital, Japan. Adult patients who underwent LNR to detect supraglottitis. Presence of supraglottitis, based on nasopharyngeal laryngoscopy or a follow-up telephone call, 7-30 days after the visit. 140 patients had LNR during the study period. 35 patients were excluded from further analysis because of lack of consent. Of the 105 eligible patients, 21 patients (20%) were given the diagnosis of supraglottitis: 17 of 29 with a radiographic abnormality, and 4 of 76 patients without a radiographic abnormality. Three of the four cases where LNR was negative was grade 1, and all cases of grade 3 or higher had abnormal LNR. Sensitivity and specificity (95% CI) of LNR for supraglottitis were 81.0% (64.2 to 97.7) and 85.7% (78.2 to 93.2), respectively. The positive predictive value of LNR was 58.6% (40.7 to 76.5) and the negative predictive value was 94.7% (89.7 to 99.8). The positive likelihood ratio of LNR was 5.67 (3.27 to 9.82) and the negative likelihood ratio was 0.22 (0.10 to 0.51). LNR showed only moderate sensitivity and specificity for supraglottitis and would miss some cases of supraglottitis if the pre-test probability is high. LNR was very sensitive for grade 3 or higher supraglottitis, but would miss milder cases. UMIN000011928.

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy

ObjectivesAdenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya. MethodsThis was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥25mm Hg using the Chemla equation. Children with mPAP of ≥25mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis. ResultsOf the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%–29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR=3.0 [95% CI 1.08–8.44] p=0.035) and hyperactivity on history (OR=0.2 [95% CI 0.07–0.59] p=0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR=5.0 [95% CI 1.01–24.37] p=0.048). ConclusionOne in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.

Unstable Less Common Chance Fracture

A 25-year-old boy presented to the emergency room with multiple trauma after a car crash in which the car had collided with a guardrail. The patient had been in the front passenger seat, wearing a seatbelt. At presentation, he was awake and complaining only of back pain. On examination, his vital signs were stable. He had tenderness over the vertebrae and a contusion where the seatbelt had been positioned over his trunk. His lungs were clear to auscultation bilaterally, and he had no respiratory distress. His heart sounds were normal, without a murmur or gallop. He had no tenderness over the sternum. His abdomen was soft to the touch with no abnormal findings. Cranial nerves were intact. Muscle strength was 5/5 for all limbs. Deep tendon reflexes (DTRs) were 2+. The patient did not have any motor or sensory deficits on neurological exam. Due to his crash injury, focused assessment with sonography in trauma (FAST) was performed in the emergency room, and there were no abnormal findings. A brain computed tomography (CT) scan was performed, and the results were normal. Lateral neck radiography showed no abnormal findings. Due to his pain, the tenderness over the vertebrae, and the contusion over his trunk, a vertebral plain radiograph was obtained (Figure 1). Based on the plain radiography findings, a vertebral CT scan was performed (Figure 2). Figure 1 Figure 2 DIAGNOSIS: Chance Fracture A chance fracture, a type of fracture caused by a flexion distraction mechanism,[1] was identified. Missing chance fractures in a multiple trauma patient can cause future complications, such as kyphosis or pain. [2] Chance fractures are typically caused by seatbelts during car crashes.[1] If a fracture has been caused by a seatbelt, a contusion over the trunk may be present which can alert the physician to the possibility of a chance fracture.[3] Chance fractures extend horizontally from the tip of the transverse process on one side through the pedicles and laminae to the tip of the opposite transverse process. The fracture may involve the posterior part of the vertebral body. However, involvement of the anterior part of the vertebral body is not common, and chance fractures with anterior involvement are usually not very severe.[4] In cases of fractures with flexion-distraction mechanisms, patients should be examined for intraabdominal injuries.1, 3, 4 Chance-type fractures are unstable injuries that present without neurological deficit and may have subtle radiographic signs.[1] CT can help in diagnosing vertebral column damage and identifying patients with risk of acute neurologic compromise.[1] The most commonly used treatment for chance fracture is closed management; however, open surgery has also been reported.[5] In our case, we observed failure of the posterior and middle vertebra with anterior wedging. Due to the severe fracture, instability, and the probability of neurological consequences, operative management and internal fixation were performed without any complications. Figure 1 (a) A thoracic wedge fracture of the T12 vertebra. (b, c) CT images of the fracture in three columns. Conclusion Severity and the probability of neurological consequences are the factors which determine the importance of considering surgical management for a diagnosed chance fracture.

Acute epiglottitis from corrosive ingestion.

Sir, Acute epiglottitis (AE) constitutes a medical emergency and most often results from infection with Haemophilus influenzae. Corrosive ingestion is a rare and hence less appreciated cause of AE. A 40-year-old female was brought to the emergency department following suicidal ingestion of about 100 ml of liquid toilet cleaner HARPIC™, containing 10.5% hydrochloric acid. She complained of dyspnea, dysphagia, odynophgia, difficulty in speaking and drooling. She was noted to have hoarseness of voice, respiratory distress with stridor and cyanosis. Examination revealed oral burns, cyanosis and crackles at both lung bases. A lateral soft tissue X-ray of the neck showed “thumb sign” [Figure 1], suggesting AE. She was kept nil per oral and managed with supplemental oxygen, nebulized budesonide and adrenaline, intravenous fluids and antibiotics. Orotracheal intubation was required after 48 h for worsening stridor and hypoxemic respiratory failure, and mechanical ventilation was initiated. Enlarged and inflamed epiglottis was confirmed by direct laryngoscopy during intubation. Contrast-enhanced computed tomography of the chest showed areas of consolidation in the right middle and lower lung lobes and left lower lobe [Figure 2], suggesting aspiration pneumonia. She required mechanical ventilation for a week and was subsequently extubated. Figure 1 Lateral soft tissue radiograph of the neck showing “thumb sign” (arrow), suggesting a severely inflamed, oedematous and enlarged epiglottis Figure 2 Contrast-enhanced computed tomography of the chest (lung window), showing areas of consolidation (black arrows) in both lungs, suggesting aspiration pneumonia “Thumb sign” in lateral soft tissue radiograph of the neck indicates a severely inflamed, edematous and enlarged epiglottis, resulting most commonly from infections with H. influenza - type b and Group-A β-hemolytic Streptococci.[1] However, corrosive injury is a rare cause of AE.[1] Along with epiglottis, rest of the supraglottic area including the vallecula, aryepiglottic folds and arytenoids are also inflamed and edematous and hence life-threatening acute upper-airway obstruction may develop rapidly.[2] Thus, AE constitutes a medical emergency. In a study involving AE patients,[3] positive “thumb sign” on lateral neck radiograph and stridor were significant predictors of requirement for airway intervention and hence their presence should warn of imminent upper-airway occlusion. Timely fiberoptic nasotracheal or less preferably orotracheal intubation by a skilled anesthetist or tracheostomy may be required for securing the airway. Adjunctive measures to reduce upper airway edema in AE include intravenous dexamethasone, nebulized budesonide and intravenous antibiotics.[1] Aspiration pneumonia and acute respiratory distress syndrome are known complications of corrosive ingestion. In a study of 273 adult patients of caustic ingestion reported from Taiwan,[4]11% had aspiration pneumonia and 8% had respiratory failure. In corrosive ingestion, presence of upper airway compromise with stridor, along with dysphagia, odynophagia, voice change and drooling should raise suspicion of AE. Timely recognition of this complication and meticulous upper airway management may be lifesaving. Absence of radiological “thumb sign” should not rule out AE.[5] In a clinically unstable patient with suspected AE, clinical stabilization and airway securement should get priority over X-ray imaging of the neck.

Delayed Dysphagia After Removal of Foreign Bodies Near Upper Esophageal Sphincter

A 70-year-old male presented to the emergency department with sudden onset of dysphagia. He had medical history of hypertension for 10 years and cerebral infarction in the territory of the middle cerebral artery 7 year ago. Lateral neck radiography revealed foreign bodies in the upper esophagus (Fig. 1A) and an upper endoscopy was performed. Two seashells with sharp edge were impacted near the upper esophageal sphincter and they were removed using hard straight cap and grasping forceps (Fig. 1B). Figure 1 Radiograph of a 70-year-old man who presented with dysphagia. Foreign bodies were lodged in the upper esophagus (blue arrow) (A) and 2 seashells were removed with endoscopic grasping forceps (B). Although white blood cell was elevated and small laceration with periesophageal inflammation was suspected at CT scan, his condition improved with non-operative management including broad spectrum antibiotics. However, dysphagia continued for 10 days after removal of foreign bodies. Modified barium swallowing showed large volume of valecular residue with tracheal aspiration despite improvement of inflammation on follow-up CT scan. High-resolution impedance manometry (HRIM) was performed to rule out esophageal motility disorder. HRIM revealed a failure of upper esophageal sphincter relaxation with impaired bolus transit (Fig. 2). Two days later, he refused to receive further treatment and was discharged.When he visited outpatient clinic 4 days after discharge, dysphagia was improved and he could take soft diet. Figure 2 High-resolution impedance manometry (HRIM) findings with 30 mmHg isobaric contour. HRIM presents a failure of upper esophageal sphincter relaxation (red arrow) with impaired bolus transit and intrapharyngeal saline pooling (yellow arrow). Recently, HRIM system was used to develop the clinical parameters of deglutitive upper esophageal sphincter relaxation and normal range values were acquired from healthy volunteers.1 In the near future, more accurate diagnosis of dysphagia might be possible based on the objective manometric findings in swallowing difficulty.

Spontaneous Pneumomediastinum

Early reports on pneumomediastinum studied the adult population, and recent analyses of pneumomediastinum in pediatric patients contain small numbers of patients. We aimed to summarize the experience of a larger number of pediatric patients with spontaneous pneumomediastinum (SPM) in a tertiary children's facility in northern Taiwan. We performed a retrospective chart review of clinical manifestations and outcome of SPM on pediatric patients who were admitted to our hospital during a 10-year period. Forty-three patients (49.4%) had primary SPM, with a male predominance in adolescents. None of the 16 patients younger than 6 years had primary SPM; 43 of 71 patients older than 6 years had secondary SPM (0% vs 60.6%, P < 0.05). The common causes of secondary SPM were asthmatic exacerbation, pneumonia or lower respiratory tract infections, or choking. Ten patients had normal frontal chest radiograph finding (sensitivity, 89.1%); the lateral neck radiographs clearly demonstrated subcutaneous emphysema in 9 of these 10 patients. All patients younger than 6 years with SPM were secondary; therefore, they should be vigilantly examined for predisposing causes. For adolescent patients with SPM with no catastrophic events, asthma with exacerbation should be considered first, and extensive or invasive diagnostic examinations are not needed. Primary SPM usually requires conservative treatment only with no sequel or recurrence. Lateral neck radiograph has a higher sensitivity for the demonstration of subcutaneous emphysema in doubtful cases.

Acute Neck Edema After 131I Ablation of the Thyroid

A 36-year-old woman with Graves' disease underwent thyroid ablation with oral I (20 mCi) following poor control of hyperthyroidism with carbimazole. Three days later, she presented to the emergency department with a choking sensation, shortness of breath, dysphagia, neck discomfort, and swelling. The prevertebral soft tissue was grossly thickened on the lateral neck radiograph. An urgent contrast-enhanced CT neck revealed severe neck edema and thyroiditis. TSH and free T4 levels were normal, and the neck swelling gradually resolved with corticosteroids. Acute neck edema is an infrequent complication of I ablation, and cross-sectional imaging is useful to exclude airway compromise or infection.

Acute Epiglottitis in a 79‐Year‐Old Man

Acute Epiglottitis in a 79‐Year‐Old Man

Diagnostic value of the upper lip bite test in predicting difficulty in intubation with head and neck landmarks obtained from lateral neck X-ray

Background:Unanticipated difficult tracheal intubation remains a primary concern of anaesthesiologists and upper lip bite test (ULBT) is one of the assessments used in predicting difficult intubation. In this study, we aimed to check the utility of lateral neck X-ray measurements in improving the diagnostic value of the ULBT.Methods:In a prospective study conducted from January 2007 until December 2010, we recorded personal and demographic data of 4500 patients who entered the study and subjected them to standard lateral neck radiography. Before the induction of anaesthesia, clinical examination and ULBT results were recorded and during induction of anaesthesia laryngoscopic grading was evaluated and recorded in questionnaires. All the compiled data were analysed by SPSS 14.0 (SPSS Inc., Chicago, IL, USA) software. Diagnostic value for each test was calculated and compared.Results:Negative predictive values (NPVs) were high in all tests. ULBT had the highest specificity and NPV compared with the other tests. The positive predictive value for all the tests had been low, but marginally high in the ULBT.Conclusion:Although all the tests used had relatively acceptable predictive values, combination of tests appeared to be more predictive. Highest sensitivities were observed with ULBT, mandibulohyoid distance and thyromental distance respectively. Use of radiological parameters may not be suitable as screening tools, but may help in anticipating and preparing for a difficult scenario.

Index of Suspicion

Index of Suspicion

Accuracy of Ultrasonography Versus Computed Tomography Scan in Detecting Parapharengeal Abscess in Children

Significant morbidity and rarely mortality have been described in parapharyngeal space infections in children; hence, the decision on the timing of surgical intervention might be crucial. The aim of this study was to compare the accuracy of plain x-rays, ultrasonography (US), and contrast-enhanced computed tomography (CT) in demonstrating a parapharyngeal abscess. A retrospective study on all patients with parapharyngeal abscess admitted and operated on from January 1996 to December 2000 was carried out. Charts were reviewed for patients' demographics, symptoms and signs, details of workup, intraoperative findings, and culture results. The CT scans were reviewed for the presence of a rim enhancement, a presence of a definable wall, and fluid-fluid level and were correlated with the plain x-rays and US results and intraoperative findings. Eighteen patients with proven parapharyngeal infection were included: 10 with proven abscess and 8 with cellulitis. The sensitivity and specificity of lateral neck radiograph and US were low compared with a specificity of 87.5 while evaluating fluid-fluid level seen on the CT scan, sensitivity of 58.3% for the presence of a definable abscess wall, and a sensitivity of 100% for the presence of a prominent wall. Our study demonstrates good rates of accuracy of CT scan for diagnosing a parapharyngeal abscess. Our study suggest that it is appropriate to obtain a CT scan upon presentation in all children with suspected parapharyngeal abscess and that a CT scan is proven to be a useful diagnostic tool in establishing a treatment plan.

Symptomatology and etiology of chronic pediatric rhinosinusitis

This study aims to define symptoms and etiology and determine how to prevent chronic rhinosinusitis in children. Between February 2003 and February 2005, 50 pediatric patients (25 girls and 25 boys; mean age 8.22 years; range 4 to 14 years) with chronic rhinosinusitis were included in the study. The patients were questioned about anterior/posterior nasal dripping, night cough, headache, nausea, vomiting and nasal obstruction for symptomatology; about school condition, smoking behavior of parents and history of asthma for etiology. Hemogram, serum biochemistry, allergy test, nasal smear, chest and lateral neck radiography and sweat test were performed. Symptomatologic examination revealed that 48% had anterior nasal dripping, 62% with postnasal dripping, 70% with headache and 90% with nasal obstruction. Evaluation of etiological factors revealed that 68% were going to school, 48% of the parents had the history of smoking, 42% with allergy test-positivity and 60% with adenoid vegetation. Our study results indicated that environmental factors are important as etiological factors in rhinosinusitis. For prevention, we recommend restriction of close relationship at school, not to smoke at home and vaccination in each year with influenza and S. pneumonia vaccine.

Thoracic outlet syndrome caused by pseudoarticulation of a cervical rib with the scalene tubercle of the first rib

A healthy 20-year-old man presented with a bony lump above the left clavicle associated with upper limb pain, numbness, and tingling. Examination in the surrender position elicited left hand weakness and pain with loss of the radial pulse. The patient had paresthesia of the ulnar border of the left hand but no interossei wasting. A lateral neck radiograph identified an unusual bony contour anteriorly at C7/T1 suggesting a cervical rib (A). Duplex ultrasound scan showed widely patent left axillary and subclavian arteries with the arm adducted but severe compression of the subclavian artery on abducting the arm to 90°. A subsequent computed tomography angiogram confirmed bilateral cervical ribs; the left articulating with an extended left transverse process of the seventh cervical vertebra, extending inferiorly to fuse with the first rib (B and C/Cover). The left subclavian artery passed immediately superior to this bony extension whereas the left vertebral artery lay immediately anterior to the origin of the cervical rib at C7. The right cervical rib was much smaller and not in proximity to the vessels. Intraoperatively, the left cervical rib was found to extend from the C7 transverse process to form a true joint with a hypertrophied scalene tubercle on the first rib; both the cervical rib and hypertrophied scalene tubercle were excised via the supraclavicular incision (D). A T1 sensory and motor neuropraxia was noted day 1 postsurgery which, together with his preoperative symptoms, completely resolved within 5 days and continued at 5-month follow-up. Cervical ribs are a known cause of arterial and neurogenic thoracic outlet syndrome. These congenital abnormalities occur in 1% of the population but are bilateral in 50%. Ninety percent are asymptomatic and do not require resection. Complete cervical ribs occur in approximately 25% of patients, most commonly attached to the first rib by a fibrous band, or more rarely, as in this case, via a true joint, often with the scalene tubercle. Surgical management involves removal of the cervical rib; if this does not provide adequate decompression of the subclavian artery and the brachial plexus, removal of the first rib should be done.

Analysing lateral soft tissue neck radiographs

A lateral soft tissue neck radiograph is a useful adjunct in diagnosing and managing the patient presenting with upper airway symptoms but is often inadequately reviewed. We present some common findings and robust systems to improve analysis of these radiographs.

The lateral neck radiograph for an impacted fish bone in the aero-digestive tract: Going back to basics

Aim: To evaluate the radioopacity of fish bones from a number of species using digital radiography in order to establish whether advances in acquisition and interpretative techniques have affected the radiologist’s ability to detect impacted fish bones. Methods: The bones from six species of fish commonly consumed in the United Kingdom were radiographed using a soft tissue neck phantom by means of a digital radiographic X-ray tube. The images were looked at by 15 radiology consultants and registrars who determined whether the bones were visible or not using General Electric (GE) PACS workstations. Results: The radio-graphed bones from all six species of fish were visible by all 15 (100%) radiology registrars and consultants. Conclusion: Digital radiogramphy and modern PACS workstations have meant that fish bones can be visualized irrespective of species. The lateral neck radiograph therefore may still have an important role in the investigation of impacted fish bones in the aerodigestive tract.

Tracheal Perforation After Thyroidectomy

A 55-year-old woman presented to our Emergency Department with progressively worsening neck swelling, dysphagia, and dyspnea after a coughing fit approximately 3 h before arrival. Her symptoms developed rapidly after the coughing fit. The neck swelling was painful and made breathing difficult. Of note, the patient had a total thyroidectomy for papillary thyroid carcinoma 4 weeks earlier. On examination, vital signs were as follows: temperature 37.2°C (99.0°F) orally, blood pressure 136/88 mm Hg, pulse 92 beats/min, respiratory rate 16 breaths/min, and SaO2 97% on room air. The patient looked uncomfortable but was able to speak normally. A homogeneous neck mass was noted. A picture of the patient’s neck (Figure 1) and a lateral neck radiograph (Figure 2) are shown.