Lateral Neck Radiograph Research Articles

A patient with dysphagia

A 19 year old man presented to the accident and emergency department with acute onset inability to swallow and a feeling of a lump in his throat after having a meal. On examination he was distressed and was drooling saliva. The patient showed marked dysphagia when asked to take sips of water. A lateral neck radiograph was taken to confirm the diagnosis (figure). Lateral radiograph of the neck 1. What is the diagnosis? 2. What are the classic features of this on a radiograph? 3. What is the management? 1. The diagnosis is a foreign body at the level of the cricopharynx. The lateral radiograph of the soft tissues of the neck shows soft tissue thickening at the cricopharynx, representing a food bolus (A), and marked presence of air in the upper oesophagus inferior to the food bolus (B). 2. A lateral soft tissue radiograph of a foreign …

Short Thyromental Distance: A Predictor of Difficult Intubation or an Indicator for Small Blade Selection?

Short thyromental distance (TMD; < 5 cm) has been correlated with difficult direct laryngoscopic intubation in adult patients. The authors hypothesized that a smaller Macintosh curved blade (No. 2 MCB) would improve the predicted difficult laryngoscopy in short-TMD patients over that with a standard Macintosh curved blade (No. 3 MCB). In a preliminary study of 11 consenting adults (7 females and 4 males), American Society of Anesthesiologists physical status I and TMD < or = 5 cm, lateral neck radiographs were recorded during laryngoscopy with a No. 2 and No. 3 MCB in sequential fashion. In a prospective clinical study, laryngoscopy and tracheal intubation were evaluated in 83 adult patients with TMD < or = 5 cm by randomly assigning them to two groups for the blade used at first intubation. Those who failed intubation with the first blade were switched to the alternate blade. In total 100 laryngoscopies and intubations were performed: the No. 2 MCB (n = 50) and the No. 3 MCB (n = 50). Lateral neck radiographs recorded at the best laryngeal view revealed that the tip of the No. 2 MCB was proximal to the hyoid body with the No. 2 MCB and distal to it with the No. 3 MCB. The intubation distance (C5 to blade tip) on neck radiographs with the No. 2 MCB was significantly greater than it was with the No. 3 MCB for similar anterior jaw displacement. In the clinical study, the laryngoscopic grade with the No. 2 blade was considered easy (median, 2B), better than the grade with the No. 3 MCB (median, 3). When the No. 2 MCB was used, external laryngeal pressure improved the laryngoscopic grade (1, full glottic view) in 46% of patients. In contrast, when the No. 3 MCB was used, pressure improved the grade in only 10% of the patients. Intubation time with the No. 2 MCB was significantly (P < 0.05) less than it was in patients with No. 3 MCB. Overall, 14 patients who failed intubation with the No. 3 MCB were switched to the No. 2 MCB, and intubation was successful with an easy laryngoscopic grade. Three patients who failed intubation with the No. 2 MCB were switched to the No. 3 MCB. The predicted difficult laryngoscopy and intubation with the use of the adult No. 3 MCB in standard adult patients with a TMD < or = 5 cm is significantly easier with use of the smaller No. 2 MCB.

In Brief: Retropharyngeal Abscess

Head and Neck Space Infections in Infants and Children. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepena H, Bluestone CD. Otolaryngol Head Neck Surg. 1995;112:375–382Retropharyngeal Abscess in Children: A 10-year Study. Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik TL. J Otolaryngol. 2004;33:352–355Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging and Current Management. Craig FW, Schunk JE. Pediatrics. 2003;111:1394–1398Retropharyngeal and Parapharyngeal Infections in Children: The Toronto Experience. Daya H, Lo S, Papsin BC, et al. Int J Pediatr Otorhinolaryngol. 2005;69:81–86Retropharyngeal abscess is an infrequent but serious condition. Early diagnosis can help prevent the potential consequences of airway compromise, sepsis, and extension to contiguous structures. The peak incidence occurs in 3- to 5-year-olds, likely due to the increased number of lymph nodes in the retropharyngeal space and the likelihood of atrophy of lymph nodes in this anatomic space as the child ages.The retropharyngeal space is a potential space anterior to the prevertebral fascia that extends from the skull base to the bifurcation of the trachea in the mediastinum, serving as a potential pathway to the chest. Most cases of retropharyngeal abscess occur in children following an upper respiratory tract infection such as tonsillitis, pharyngitis, and lymphadenitis and probably represent spread of infection from contiguous areas. Some cases are idiopathic; the remainder (more common in older age groups) are due to trauma, foreign body ingestion, or immunocompromised state.Infection nearly always is polymicrobial and commonly includes aerobes (Streptococcus viridans, group A Streptococcus, Staphylococcus aureus, S epidermidis) as well as anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus sp). Throat swabs may not be useful and are likely to represent oropharyngeal flora. Additionally, many patients already may be receiving antibiotics at the time of diagnosis.The clinical presentation of retropharyngeal abscess appears to be highly inconsistent; symptoms may include neck pain, neck swelling, fever, sore throat, and food refusal by younger patients. Limitation of neck movement (particularly with hyperextension) or torticollis seems to be an especially important clue. Respiratory distress or stridor occurs less frequently than commonly believed, and most patients do not appear “toxic.” Often, the differential diagnosis includes pharyngitis, cervical adenitis, meningitis, epiglottitis, and cellulitis.Soft-tissue films of the neck may reveal prevertebral swelling, which can be determined quickly by comparing the width of the prevertebral soft-tissue plane to the corresponding vertebral body. This width should be less than one half the width of the corresponding vertebral body. More precise measurements are usually obtained at C2, where the soft-tissue space can be up to 7 mm in width, and at C6, where it can be up to 14 mm (22 mm in adults). However, the prevertebral space may appear falsely enlarged during neck flexion or crying. Computed tomography (CT) remains the best imaging method to confirm the diagnosis, although it has been demonstrated to have a low sensitivity (43%) and specificity (63%) in distinguishing between retropharyngeal abscess and cellulitis. CT scan is helpful to assess the extent of the infection and determine if it has spread to contiguous structures. However, such scans introduce issues of sedation (particularly problematic if there are airway issues) and additional radiation. Ultrasonography of the affected region is technically difficult.Traditional management of a retropharyngeal abscess has involved transoral surgical drainage. However, recent published pediatric reviews suggest that only 25% to 50% of patients require surgery; most pediatric patients can be treated successfully with medical therapy alone as long as there is no airway compromise. Thus, it may be appropriate to wait 24 to 48 hours while the patient is receiving broad-spectrum antibiotics before considering surgical intervention. Clindamycin remains the first-line antibiotic choice. Given the polymicrobial nature of this disease and the increasing frequency of resistance to clindamycin, it may be useful to expand antibiotic coverage to include either a third-generation cephalosporin or a beta-lactamase-resistant penicillin in geographic areas where clindamycin resistance is present.Comment: The diagnosis of retropharyngeal abscess can be challenging, and clinicians must keep it in their differential diagnosis. Although CT of the neck has become the gold standard in diagnosis, a lateral neck radiograph remains helpful for clinical sites where access to CT may be difficult or to help rule in the diagnosis when nonspecific signs or symptoms exist. Research studies have demonstrated the effectiveness and safety of initial treatment of children who have no airway compromise with antibiotics for 48 hours rather than immediate surgical drainage. These findings have advanced the treatment of retropharyngeal abscess and prevented many children unnecessary morbidity from exposure to anesthesia and surgical intervention.

Lateral neck radiography

Reply EDITOR: We appreciate the comments on our original article. Drs Ates and Alanoglu have raised 3 questions. The first question relates to descriptive data concerning the distribution of age groups and statistical comparison between age, gender and study parameters. These data were analysed in our patients, however there were no statistically significant differences between them [1]. The second question concerns the number of the patients in the study (100 patients) and the low incidence of patients with difficult intubation. As was noted in the article’s introduction, the incidence of difficult intubation in surgical patients undergoing general anaesthesia is approximately 1–18% [2]. Accordingly, the minimum sample size was estimated using an a priori power analysis based on a confidence level of 0.95 and a power of 0.90. Therefore, the power of the study is statistically valid. In our study the incidence of difficult intubation was 15% (15 out of 100 patients), which was statistically sufficient [1]. Similar studies in which various clinical, skeletal (lateral X-rays) and soft tissue (three-dimensional computed tomography imaging or magnetic resonance imaging) measurements were used to predict difficult intubation, used similar number of patients (20 patients with difficult intubation) [3,4]. It must be noted that the four patients which were described by Drs Ates and Alanoglu, were classified as difficult intubation according to Mallampati Class II scoring. The last comment concerns the cost–benefit of requesting a lateral X-ray prior to operation. At University Hospitals in Iran the cost of a lateral neck X-ray is 20 000 Iranian Rials and with insurance (which almost everyone carries) is 2000 Rials, approximately a quarter of a US Dollar. This cost is considered as very low or negligible and would not bring an additional cost in large-scale hospitals if used as a screening test. I should also note that when an anaesthetist faces an unpredicted difficult intubation it might cost the patient much more. In our setting, a single fibreoptic bronchoscopy costs 100 times more than a single lateral X-ray. However, we agree with the comment that in other institutions, this non-invasive technique will cost more and it may be wise to use it only in patients predicted as a difficult intubation such as patients with higher Mallampati Classes (III–IV).

Lateral neck radiography

Lateral neck radiography

Cervical spine abnormalities associated with Down syndrome

Atlantoaxial instability (AAI) affects 10-20% of individuals with Down syndrome (DS). The condition is mostly asymptomatic and diagnosed on radiography by an enlarged anterior atlanto-odontoid distance. Symptomatic AAI, which affects 1-2% of individuals with DS, manifests with spinal cord compression. Cervical spondylosis, which is common in DS, also has the potential for cord damage but it has received less attention because paediatric populations were mostly studied. Forty-four Kuwaiti subjects with DS, whose ages were > or = 15 years, were evaluated clinically and radiographically. Lateral neck radiographs were taken in the neutral and flexion positions. Asymptomatic AAI was diagnosed in eight subjects (18%) and congenital anomalies of C1-2 were found in five (12%). Five patients had AAI in flexion only while three patients had it in both views. Three patients with AAI had odontoid anomalies contributing to the condition. When assessing AAI, the posterior atlanto-odontoid distance has to be considered because it indicates the space available for the cord. Cervical spondylosis was noted in 16 (36%) subjects. Degenerative changes increased with age, occurred earlier than in the normal population, and affected mostly the lower cervical levels. Half the patients with AAI had cervical spondylosis, a comorbidity that puts the cord at increased risk.

Lateral neck radiography for prediction of difficult orotracheal intubation

Failed endotracheal intubation is a principal cause of morbidity and mortality in anesthetized patients. The aim of this study was to investigate the efficiency of lateral neck radiography in predicting difficult intubation. In a prospective triple-blind study, 100 patients (aged 18-89 yr), scheduled for elective surgery were randomly selected. Lateral neck X-ray was obtained from each of the patients before operation. Several angles and parameters on the X-ray were proposed to illustrate a relationship with easy or difficult intubation. A radiologist recorded these angles before the operation. An anaesthesiologist also determined the Mallampati score preoperation. At the time of intubation, two other anesthesiologists performed a laryngoscopy and, according to established criteria, identified the patients as easy or difficult intubation. The results were then compared with each other. Fifteen patients were identified as having difficult intubation (laryngoscopy Grades III and IV). Sensitivity and specificity of the Mallampati Class test were 26% and 100%, respectively. The sensitivity and specificity of the lateral neck X-ray for three measured angles were 100%. The positive and negative predictive values (NPVs) for those angles were 100% and for Mallampati classification were 100% and 80%, respectively. Compared to the Mallampati Class test, our method of analyzing the lateral X-ray, although not as easy and universally applicable as Mallampati Class test, proved to be a suitable method for predicting difficult intubation.

Diagnosis

Visualization using a bedside nasopharyngeal scope demonstrated edema of the epiglottis and other supraglottic structures and purulent material on the epiglottis, consistent with epiglottitis. The patient was started on ceftriaxone and admitted to the ICU for close observation. She was discharged from the hospital after 2 days with a prescription for oral Augmentin. Epiglottitis is the inflammation of the epiglottis and aryepiglottic structures usually as a result of a viral infection. Sore throat and odynophagia are often the presenting symptoms in adults, whereas children present with stridor and difficulty breathing. Adults also are more likely than children to have anterior neck tenderness. Other presenting symptoms include fever, drooling, shortness of breath, and stridor. The reported incidence of epiglottitis in adults is increasing and is now 2.5 times greater than that of children.1.Sack J.L. Brock C.D. Identifying acute epiglottitis in adults.Postgrad Med. 2002; 112 (85-86): 81-882Crossref PubMed Scopus (17) Google Scholar Diagnosis of adult epiglottitis typically begins with a soft tissue lateral neck radiograph (Figure). This radiograph may demonstrate the classic “thumb sign” as well as the “vallecular sign.” The “thumb sign” describes the rounded shape of the epiglottis due to the swelling and thickening of the tissue, giving it the shape of an adult thumb. The “vallecular sign” is the complete or partial obliteration of the vallecular airspace as the epiglottis swells and extends anteriorly.2.Schamp S. Pokieser P. Danzer M. et al.Radiologic findings in acute epiglottitis.Eur Radiol. 1999; 9: 1629-1631Crossref PubMed Scopus (3) Google Scholar Proper airway management and prompt initiation of antibiotic therapy are often essential for patient survival. Patients with epiglottitis should be admitted to a monitored bed where they can be closely observed for any deterioration in the status of their airway. Images in emergency medicineAnnals of Emergency MedicineVol. 44Issue 4PreviewA 78-year-old woman presented to the emergency department with a 2-day history of sore throat, odynophagia, and hoarseness. Her only past medical history included atrial fibrillation for which she took coumadin. The patient's vital signs on initial presentation were temperature 37.4°C (99.4°F), pulse rate 110 beats/min, respiratory rate 20 breaths/min, blood pressure 105/34 mm Hg, and oxygen saturation of 95% on room air. Full-Text PDF

Prevertebral Soft Tissue Measurements in Thyroid Enlargement: The Value of Lateral Neck Radiographs

Measurement of prevertebral soft tissue is commonly used to assess prevertebral abnormalities, such as retropharyngeal abscess or injury to the cervical spine. In the presence of goitres, the widened prevertebral tissue seen on plain lateral neck radiograph may be diagnostic of an enlarged tubercle of Zuckerkandl (ZT), which may be responsible for most pressure symptoms. The aim of this study was to substantiate the value of plain lateral neck radiographs in preoperative demonstration of enlarged ZT. Fifty patients who underwent thyroid surgery between June and December 2000 were included in this prospective, non-randomized study. Measurements of prevertebral soft tissue were taken at C4, C5 and C6, and were correlated with the weight of goitres and the grades of changes in the ZTs. Of patients, 44% had large goitres weighing more than 100 g; 52% of ZTs were classified as grade 3. Of the large ZTs, 82% were associated with large goitres and, of these, 88% were associated with significant pressure symptoms. Prevertebral measurements were abnormal, particularly at C4, C5 and C6. The most promising predictor of the presence of an enlarged ZT is the measurement taken at C4 (p<0.05). The ratio of the prevertebral space to the vertebral body (PVS/VB) in grade 3 ZT was also increased at C4, C5 and C6. However, these ratios were not statistically significant. A measurement of prevertebral soft tissue, particularly at C4, greater than 16.5 mm correlates 100% with an enlarged grade 3 ZT. The results of this study support the concept that the plain radiograph shows significant widening of the lateral neck in the presence of an enlarged ZT. Plain lateral radiography is a simple procedure that could provide valuable information for preoperative assessment of an enlarged ZT, particularly in patients with large goitres who have significant pressure symptoms.

Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends.

To describe the epidemiology, natural history, and treatment of epiglottitis in the Hemophilus influenzae type B (Hib) vaccine era. Ten-year retrospective study. Tertiary-care children's hospital. Nineteen patients with a discharge diagnosis of epiglottitis. As indicated by the presentation of the patient, including direct laryngoscopy, intubation, intravenous antibiotics, and steroids. Presentation, management, and microbiology. Presenting symptoms included fever, drooling, and hot potato voice. Patients' ages ranged from 15.8 months to 17.5 (mean 8.9) years. From 1992 to 1997, the mean age was 5.8 years; from 1998 to 2002, the mean age was 11.6 years. Sixty-eight percent of patients were transferred from an outside hospital. A lateral neck radiograph was recorded in 84% of patients. Mean leukocyte count was 16600. Direct laryngoscopy with intubation was performed in 79%; intubation was for an average of 3.5 days. H. influenzae was cultured in six patients, five of which had up-to-date immunizations. The most commonly administered antibiotics were ampicillin/sulbactam and ceftriaxone. Steroids were administered to 63% of patients. Complications included deep neck space infection (2), seizure (1), recurrent illness (1), and vocal granuloma (1). There were no deaths. The demographics, causative organisms, and natural history of epiglottitis have changed substantially in the Hib vaccination era. The clinician evaluating and treating patients with epiglottitis should be aware of current trends.

Lateral Neck Radiography versus Direct Video Rhinoscopy in Assessing Adenoid Size

To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhinoscopy in assessing adenoid size and the relationship of these methods to associated symptoms and thus the severity of the disease. Children with suspected adenoid hypertrophy underwent standard lateral neck soft tissue radiographs: the percentage of airway occlusion, adenoid to nasopharynx (AN) ratio, airway to soft palate ratio, and adenoid thickness were assessed by a radiologist. The percentage of airway closure was assessed by direct fibre-optic rhinoscopy in an ear, nose, and throat clinic. Associated clinical symptoms were assessed by parents using a standardized questionnaire, evaluating the severity of symptoms (snoring, sleep apnea, mouth breathing, and otitis media) to give a total symptom score out of 16. Nonparametric statistical analysis using Spearman's correlation coefficients was performed on 32 patients. There was a weak correlation, which approaches significance, between the percentage of airway occlusion assessed by fibre-optic rhinoscopy and the total symptom score (r = .344, p = .054). However, this correlation becomes significant when the frequency of otitis media is omitted (r = .367, p = .039). There was also a significant correlation between airway occlusion assessed by rhinoscopy and the percentage of airway occlusion as determined by lateral neck radiography (r = .431, p = .014). There was no correlation between any of the measurements taken by lateral soft tissue neck radiography and total symptom score. Dynamic video rhinoscopy is more accurate at assessing adenoid hypertrophy, and the percentage of airway occlusion, as estimated by video rhinoscopy, is better correlated to the severity of symptoms than are values obtained by lateral neck radiography.

Retropharyngeal or cervicomediastinal haematomas following stellate ganglion block

Retropharyngeal or cervicomediastinal haematomas following stellate ganglion block

Apnea.

Apnea.

舌へん桃に発生した結石症例

A 42-year-old woman came to our hospital with a 1-month history of foreign body sensation in the pharynx. Lateral neck radiograph and computed tomography scan showed a calcification in the root of the tongue. We suspected that the object was a foreign body, because her symptom had appeared just after a meal. Extirpation with direct laryngoscope was done under general anesthesia. The location of the object was easily detected with fluoroscopy. Infrared spectrum revealed that it was a calculus of the lingual tonsil. 37 cases of tonsillolith have been reported previously in Japan, but all cases were calculi of the palatine tonsil. This case is the first report to our knowledge of calculus of the lingual tonsil.

Difficult Retrograde Endotracheal Intubation: The Utility of a Pharyngeal Loop

Difficult Retrograde Endotracheal Intubation: The Utility of a Pharyngeal Loop

Historical review of croup

Historical review of croup

Acute epiglottitis in the tropics: is it an adult disease?

Acute epiglottitis has traditionally been described as a paediatric disease in reports from temperate countries. There have been very few reports from tropical countries. This is a retrospective review of 32 cases of acute epiglottitis from Singapore over an eight-year period from 1992 to 1999. There were 31 adults and only one child. In Singapore, Haemophilus influenzae Type b (Hib) immunization in not routine, and thus the increased prevalence in adults cannot be attributed to Hib immunization. Eleven patients required airway intervention, of whom nine had endotracheal intubation and two had a surgical airway. Significant predictors for airway intervention included the sex of the patient, stridor, presence of airway compromise on examination and a "thumb sign" on the lateral neck radiograph. In adults, selective airway intervention is recommended as those without airway compromise at presentation recover very well with medical treatment alone.

Viral croup.

Viral croup.

Radiologic laryngeal parameters in acute supraglottitis in Korean adults.

Soft-tissue lateral neck radiography is important for diagnosing acute supraglottitis. This study aimed to determine the objective criteria for a diagnosis of acute supraglottitis from soft-tissue lateral neck radiographs in Korean adults. The parameters in 30 adult patients with acute supraglottitis were compared with those of age- and sex-matched normal 30 Korean adults. The mean of epiglottis width (EW) and aryepiglottic fold width (AEW) in the control group were 4.37 +/- 0.93 mm, 2.45 +/- 0.71 mm, respectively and in the patient group they were 15.87 +/- 3.60 mm, 6.4 +/- 2.55 mm, respectively. The sensitivity and specificity of an EW greater than 7 mm were 100%, and 100% respectively. The sensitivity and specificity of an AEW greater than 4.5 mm were 83%, and 100% respectively.

Safety of neck rotation for ear surgery in children with Down syndrome.

Seek information about spinal cord safety for children with Down syndrome positioned for ear surgery. Prospective consecutive patients, each serving as his or her own control. Somatosensory evoked potentials were recorded from 17 children who were undergoing elective otolaryngological surgery. None of the patients had neurological symptoms or physical examination findings suggesting cervical spinal cord embarrassment. Specifically, muscle tone was normal or mildly reduced globally, consistent with Down syndrome, and deep tendon reflexes were normal and not appreciably different in the upper and lower extremities. On plain lateral radiographs obtained in the neutral, flexed, and extended positions, the patients' cervical spines were normal. When the anesthetized children had their necks placed in either right or left 60 degrees rotation, no significant change in somatosensory latency or amplitude was found. With more than 99.999% certainty, neurologically intact children with Down syndrome with normal plain cervical spine radiographs were not exposed to extra risks by 60 degrees neck rotation during surgery. Patients with Down syndrome who are neurologically intact and who have normal lateral neck radiographs do not appear at great risk with neck rotation.