Soft Tissue Neck X-ray Research Articles

Laryngeal carcinoma: Experience in Ile-Ife, Nigeria

This study aimed to determine the prevalent age, pattern of presentation, histopathology type, and outcome of management of laryngeal carcinoma in our environment. This was a 10-year retrospective study carried out at a teaching hospital. Records of patients managed for laryngeal carcinoma from January 1994 to December 2004 were reviewed. Only 13 cases with tissue diagnosis were included in this review. The age, sex, occupation, presentation, use of cigarette and alcohol, investigations, histology, outcome of management, and duration of follow-up were extracted and analyzed. The patients had a mean age of 69.9 years (range 38-88 years) and a male-to-female ratio of 12:1. Histopathology was squamous cell carcinoma in all. Symptoms included hoarseness in voice and breathlessness in all, cough in 7 (53.8%), weight loss in 7 (53.8%), and otalgia in 6 (46.2%). Two patients indulged in alcohol and two were also regular cigarette smokers. All the patients presented with stage IV disease and in respiratory distress necessitating emergency tracheostomy. Seven (53.8%) patients had total laryngectomy plus postoperative radiotherapy while 2 (15.4%) had pharyngolaryngectomy, thyroidectomy, radical neck dissection plus postoperative radiotherapy and thyroxine supplement. Surgical complications included pharyngocutaneous fistula in 2 (15.4%) patients, pharyngeal stenosis, stomal stenosis, and hypocalcemia with hypothyroidism in 1 patient each. The fistulae were managed conservatively and prognosis was good despite late presentation. Laryngeal carcinoma mainly occurs in males. Presentation is late with hoarseness in voice and breathlessness in our community. Soft-tissue neck x-ray is a useful diagnostic tool. Scarce radiotherapy centers, ignorance, local taboo, poverty, and poor recognition by primary healthcare providers have a negative impact on its management. Laryngeal carcinoma should be excluded when managing elderly patients for bronchial asthma.

Use of intubating laryngeal mask airway for intubation in patient with massive goitrous thyroid

Sir, Large thyroid masses are a nightmare for the anaesthesiologist not only because of thyroid endocrinal abnormality but also because of difficult airway.[1] Fiberoptic bronchoscopy for tracheal intubation is considered the gold standard in such scenarios but may not be available sometimes.[23] We report a successful airway management in a patient with a large thyroid mass with distorted laryngeal anatomy using an intubating laryngeal mask airway (ILMA). A 65-year-old male was scheduled for total thyroidectomy for multinodular goitre. Patient complained of progressively increasing swelling over neck and difficulty in speaking, swallowing and breathing since last six months. The swelling extended superiorly up to the chin, laterally up to the posterior border of sternocleidomastoid and below up to the suprasternal notch (size, 30 × 20 cm) [Figure 1a and b]. There was prominence of veins over the mass and also over the anterior chest. Airway assessment revealed adequate mouth opening, modified mallampati class MMC II and neck movements were restricted. Investigations revealed normal haemogram, biochemical and thyroid profile. Indirect laryngoscopy revealed fixed left vocal cord and left pyriform fossa was not opening up. Soft tissue neck X-ray revealed compression and right deviation of trachea [Figure 2]. Contrast-enhanced computed tomography scan of neck and chest showed compression and right anterior displacement of the trachea. After overnight fasting, pantoprazole (40 mg) and glycopyrrolate (0.2 mg) was administered in the morning of surgery. In the operation room, routine monitors were attached. Lignocaine (4%) gargles were done. Left radial artery was cannulated. Anaesthesia was induced with sevoflurane (6%) in 100% oxygen. After lignocaine spray (10%), laryngoscopy revealed Cormack lehane CL Grade III. Even after manipulating the thyroid mass externally, the glottic chink could not be visualised. We could only appreciate a small hole in the left lateral aspect of the oral cavity and glottis was oedematous. We tried to negotiate the tube with a stylet but could not achieve tracheal intubation. Even bougie could not be negotiated. We attempted intubation using ILMA and optimal ventilation was achieved after adjusting the ILMA handle in different directions. This was achieved only when ILMA was rotated laterally and anteriorly. Stabilising the ILMA at this position of best ventilation and optimal capnograph, endotracheal tube was gently inserted and successful intubation was achieved. Thereafter the anaesthetic procedure was uneventful.Figure 1: (a, b). Patient with a larger thyroid massFigure 2: X-ray soft tissue neckWe predicted difficulty in tracheal intubation in our patient. Fiberoptic bronchoscope was not available with us for this patient. Tracheostomy as a definitive airway was not possible in our patient because of the large thyroid mass extending till the suprasternal notch and also due to airway distortion. So we planned to topicalize the airway and to secure the airway under sevoflurane induction. Since the endotracheal tube could not be negotiated in multiple attempts even after using bougie and stylet and manipulating the thyroid mass, ILMA was used as a rescue attempt. By manoeuvring the ILMA based on the predicted location of the glottic chink to achieve optimal ventilation helped us to adjust the ILMA cuff in line with the glottis and thereafter tracheal intubation was achieved in the first attempt. ILMA has been attempted earlier for tracheal intubation in patients with larger goitre but intubation was not successful though ventilation was easy.[4] They presumed that it could be because of distorted laryngeal anatomy and they performed standard manoeuvres for achieving the tracheal intubation. But we suggest that the manoeuvres need to be done on the basis of the predicted location of the glottic opening. We suggest that achieving optimal ventilation by ILMA could help in aligning the glottic chink and thus successful tracheal intubation could be done in a patient with a large goitrous thyroid with distorted laryngeal anatomy.

Atypical locations of retropharyngeal abscess: Beware of the normal lateral soft tissue neck X-ray

Retropharyngeal abscesses (RPA) are uncommon but potentially lethal deep neck space infections, over 95% of which occur in children under six years of age [1,2]. Without a high index of suspicion, early recognition and prompt intervention, catastrophic consequences can ensue, and mortality can be as high as 60% if jugular vein thrombosis or mediastinitis occurs [3]. While older children may have specific complaints referable to the pharynx, infants and young children may present with vague symptoms [4]. To date, a lot of emphasis continues to be placed on the importance of lateral soft tissue neck X-ray in the diagnosis and management of patients with suspected retropharyngeal abscesses; and lateral neck X-ray has been cited as the most useful radiological view of the laryngopharynx [5]. While we recognise the role of lateral neck X-rays in retropharyngeal and other upper airway pathologies, we present three case series in which lateral neck X-rays were normal and diagnosis was made only after CT scanning. These three cases were unusual as the abscesses were located high in the naso-pharynx making them impossible to detect on the lateral soft tissue neck X-rays and this underscores the need for high index of suspicion and prompt CT or MRI scanning, in any child with symptoms or signs suggestive of a possible retropharyngeal abscess.

Relative radio‐opacity of commonly consumed fish species in South East Queensland on lateral neck x‐ray: an ovine model

To determine the relative radio-opacity on plain x-ray of bones of fish species commonly consumed in South East Queensland. A cadaveric sheep model was used to mimic the soft tissues of a human neck. Bones of 10 fish species were placed in the paratracheal tissues and adjacent to the larynx. X-rays were taken and the images (including four control images with no bones) were incorporated into a Microsoft PowerPoint presentation to be interpreted by emergency specialists and registrars. Observers were blinded to which specimens contained fishbones and which did not. Sensitivity and specificity of plain x-rays for detecting impacted fishbones. Significant interobserver variability was identified. Despite this, the overall specificity of plain x-rays was 90%. The sensitivity of the technique was 79% overall, but varied significantly between fish species. Lateral soft tissue neck x-ray is an appropriate screening tool in cases of a suspected impacted fishbone. If a fishbone is identified on x-ray, the patient should be referred for endoscopy without further imaging. X-ray may be of limited value in cases of Dory or Spanish mackerel bone ingestion. In such cases, a computed tomography scan should be the first-line investigation.

Lateral soft tissue neck X-rays: are they useful in management of upper aero-digestive tract foreign bodies?

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

Junior doctors' ability to interpret lateral soft tissue neck X-rays: is there a training issue?

In light of the introduction of the European Working Time Directive and Modernising Medical Careers initiative, this article reports the results of a study to see whether junior doctors possess adequate skills to correctly interpret lateral soft tissue neck X-rays and if they receive adequate training.

Role of Plain Xray Soft Tissue Neck Lateral View in the diagnosis of Cervical Esophageal Foreign Bodies

Role of Plain Xray Soft Tissue Neck Lateral View in the diagnosis of Cervical Esophageal Foreign Bodies

Impacted Denture in the Oesophagus: Case report and review of Literature

Objective: To report a rare case of impacted foreign body (artificial denture) in the oesophagus and review the literature. Case Report: This is a case report of impacted foreign body (artificial denture) in the oesophagus. The wire could be seen on xray soft tissue neck lateral view. But rigid oesphagoscopy could not remove the denture and the patient developed cervical emphysema in the first post operative period. Foreign body (artificial denture) was removed by Oesophagotomy and retrieval of denture and sternocleidomastoid muscle patching via external approach. Conclusion: Foreign body ingestion is a common problem. Early removal of foreign bodies must be considered to reduce the risk of complications. Impacted denture in the oesophagus which was removed by oesophagotomy is an unusual presentation. To the best of our knowledge this is the first case report from Nepal.

Oesophageal Foreign Bodies in Children

Foreign body ingestion is a common occurrence and carries significant morbidity and mortality. Failure to treat foreign bodies immediately can lead to various serious complications. This study was done to identify the types as well as site of foreign body ingested and its complication in children. A retrospective study of 122 cases of suspected foreign body ingestion in patients admitted in ENT and Head and Neck Surgery of TU Teaching Hospital, Kathmandu were done in between April 2004 to July 2008. Ages less than 12 years were included. In all cases x-ray soft tissue neck lateral and chest x-ray posterio-anterior views were done along with other preoperative investigations. Rigid oesophagoscopy or hypopharyngoscopy were done under general anesthesia to remove foreign bodies. There were 64.7% male and 35.3% female children. Foreign bodies were common in 0-4 year age group. Most common foreign body were coin (64.0%) followed by meat bone (14.0%). No foreign bodies were found in 2.4% patients as they were passed in stomach. No complications were noted during the entire period of this study. Most common foreign bodies in children are coin. Though complications with these foreign bodies are rare, these do occur due to delay in presentation and removal. No complications were noted in our series. Eventhough children who swallow foreign bodies are asymptomatic; we must maintain a high index of suspicion and undergo diagnostic procedure, if there is a positive history.

Lateral soft tissue neck X-rays: are they useful in management of upper aero-digestive tract foreign bodies?

To assess the value of lateral soft tissue neck X-rays in patients presenting with upper aero-digestive tract foreign bodies. Retrospective study. (1) Patients referred to the ENT team, via either the accident and emergency department or their general practitioner; (2) a history of a non-aspirated, upper airway, aero-digestive tract foreign body; and (3) a lateral soft tissue neck X-ray taken on admission. A total of 62 patients met the inclusion criteria. Twenty-four patients (38.7 per cent) had positive findings on lateral soft tissue neck X-ray. 'Soft' signs, such as widened pre-vertebral shadow and loss of lordosis, were seen in all 24 patients, and foreign bodies were visualised in six patients. Overall, lateral soft tissue neck X-rays were helpful in the management of 32 patients (51.6 per cent). Rather worryingly, doctors in the accident and emergency and ENT departments missed 79.2 and 66.6 per cent of the positive findings, respectively. A lateral soft tissue neck X-ray is a helpful tool in the management of patients presenting with upper aero-digestive tract foreign bodies. Junior doctors need better radiology training.

A 92-year-old woman with dyspnoea and stridor

taking daily medications. She had never seen a doctor prior to this visit. Vital signs: BP 200/95 Torr, HR 105 beats/min, RR 24 breaths/min, T 37.2°C and O2 sat 100% on 2-l nasal cannula. The patient had a hoarse voice with moderate stridor. She was able to speak in one to two word sentences, but could not speak in full sentences. She was leaning forward in the tripod position. The oropharynx was normal in appearance. The anterior neck revealed no masses, lymphadenopathy or tenderness. The trachea was midline. The chest examination was clear with symmetric breath sounds, and no wheezing or crackles. A STAT portable chest radiograph (CXR) and soft tissue neck X-ray were obtained. The CXR was unremarkable, but the soft tissue neck X-ray revealed an approximately 2-cm round radiopaque density at the posterior aspect of the glottic inlet.

The Picture Archiving and Communication System: a useful tool in a case of upper oesophageal foreign body

We present a case of an oesophageal foreign body (approximately 2x2 cm) which was not seen on the initial lateral soft tissue neck X-ray but was detected following manipulation of the X-ray using the Picture Archiving and Communication System of X-ray viewing. This system gives the user much greater flexibility, including a choice of magnification and contrast.

An Unusual Cause of Dysphagia in a Mentally Retarded, Deaf and Dumb Child

We report a 7 year old mentally retarded, deaf and dumb male child presenting with history of fever, cough and swallowing difficulty for 3 days. On examination he was found to be febrile with pharyngeal congestion and mild bilateral tonsilar enlargement. A provisional diagnosis of retropharygeal abscess was made, and an X-ray soft tissue neck was asked for. Surprisingly the X-ray showed a toe ring in the hypopharynx which was removed by esophagoscopy. It is extremely difficult to diagnose foreign body as the cause of dysphagia in a deaf and dumb child, especially in a mentally retarded one. This causes delay in diagnosis and increases complications. Physicians should maintain a high index of suspicion of such a rare cause of dysphagia in the mentally challenged children.

Asymptomatic Foreign Body Aspiration In A Young Adult: A Case Report

Foreign body aspiration is a well documented clinical scenario. However establishing the diagnosis can be challenging. A case of an asymptomatic aspiration of a significant foreign body is presented here. CASE REPORT A 33 yr old white male who was previously fit and well presented to the Accident & emergency department with the symptoms of foreign body sensation in the throat following a meal. He denied any problems with breathing or any difficulty with swallowing. He also denied any violent attacks of coughing or haemoptysis. Clinical examination was unremarkable. He was afebrile and breath sounds were equally heard bilaterally. Surprisingly soft tissue neck X-ray revealed a foreign body in the trachea. He underwent rigid endoscopy and a chicken bone was removed. Patient was discharged the following day. Figure 1 Asymptomatic Foreign Body Aspiration In A Young Adult: A Case Report

A prospective study of foreign-body ingestion in 311 children

Objective: To determine the preferable management protocol of foreign body ingestion in pediatric patients. Methods: All pediatric patients aged less than 12 years who presented with suspected foreign body ingestion in a hospital setting over a period of 3 years were prospectively studied. The usefulness of symptoms and various diagnostic procedures to identify the impacted foreign bodies were analyzed. Results: Of 311 children aged 4 months to 12 years, 115 foreign bodies were encountered. The presentations in children aged younger than 5 years were markedly different from the older children, who behaved more like adults. All sharp foreign bodies (107 cases or 93%), mostly fish bones (90.4%), were found in the oropharynx under direct vision using either tongue depressor (57%), Macintosh laryngoscope (6%), indirect laryngeal mirror (2%) or transnasal flexible endoscopy (28%). Coins (eight cases or 7%) were the only foreign body impacted at or below the level of cricopharyngeus. A plain cervical X-ray has a low sensitivity (15.9%) and a high specificity (99.5%) in identifying the foreign bodies. Conclusions: As the majority of the foreign bodies were sharp bones and situated in the oropharynx, a management protocol involving examination with a tongue depressor, transnasal laryngoscope, selective lateral soft tissue neck X-ray, chest X-ray and watchful observation is usually adequate. Removal of these foreign bodies can be accomplished using a tongue depressor and Macintosh laryngoscope. Patients with a suspected coin ingestion have to be evaluated by X-ray, and a rigid pharyngo-oesophagoscopy should be the mainstay of treatment.

Incidence and types of post extubation complications following endotracheal intubation and tracheostomy

This study was undertaken to study early and late post extubation complications following endotracheal intubation and tracheostomy. A total 60 patients who were admitted in Dayanand Medical College and Hospital were studied prospectively. They were divided into 3 groups and were screened with various modalities like fiberoptic laryngoscopy. Bronchoscope, X-Ray Soft Tissue Neck and CT Scan, Complications like glottic edema, vocal tears, vocal granuhmas and tracheal stenosis were seen and were accordingly managed.

Occult pharyngeal perforation secondary to ‘pencil injury’

Palatopharyngeal injuries due to impaction of rigid objects held in the mouth are common. Most are essentially innocuous injuries requiring no specific treatment. However, there is the potential for perforation of the pharyngeal wall with the subsequent development of serious infection such as retropharyngeal abscess or mediastinitis. This possibility is more likely to be suspected in the presence of a visible laceration or puncture wound at the site of impact in the mouth or pharynx. We report three cases in which occult pharyngeal perforation occurred without any clinical signs of breech of the pharyngeal wall. In all cases a lateral soft tissue neck X-ray was diagnostic of perforation, showing the presence of retropharyngeal air. We, therefore, advocate the routine performance of soft tissue neck X-rays in all patients who present with a history of falling on a rigid object held in the mouth.

Lateral Cervical Radiographs and Adenoid Size: Do They Correlate?

Clinicians have questioned the value of lateral soft tissue neck x-ray (LSTN) in assessing adenoid size. Elaborate cephalometric assays have been devised to measure degree of nasopharyngeal obstruction secondary to adenoid hypertrophy. This study prospectively studied 73 children, aged 11 months to 13 years, with clinical evidence of adenoid hypertrophy to assess how well a LSTN correlates with direct intraoperative observation of adenoid size and nasopharyngeal obstruction. We found a relatively weak correlation (Pearson coefficient r = 0.34) between x-ray and operative observations. We conclude that LSTN is an appropriate examination in the preoperative assessment of children being considered for adenoidectomy. However, this test must be interpreted by recognizing the inherent limitations of evaluating a dynamic structure, such as the nasopharynx, through a non-dynamic modality.

Pneumomediastinum Secondary to a Mandible Fracture

Pneumomediastinum may be produced by a simple facial fracture. It may also be a sign of other aerodigestive tract injuries, and this possibility should be ruled out. A minimal patient workup should include panendoscopy and soft tissue neck x-ray films in all cases. If no other injuries are found, resolution of the pneumomediastinum may be expected without further treatment.