Outline
 Relevant Anatomy
 Cases
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Epiglottitis
Retropharyngeal Abscess
Bacterial Tracheitis
Croup
FB
 Test Characteristics
Case 1
 4 year old male
 Inspiratory stridor
 Unwell for past 24 hours
 Mom found him in his room with increased work of
breathing
When to order films…
 Sub-acute presentation
 Diagnosis is unclear
 Impending airway embarrassment  something else
Epiglottitis
 Enlarged epiglottis
 Loss of valecular airspace
 Thickened aryepiglotic folds
 Distended hypopharynx
 Straightening of the cervical spine
 Sensitivity (38-88%)
 Specificity (78%)
Croup and epiglottitis: a radiologic study. AU Stankiewicz JA; Bowes AK SO Laryngoscope 1985 Oct;95(10):1159-60.
Epiglottitis and croup. AU Sobol SE; Zapata S SO Otolaryngol Clin North Am. 2008 Jun;41(3):551-66, ix.
Adult epiglottitis: the Toronto Hospital experience. AU Solomon P; Weisbrod M; Irish JC; Gullane PJ SO J Otolaryngol.
1998 Dec;27(6):332-6.
Case 1
 4 year old male
 Inspiratory stridor
 Unwell for past 24 hours
 Mom found him in his room with increased work of
breathing
Retropharyngeal Infection
 Widened retropharyngeal space
 C2 – 7mm or C6 – 14mm (kids)
 C6 – 22mm (adults)
 Reversal of normal cervical lordosis
 Foreign body
 Air-fluid level
 Gas
False Pre-vertebral Swelling
 Oblique lateral
 Neck flexion
 Crying
Case 1
 4 year old male
 Inspiratory stridor
 Unwell for past 24 hours
 Mom found him in his room with increased work of
breathing
Case 1
 3 year old male
 Inspiratory stridor
 Unwell for past 24 hours
 Mom found him in his room with increased work of
breathing
Case 1
 4 year old male
 Inspiratory stridor
 Unwell for past 24 hours
 Mom found him in his room with increased work of
breathing
Foreign Body
 Visualization of radiopaque FB
 Widened pre-vertebral shadow
 Loss of lordosis
 Location
 Esophagus – coronal plane
 Trachea – sagittal plane (best seen on lateral)
Test Characteristics
Sensitivity
Specificity
Epiglottitis
33-88%
78%
Retropharyngeal abscess
80%
100%
Croup
Foreign Body
84%
Questions?
Thank You!
 Triple blinded prospective study
 100 elective surgery patients
 Lateral neck x-ray compared with Mallampati
 Anesthesiologist gold standard (grade III or IV)
 Results
 Mallampati sens: 26% spec: 100%
 Lateral neck film: sens: 100% spec:100%
Adult Epiglottitis
Radiographic Criteria
 Epiglottic height-to-width ratio >0.6
 Epiglottic to C4 vertebral body width ratio >0.33
 Aryepiglottic fold to C3 vertebral body width ratio >0.35
 Prevertebral soft-tissue to C4 vertebral body width ratio
>0.25
 Hypopharyngeal airway to C4 vertebral body width ratio
>1.5