Suhas Radhakrishna, HMS III

Gillian Lieberman, MD

Radiographic Evaluation of
Stridor in Children

Focusing on Infectious Causes

Suhas Radhakrishna
Harvard Medical School, Year III
Gillian Lieberman, MD
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Overview

Clinical Basics
Radiographic Anatomy
Patient Cases

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Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Clinical Basics

Stertor: inspiratory snoring

nose, nasopharynx, oropharynx

Stridor: low to medium pitch sound

Inspiratory = extrathoracic airway obstruction

Expiratory = intrathoracic obstruction

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Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Sites of Obstruction

Nasopharynx Reynolds, P., Abrahams, P. McKinns Interactive Clinical

Anatomy Head and Neck. CD ROM. Mosby 1996.

Oropharynx and
Hypopharynx
Supraglottic
Glottic
Subglottic
Tracheobronchial

4
1
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Differential Diagnosis

Congenital Anomalies
Trauma or Intubation
Foreign Body
Infection and Inflammation
Neoplasm

CT FIN
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Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Examining the Upper Airway Radiologically

Neck soft tissue Plain Films

4 views
Inspiratory and expiratory
AP and Lateral
Extension of neck if possible for best view

If patient is in severe respiratory distress, need

to intubate and transfer to ICU
CT / MRI for better visualization

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 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD
Normal Radiographic Anatomy- Lateral
Approach to Films: Survey the Entire Airway
Reynolds, P., Abrahams, P. McKinns Interactive Clinical
Tongue Anatomy Head and Neck. CD ROM. Mosby 1996.

Nasopharynx
Uvula
Tonsils/ Adenoids
Oropharynx
Hypopharynx
Retropharynx
Larynx Region
Trachea
Esophagus
Stram, E. Bacterial Tracheitis. Boston Childrens Hospital
Teaching File Case 6-291

7
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Normal Radiographic Anatomy Lateral

Coned down view of larynx

Reynolds, P., Abrahams, P. McKinns Meschan, I. The Respiratory System. An Meschan, I. The Respiratory System. An
Interactive Clinical Anatomy Head Atlas of Normal Radiographic Anatomy. Atlas of Normal Radiographic Anatomy.
and Neck. CD ROM. Mosby 1996. Chapter 10. WB Saunders, 1959 Chapter 10. WB Saunders, 1959

Tongue Epiglottis Vocal Fold

Hyoid Bone Aryepiglottic folds Vestibular Fold
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Vallecula Vestibule of Larynx Sinus/Ventricle of Larynx
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Normal Radiographic Anatomy - Frontal

Epiglottis
Meschan, I.
The
Respiratory
Aryepiglottic Folds
System. An
Atlas of
Normal
Radiographic
Arytenoid Cartilage
Anatomy.
vallecula Chapter 10.
WB Saunders,
1959

Meschan, I. The Respiratory System. An

Atlas of Normal Radiographic Anatomy.
Chapter 10. WB Saunders, 1959

Grays Anatomy
Vestibular Cord Ventricle Subglottis
9
Vocal Cord Glottis
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient HP

6 mo old female presents with fever and

respiratory distress x 1 day
On exam
Stable vital signs
Nontoxic appearing
? Inspiratory stridor, + subcostal retractions
Elevated WBC (18.49)
Differential includes viral URI, bronchiolitis,
PNA, croup
Chest and neck films were ordered
Chest film shows no evidence for PNA
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient HP Lateral film

Normal retropharyngeal soft
tissue width

Anatomy:

Posterior Tongue
Vallecula
Epiglottis
Aryepiglottic fold

Glottis / Vocal Cords

Subglottic region
hazy with suggestion
Courtesy of Dr. Maryellen Sun
of narrowing 11
 Patient HP Frontal Film
Courtesy of Dr. Maryellen Sun

Subglottic
Stenosis

Tracheal Deviation
Normal in infants

Diagnosis?
Croup
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Normal vs Croup
Kandarpa, K. Normal vs Croup Boston
Childrens Hospital Teaching File Case 5-273

Normal
shoulder Steeple sign

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Normal Croup
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Radiographic Differential Diagnosis

Assymetric

Swischuk, L. and John, S. Differential Diagnosis in Pediatric

Radiology. Second Edition, Williams and Wilkins 1995,
Baltimore Maryland.

14
Patient JW

4 y/o boy presented to ED with 6 day hx

of headache and 5 day hx of bilateral
swollen and sore neck and fever to 103.6.
Poor PO intake, trouble turning head,
new cough, mild stridor, snoring at night.
Exam showed bilateral cervical LAD
WBC 27.04
Patient JW CT scan
See any hypodense areas
that could represent
edema or inflammation?
Tracheal
Retro- deviation and
pharyngeal compression
abscess

Courtesy of Raymond Mak, HMS IV

 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Plain Film Diagnosis of Retropharyngeal Abscess

Lateral coned down view
Normally
there is a
step off
from the
Step- off
hypo-
pharynx to
the larynx.
This is due to
the soft tissue
Swischuk, L. and John, S. Differential Diagnosis in Swischuk, L. and John, S. Differential Diagnosis in

density of the Pediatric Radiology. Second Edition, Williams and

Wilkins 1995, Baltimore Maryland.
Pediatric Radiology. Second Edition, Williams and
Wilkins 1995, Baltimore Maryland.

undistended Normal RP abscess

esophagus
posterior to In a retropharyngeal abscess there is obliteration
the tracheal of the step off, due to the swelling of the posterior
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air column. space into the hypopharynx.
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Retropharyngeal Fakeout
Retropharyngeal
abscess?

Patient was crying!

Beware the fakeout:

Crying, expiration,
and swallowing can
look like a
retropharyngeal soft
tissue swelling.

Courtesy of Dr. Maryellen Sun

18
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Radiographic Differential Diagnosis

Swischuk, L. and John, S. Differential Diagnosis in Pediatric Radiology. Second Edition,

Williams and Wilkins 1995, Baltimore Maryland.

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 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient JF

4 y/o boy who had a 1 wk history of URI.

1 day prior to admission he had: fever to
105 F, cough, stridor, drooling, and
vomiting.
Let us compare JFs normal follow up
film from next year to JFs film from
today.

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 Patient JF
Hankins, Carol. Boston Childrens Hospital
Teaching File Case 5-272
Diagnosis?
Retropharynx Epiglottitis
Hypopharynx Dilation

Normal
Epiglottis and
Aryepiglottic Folds Thickening

Subglottic
trachea Normal
Straightened,
Normal C-spine leaning
lordosis forward
JF next year (normal film) JF today
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient S

2 year old boy

2 week history of URI
1 day history of dysphagia and
temperature to 104 F.
He arrives at 6:30 am and neck films are
taken.

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 Patient S Lateral Film

6:30 am
There is a suggestion
of epiglottic
thickening and the
rest of the film
appears normal

Hankins, Carol. Boston Childrens Hospital

Teaching File Case 5-272
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient S
11:30 am
Just 5 hours later Diagnosis?
Our patient S is now in
Epiglottitis
significant distress, extending He needs
his neck in a struggle to immediate
breathe
intubation!
The epiglottis and
aryepiglottic folds are
markedly thickened

The glottic region is hazy and inflamed

The subglottic trachea and retropharyngeal

space appear normal. 24
Hankins, Carol. Boston Childrens
Hospital Teaching File Case 5-272
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Epiglottitis Fakeouts
Omega Epiglottis
Buckling on poor inspiration Normal variant
Note thin aryepiglottic fold

Swischuk, L. and John, S. Differential Diagnosis in Pediatric

Radiology. Second Edition, Williams and Wilkins 1995,
Baltimore Maryland.

25
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Differential Diagnosis

Swischuk, L. and John, S. Differential Diagnosis in Pediatric

Radiology. Second Edition, Williams and Wilkins 1995,
Baltimore Maryland.

26
 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Patient JO

6 year old girl with a 2 day history of

fever to 102 F and sore throat
Physical exam appears normal
Neck films are obtained
 Patient JO Frontal Film

Subglottic stenosis

Tracheal narrowing

Stram, E. Boston Childrens Hospital Teaching File Case 6-291

 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

JO- Lateral Neck Soft Tissue Film

Normal appearing
epiglottis;
Diagnosis?
thickening of Bacterial Tracheitis
aryepiglottic fold

Subglottis dense and hazy

Tracheal
Pseudomembrane
Strand of exudate Stram, E. Boston Childrens
Hospital Teaching File Case 6-291

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 Suhas Radhakrishna, HMS III
Gillian Lieberman, MD
Summary of Infectious Causes of Stridor
Croup Bacterial Tracheitis Epiglottitis
Age Infants to preschool

Prodrome
URI
+ + +/-
Toxicity
+ +++
Microbiology Viral S aureus H. influenza
C diphtheria S. aureus
Radiographic Steeple on AP Subglottic Thumb sign =
Findings = Subglottic narrowing Thickened
narrowing Irregular tracheal epiglottic and
Dilated margin aryepiglottic folds
hypopharynx Pseudomembranes
Treatment Mist Artificial Airway Artificial Airway
Epinephrine Antibiotics Antibiotics
Steroids 30
Modified from Rudolph, A. Fundamentals of Pediatrics. Third Edition. Mc-Graw Hill, 2002.
Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

Acknowledgments

Dr. Maryellen Sun

Dr. Gillian Lieberman
Pamela Lepkowski
Larry Barbaras, Webmaster
Raymond Mak, HMS
Shreya Kangovi, HMS

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Suhas Radhakrishna, HMS III
Gillian Lieberman, MD

References
Bingam, Brian J MBChB, FRCS. Atlas of Clinical Otolaryngology. Mosby Year
Book, Inc , 1992
Bellet, P. The Diagnostic Approach to Symptoms and Signs in Pediatrics. Second
Edition. Lippincott Williams & Wilkins, 2002.
Hankins, Carol. Epiglottitis. Boston Childrens Hospital Teaching File Case 5-272.
Kandarpa, K. Normal vs Croup Boston Childrens Hospital Teaching File Case 5-
273.
Kushner, D. Obstructing Lesions of the Larynx and Trachea in Infants and
Children. Radiologic Clinics of North America. Vol XVI, No 2, August 1978.
Lefebvre, J. Clinical Practice in Pediatric Radiology, The Respiratory System.
Volume 2. Masson Publishing USA Inc 1979.
Reynolds, P., Abrahams, P. McKinns Interactive Clinical Anatomy Head and
Neck. CD ROM. Mosby 1996.
Rudolph, A. Fundamentals of Pediatrics. Third Edition. Mc-Graw Hill, 2002.
Stram, E. Bacterial Tracheitis. Boston Childrens Hospital Teaching File Case 6-291.
Swischuk, L. and John, S. Differential Diagnosis in Pediatric Radiology. Second
Edition, Williams and Wilkins 1995, Baltimore Maryland.
Zawin, J. Epiglottitis. Boston Childrens Hospital Teaching File Case 5-272.
Meschan, I. The Respiratory System. An Atlas of Normal Radiographic Anatomy.
Chapter 10. WB Saunders, 1959.

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