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com
Original article
1
Department of Otolaryngology
Head and Neck Surgery, Ehime
University, Toon City, Ehime,
Japan
2
Department of Emergency
Medicine, Kurashiki Central
Hospital, Kurashiki City,
Okayama, Japan
3 Participants Adult patients who underwent LNR to
Department of Radiology,
Kurashiki Central Hospital,
Kurashiki City, Okayama, Japan
4 spectrum bias.
Department of Emergency
Medicine, Kurashiki Central
Hospital, Kurashiki City,
Okayama, Japan
5
Department of Otolaryngology
Head and Neck Surgery,
Kokura Memorial Hospital,
Kitakyushu City, Fukuoka,
Japan
Correspondence to
T Fujiwara, Department of
Otolaryngology Head and Neck
Surgery, Ehime University,
Shitsukawa, Toon City, Ehime
791-0295, Japan;
t.fujiwarabi@gmail.com
Received 19 October 2013
Revised 21 February 2014
Accepted 28 March 2014
Published Online First
20 August 2014
To cite: Fujiwara T,
Okamoto H, Ohnishi Y, et al.
Emerg Med J 2015;32:
348–352.
348
Diagnostic accuracy of lateral neck radiography
in ruling out supraglottitis: a prospective
observational study
Takashi Fujiwara,1 Hiroshi Okamoto,2 Yasuhiro Ohnishi,3 Toshio Fukuoka,4
Kazuyuki Ichimaru5
ABSTRACT
Objective To assess the diagnostic accuracy of lateral Key messages
neck radiographs (LNR) for acute supraglottitis in adults.
Design A single centre prospective observational study.
What this paper adds
Setting Emergency department at Kurashiki Central
▸ Observational studies have suggested that
Hospital, Japan.
lateral neck radiographs can be used to rule
out supraglottitis, but the diagnostic accuracy
detect supraglottitis.
of the test in prior studies may be affected by
Main outcome measures Presence of supraglottitis,
based on nasopharyngeal laryngoscopy or a follow-up
▸ In this prospective study, lateral neck
telephone call, 7–30 days after the visit.
radiographs had a PPV of 58.6% and NPV of
Results 140 patients had LNR during the study period.
94.5%, with a negative LR of 0.22.
35 patients were excluded from further analysis because
Radiographs could not rule out all cases of
of lack of consent. Of the 105 eligible patients,
supraglottitis in this prospective study and
21 patients (20%) were given the diagnosis of
appears to miss milder cases.
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
settings.3 4 Abnormal findings on LNR in patients
abnormal LNR. Sensitivity and specificity (95% CI) of
with supraglottitis are thickening of the epiglottis,
LNR for supraglottitis were 81.0% (64.2 to 97.7) and
called the ‘thumb sign’,5 6 and a poorly defined val-
85.7% (78.2 to 93.2), respectively. The positive
lecula air pocket, termed the ‘vallecula sign’.7
predictive value of LNR was 58.6% (40.7 to 76.5) and
Previous studies reported high sensitivity (83–
the negative predictive value was 94.7% (89.7 to 99.8).
100%) and specificity (87–100%) of LNR for
The positive likelihood ratio of LNR was 5.67 (3.27 to
supraglottitis.6–8 However, these retrospective
9.82) and the negative likelihood ratio was 0.22 (0.10
studies calculated diagnostic accuracy using
to 0.51).
inappropriate spectrum patients. The diagnostic
Conclusions LNR showed only moderate sensitivity
value of LNR was calculated using patients with
and specificity for supraglottitis and would miss some
supraglottitis diagnosed by laryngoscopy. Generally,
cases of supraglottitis if the pre-test probability is high.
LNR are used to screen for, and laryngoscopy is
LNR was very sensitive for grade 3 or higher supraglottitis,
not always performed in patients who have normal
but would miss milder cases.
LNR.6 7 Previous studies did not sufficiently
Trial registration UMIN000011928.
address those patients who had radiographs but did
not have laryngoscopies. Also, the specificity of
LNR was calculated using patients with trauma and
INTRODUCTION
foreign bodies as the control group,7 although
Supraglottitis is an inflammation of the epiglottis
LNR of lingual tonsillitis patients, who present
and surrounding soft tissues, and can cause sudden
with similar symptoms to supraglottitis, may also
life threatening airway obstruction which may
have abnormal radiographs.9 Spectrum bias is asso-
require emergency airway management.1 The most
ciated with a risk of overestimating the test accur-
common symptom of supraglottitis is a sore throat;
acy.10 Therefore, we conducted a prospective
however, this is a very common symptom in the
validation study to determine the diagnostic accur-
emergency setting, resulting mostly from self-
acy of LNR in the diagnosis of supraglottitis in
resolving diseases, such as the common cold.
adults.
Ruling out supraglottitis is thus challenging for the
emergency physician. Direct visualisation of the
epiglottis by nasopharyngeal laryngoscopy or indir- METHODS
ect laryngoscopy is the gold standard for a diagno- Study population and protocol
sis of supraglottitis; however, these tests require We performed a single centre, non-interventional,
special training and expertise.2 Soft tissue lateral prospective study in the emergency department of
neck radiographs (LNR) are a common procedure Kurashiki Central Hospital, from 16 April 2011 to
for screening for supraglottitis because they are 31 March 2013. The study was conducted and
easily obtained and available in most clinical reported in accordance with Standards for
Fujiwara T, et al. Emerg Med J 2015;32:348–352. doi:10.1136/emermed-2013-203340
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Reporting of Diagnostic Accuracy principles.11 We prospectively
recruited consecutive adult patients (>15 years old) whom had
undergone LNR to evaluate supraglottitis. LNR were performed
if patients had a sore throat, odynophagia, drooling, voice
change or dyspnoea. The emergency department physicians
decided whether the patients needed LNR, and trained radio-
logical technologists performed the LNR. Nasopharyngeal laryn-
goscopy was performed in patients with radiographic
abnormalities, as well as in those without abnormalities but in
whom the emergency physician still suspected supraglottitis. All
enrolled patients were followedup by telephone interview after
7–30 days. Planned exclusions were patients who did not provide
consent or who were not followed up by telephone interview.
For each enrolled patient, data on patient characteristics,
symptoms and the presence of supraglottitis were collected from
the medical records. The institutional review board of Kurashiki
Central Hospital approved the study.
In contrast with therapeutic or interventional studies, formal
sample size calculations based on power assumptions for diag-
nostic modelling cohort studies do not exist. As we intended to
roughly calculate the sensitivity and specificity of LNR in the
clinical setting, we defined the sample size as 18 patients with
supraglottitis; this number is similar to the numbers in previous
studies.5–7 The incidence of supraglottitis in adults is 1–3 per
100 000/year.12 13 Kurashiki Central Hospital is an urban hos-
pital that serves 800 000 people in the western area of Okayama
prefecture, and there are approximately 70 000 visits to the hos-
pital emergency department annually. At Kurashiki Central
Hospital, 10–15 patients with supraglottitis were hospitalised
annually from 2000 to 2010, and about 20% were diagnosed
without LNR. We set a 2 year study duration to enroll a suffi-
cient number of patients with disease.
Index and reference standard
The index test was the LNR. A trained radiological technologist
performed all LNR. One emergency physician (HO) and one
radiologist (YO) independently interpreted each LNR. HO and
YO were blind to the patient’s history, symptoms and laryngo-
scopic results. Disagreement was resolved by discussion, and the
presence of a ‘thumb sign’ and ‘vallecula sign’ were recorded.
Interobserver differences between HO and YO were analysed
using k statistics, including 95% CI.
The reference standard was the findings of nasopharyngeal
laryngoscopy or follow-up telephone interview after 7 days.
The laryngoscopies were performed in the emergency depart-
ment or otolaryngology department by otolaryngologists. Two
Figure 1 Katori’s scope grading of supraglottitis. (A) Grade 1: the patient’s epiglottis is slightly swelled and the entire length of the vocal folds
can be seen with the scope. (B) Grade 2: the patient’s epiglottis is moderately swelled and more than half of the posterior vocal folds can be seen
with the scope. (C) Grade 3: the patient’s epiglottis is severely swelled and only less than half of the posterior vocal folds can be seen with the
scope.
Fujiwara T, et al. Emerg Med J 2015;32:348–352. doi:10.1136/emermed-2013-203340
Original article
otolaryngologists (TaF and KI) classified the findings according
to Katori’s laryngoscopic grading system: grade 1: the patient’s
epiglottis is slightly swollen with the entire length of the vocal
folds visible by scope; grade 2: the patient’s epiglottis is moder-
ately swollen with more than half of the posterior vocal folds
visible by scope; and grade 3: the patient’s epiglottis is severely
swollen with less than half of the posterior vocal folds visible by
scope (figure 1).14 Emergency department physicians decided
whether to prescribe antibiotics before or after the laryngoscopy
or if the patient did not undergo the procedure. For those who
did not undergo nasopharyngeal laryngoscopy during the visit,
we conducted a follow-up telephone interview after 7 days
because supraglottitis generally worsens within 7 days. If we did
not reach participants at this time, we called repeatedly in an
attempt to reach them within 30 days of the visit. If the patient’s
symptoms had resolved, we defined the outcome as negative for
supraglottitis. If the patient visited the emergency department
repeatedly, we defined the outcome as positive or negative based
on the diagnosis at the subsequent emergency department visits.
We also asked whether patients were prescribed antibiotics from
other hospitals or physicians.
Statistical analysis
Using the laryngoscopic diagnosis of supraglottitis or the tele-
phone interview as the standard, we calculated the test
characteristics (sensitivity, specificity, predictive value and likeli-
hood ratios) of LNR with 95% CI using the normal approxima-
tion. All statistical analyses were performed using SPSS software
V.19.0 (SPSS Inc, Chicago, Illinois, USA). The first author (TaF)
had full access to all study data and analyses.
RESULTS
From 16 April 2011 to 31 March 2013, 140 LNR were per-
formed to rule out supraglottitis, and 105 LNR met the inclu-
sion and exclusion criteria of the study. Thirty-five patients
(25%) were excluded because they did not give consent. No
patient had respiratory obstruction precipitated by LNR.
Nasopharyngeal laryngoscopy was performed in 71 (67.6%)
patients, 34 (32.4%) patients were followed-up by telephone
interview. (figure 2). The characteristics and symptoms of the
105 enrolled patients are shown in table 1.
Twenty-nine patients had positive LNR. Interobserver agree-
ment for the thumb sign was substantial, at 92.1% (12.1%
agreement on positive ratings and 80.0% agreement on negative
ratings), with a κ value of 0.71 (95% CI 0.55 to 0.87).
Interobserver agreement for the vallecula sign was substantial, at
349
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Original article

Figure 2 Details of the patients who underwent lateral neck radiographs.

92.9% agreement (13.6% agreement on positive ratings and department physicians in four cases before the subsequent laryn-
79.3% agreement on negative ratings), with a κ value of 0.75 goscopy, while six patients who did not undergo laryngoscopy
(95% CI 0.60 to 0.90). Of the 29 patients with an abnormal were treated with antibiotics.
radiograph, 26 underwent LNR and 3 were discharged by the A radiographic abnormality was seen in 57.1% of the radio-
emergency physician. Of the 76 patients with a normal radio- graphs with grade 1 supraglottitis. Four patients (19%) with
graph, 45 underwent LNR and the rest were discharged. Among supraglottitis had false negative LNR; 3 of these were grade 1.
patients who had normal LNR and were discharged with phone All patients with grade 3 supraglottitis, which is an indication
follow-up, 71.0% had a sore throat and 41.9% had odynopha- for artificial airway management,15 had an abnormality on x-ray
gia, while among those who had a normal x-ray and laryngos- (positive thumb or vallecula sign).; 87.5% (7/8) of grade 2
copy, 100% had a sore throat and 68.9% had odynophagia. In supraglottitis patients had detectable radiographic abnormalities.
sum, 71 patients underwent laryngoscopy, and supraglottitis was (table 2). In all patients who were followed-up by telephone
diagnosed in 21 (grade 1=7, grade 2=8, grade 3=6) (table 2), interview, symptoms had resolved.
for a total incidence of 20% (figure 2). Supraglottitis was diag- The test characteristics of the LNR using the final interpret-
nosed in 17 of the 26 (65%) patients who had abnormal x-rays, ation agreed on by both the emergency physician and radiologist
and four of the patients (13%) who had normal xrays. No are displayed in Table 3. The LR positive of the LNR was 5.67
patients who were discharged had supraglottitis. (95% CI 3.27, 9.82) and the LR negative was 0.22 (95% CI
Half of the laryngoscopies were performed within 1 h of the 0.10, 0.51). The sensitivity of the emergency physician's inter-
LNR. The median time interval from LNR to laryngoscopy was pretation was slightly higher than the radiologist's 81% (62.2,
1 h (mean±SD, 3.6±5.2). Laryngoscopies were delayed in 97.8) vs. 66.7% (95% CI 46.5, 86.8), but specificity was similar
patients who had normal radiographs and were less likely to (84.5% vs. 85.7%).
have supraglottitis and in those who underwent radiographs on Six of the patients with negative LNR who did not undergo
the weekend. All of the laryngoscopies were performed within larygnoscopy were treated with antibiotics. The diagnoses of
24 h of the LNR. Antibiotics were prescribed by emergency these patients were acute pharyngitis (n=4), tonsillitis (n=1)
and intestinal perforation (n=1). We could not be certain if
these six patients had supraglottitis. If we re-analysed the results
Table 1 Demographics and clinical symptoms of enrolled patients without these six patients, specificity decreased from 85.7% to
84.6 (76.6 to 92.6)%.
Enrolled Laryngoscope Telephone
patients follow-up interview
(n=105) (n=71) follow-up (n=34) DISCUSSION
In this prospective study, LNR had relatively low sensitivity and
Age (years) 42.8±18.1 43.8±17.6 40.7±19.1
specificity for supraglottitis in adults. Previous studies reported
Males (n (%)) 56 (53.3) 43 (60.6) 13 (38.2)
a sensitivity and specificity of the classic thumb sign of 83–
Symptoms (n (%))
100% and 87–100%, respectively.6 8 In 1997, Ducic et al7
Sore throat 95 (90.5) 70 (98.6) 25 (73.5)
reported a new radiographic sign, vallecula sign, which had
Odynophagia 69 (65.7) 53 (74.6) 16 (47.1)
98.2% sensitivity and 99.5% specificity in their report. Based
Dyspnoea 13 (12.4) 5 (7.0) 8 (23.5)
on these findings, some authors suggested that the LNR might
Voice change 8 (7.6) 8 (11.3) 0 (0.0)
obviate the use of routine laryngoscopy. However, these retro-
Fever (37.5°C) 40 (38.1) 26 (36.6) 14 (41.2)
spective studies were at high risk of overestimating the diagnos-
Enrolled patients (n=105) included patients followed by laryngoscopy (n=71) and tic value, and no validation study of the vallecula sign has been
those followed by telephone (n=34).
reported.
350 Fujiwara T, et al. Emerg Med J 2015;32:348–352. doi:10.1136/emermed-2013-203340
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Original article

emergency department population. As previous studies calculat-

Table 2 Results and outcomes of lateral neck radiographs
ing the diagnostic accuracy were limited by spectrum bias,6 7 the
Supraglottitis true sensitivity and specificity were not clear. The incidence of
Grade 1 Grade 2 Grade 3 No supraglottitis Total supraglottitis in this study was similar to that in previous
reports,12 13 so our results can be generalised to other clinical
Radiographic abnormality settings. Kurashiki Central Hospital serves 800 000 people in
Positive 4 7 6 12 29 the western area of Okayama prefecture, where few hospitals
Negative 3 1 0 72 76 have more than one otolaryngologist to manage supraglottitis.
Thumb sign Thus a patient with suspected supraglottitis at other hospitals in
Positive 2 7 5 5 19 the western Okayama prefecture would be transferred to
Negative 5 1 1 79 86 Kurashiki Central Hospital. In our study, the incidence of supra-
Vallecula sign glottitis was 20.0%. The pre-test probability might change
Positive 4 7 4 10 25 according to the clinical setting and the physician’s decision.
Negative 3 1 2 74 80 The negative/positive predictive value of this study will be
Total 7 8 6 84 105 affected by the incidence in the population. This study included
Radiographic abnormality—positive means thumb sign positive or vallecula sign only adults, and it might not be possible to generalise our
positive. results to paediatric supraglottitis which may have a more
serious course.
The study had some limitations. Firstly, not all patients under-
The LNR is often used to rule out a diagnosis of supraglotti- went laryngoscopy to verify the diagnosis. It is difficult to have
tis; hence a low negative likelihood ratio and high negative pre- an otolaryngologist available at all times to perform laryngos-
dictive value are needed. In this study, the negative likelihood copy because they tend to have other commitments. If a patient
ratio was 0.22, which generates small changes in probability, is suspected of having supraglottitis, because of the risk of
and the negative predictive value was 94.7%, which indicated airway obstruction, laryngoscopy takes priority over the otolar-
that 1 in 20 patients would be missed by LNR. As ruling out yngologist’s other work, while in patients who are suspected of
supraglottitis based on negative LNR findings might result in having the common cold, laryngoscopy is not prioritised. It is
misdiagnosis, for patients with probable supraglottitis, nasopha- improper to make the latter patients wait for laryngoscopy and
ryngeal laryngoscopy should be considered to make a definite also ethically improper to subject a patient suspected of having
diagnosis. However, compared with paediatric supraglottitis, a common cold to unnecessary invasive laryngoscopy.
adult supraglottitis is less severe, with a lower risk of airway Therefore, we defined the reference standard as laryngoscopy or
obstruction, especially for grade 1 supraglottitis. Thus, if the telephone follow-up. In this study, only 57% (4/7) of grade 1
role of LNR is to detect only severe supraglottitis, then perhaps supraglottitis patients had a radiological abnormality, and 8.9%
these x-rays have sufficient diagnostic accuracy. (4/45) of patients with normal radiographs and laryngoscopy
In this study, one emergency physician and one radiologist had supraglottitis. Patients who had normal radiographs without
interpreted the LNR independently, and we evaluated interob- laryngoscopy were followed-up by telephone interview because
server disagreement. The thumb and vallecula signs were in the emergency department physician estimated that they had a
agreement about 92% of the time, and the kappa value sug- low probability of supraglottitis. It is possible that a maximum
gested moderate interobserver agreement. The radiologist is an of 8.9% of patients followed-up by telephone had supraglottitis.
expert in the interpretation of radiographs, including LNR. 35 patients were excluded because they did not consent to
However, in Japan, emergency physicians almost always inter- participate in the study. Most of the excluded patients had
pret LNR. This is because of the increased need for interpret- normal radiographs and a lower rate of odynophagia (65.7% in
ation of CT, MRI and positron emission tomography images by the enrolled patients vs 42.9% in the excluded patients), and
radiologists, whose time might otherwise be spent interpreting were younger (42.8±18.1 years for the enrolled patients vs 36.1
LNR. The sensitivity of the LNR read only by an emergency ±16.5 for the excluded patients). Patients at low risk of epiglot-
physician was higher than the radiologist’s, but specificity was titis were excluded from the study, which might decrease the
similar. validity of the study. In all of the patients who were followed-up
by telephone interview, symptoms had resolved, and none was
Strengths and limitations diagnosed with supraglottitis. Therefore, it is unlikely there
To our knowledge, this is the first prospective validation study were many missed patients with supraglottitis and hence missed
of LNR for detection of adult supraglottitis in a general cases should have had little, if any, effect on our results.

Table 3 Lateral neck radiograph test characteristics

Radiographic abnormality
(thumb or vallecula sign) Thumb sign Vallecula sign

Sensitivity (%) 81.0 (64.2 to 97.8) 66.7 (46.5 to 86.8) 71.4 (52.1 to 90.8)
Specificity (%) 85.7 (78.2 to 93.2) 94.0 (89.0 to 99.1) 88.1 (81.2 to 95.0)
Positive predictive value (%) 58.6 (40.7 to 76.5) 73.7 (53.9 to 93.5) 60.0 (40.8 to 79.2)
Negative predictive value (%) 94.7 (89.7 to 99.8) 91.9 (86.1 to 97.6) 92.5 (86.7 to 98.3)
Positive likelihood ratio 5.67 (3.27 to 9.82) 11.2 (4.74 to 26.5) 6.00 (3.21 to 11.20)
Negative likelihood ratio 0.22 (0.10 to 0.51) 0.35 (0.20 to 0.63) 0.32 (0.17 to 0.62)
Values are median (95% CIs).

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Original article
We enrolled only 21 patients with supraglottitis, similar to
previous reports.6 7 The small sample size resulted in wide 95%
CIs, and further research with larger samples is needed to calcu-
late the test accuracy precisely.
Finally, laryngoscopy was delayed for a maximum of 24 h
after LNR; while half of the laryngoscopies were performed
within 1 h of the LNR, a delay could have resulted in more
negative laryngoscopies.
CONCLUSION
LNR in our practice had a 0.22 negative likelihood ratio for
supraglotittis. Although the sensitivity of LNR was 100% for
severe (grade 3) supraglottitis, the test the test cannot be used to
rule out mild supraglottitis when the pre-test probability is high.
Physicians should consider nasopharyngeal laryngoscopy in
patients with suspected supraglottitis, even if there are no radio-
graphic abnormalities.
Contributors TaF and ToF designed the study protocol. HO and YO interpreted the
lateral neck radiographic data (index test). KI and TaF interpreted the
nasopharyngeal laryngoscopy data (reference standard test). TaF was primarily
responsible for writing the draft. All authors revised and approved submission of the
current manuscript.
Competing interests None.
Ethics approval The study was approved by the institution review board of
Kurashiki Central Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.
352
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Diagnostic accuracy of lateral neck

radiography in ruling out supraglottitis: a
prospective observational study
Takashi Fujiwara, Hiroshi Okamoto, Yasuhiro Ohnishi, Toshio Fukuoka
and Kazuyuki Ichimaru

Emerg Med J 2015 32: 348-352 originally published online August 20,
2014
doi: 10.1136/emermed-2013-203340

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