Approach to stridor in a 6 year old child
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Transcript of Approach to stridor in a 6 year old child
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Approach to stridor in a Approach to stridor in a 6 year old child6 year old child
Jacques le Roux24/08/2012
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APPROACH TO STRIDOR IN 6 YEAR OLD CHILD
• Anatomy (upper airways)
• General reminders
• Etiology
• Approach- Imaging options- Imaging findings
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ANATOMY
1. Supraglottic Region – above vocal cords•Epiglottis with•Aryepiglottic folds (runs laterally and convex-INF)
2. Glottic •Level of true vocal cords (triangular space)•Level of thyroid cartilage
3. Subglottic •Trachea starts here•Level of cricoid cartilage
Trachea on:- frontal X-Ray, convex shoulders- axial imaging, round (if not pathology)
•Thoracic inlet: Line through sternal angle / T4
- Above is upper airway- Below starts lower airway
•Retrophareng. (prevert soft tissue)- From C1 – C4 : normal ¾ of vertebral body- Lat must be taken in extension (flexion makes it wider)
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GENERAL REMINDERS (CAUSES OF AIRWAY OBSTRUCTION IN A CHILD)
CLASSICAL
• < 3 years - croup (subglottic laringo-tracheo bronchitis) - not life-threatenig (self limited disease)
• Life-threatening- Infant – choanal atresia- 3-6 years – epiglottitis- Any age - foreign bodies (also in esoph)
- 80% radiolucent- Angioneurotic edema
• ± 6 years - other causes - think: upper or lower airways and intrinsic or extrinsic causes
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ETIOLOGYUPPER AIRWAYS- Above thoracic inlet-Inspiratory stridor-Usually acute (infective)
ACUTE1. Foreign bodies2. Retropharengeal - Cellulitis - Abscess (gas)3. Quinsy (tonsils)4. Lymphadenitis
- BACT- TB (scrofula)
5. Exudative tracheitis6. Angioedema
CHRONIC1. Enlarged tonsils (adenoid, palatine, lingual)2. Large tongue (Down)
LOWER AIRWAYS- Below thoracic inlet-Inspiratory stridor and expiratory wheeze (some also call it stridor)-More chronic-Some asymptomatic
-Intrinsic/Extrinsic
INTRINSIC1. Foreign bodies2. Post intubation stricture /granuloma3. Hemangioma (most common mass in trachea)
- Subglottic (Ass with facial hemangiomas)
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LOWER AIRWAY OBSTRUCTIONEXTRINSIC – think ant. and middle mediastinumA. ANT – the 4 T’s
Normal thymus - large until 6 years - never compresses airways / vessels - ABN one does – look for Ca⁺⁺
1. Lymphoma (“terrible”) - most common ant. mass (older child) - look for other nodes
2. Thymic masses (cyst – AIDS, thymomas – rare)3. Teratoma - Ca⁺ and fat4. Thyroid tumors – rare
B. MIDDLE1. Nodes (lymphoma, TB, METS) – most common mass2. Duplication cysts
(a) bronchogenic, ass with carina(b) enteric – ass with GIT
3. Vascular – rings - encircle esoph. and trachea Pulmon. sling – between trachea and esoph.4. ↑ L Atrium
C. POST - Rare cause Neurogenic tumors
•Ganglioneuroblastoma and ganglioneuroma (6 years)•Neuroblastoma (classic < 2 years)
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IMAGING OPTIONS
A. CHOICEFrontal and lat. neck and CXR
B. BACK-UP -Δ various intrins and extrins lesions
1. CT (better than MRI) • faster, seldom sedation• Risk - radiation, CT (10mSv)
MDCT (20-30mSv) - contrast reactions• options - multiplanar, 3D volume rendered
- vascular rings, sling - abscess : cellulitis - metallic for. bodies
2. Upper GI series - vascular rings, sling
3. Sonar : Ant. mediast. - ABN thymus (heterog Ca⁺⁺, fat) - biopsy + local is choice - if trachea > 50% narrow and with general – expect problems
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FOREIGN BODIES and IMAGING
• 80% RADIOLUCENT (look for indirect signs)
1. Fluoroscopy (Dynamic)• Mediast. shifts away from obstruc. with expiration (airtrapping)
2. Lat. Decubitus• Normal: Dependent side hypo-aerated
with FB stays hyper-aerated 3. EXP CXR - airtrapping (radiolucent) - flat diaph. (normal inspiration R 6 rib – L 2cm lower) • 20% RADIO OPAQUE eg coin – lateral XR
• In airways - perpendicular (round) to projection• In esoph. - parallel (slim-like, pancake)
• Bronchoscopy Δ and treatment
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IMAGING FINDINGSUPPER AIRWAYS – ACUTE/CHRONIC
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TWO REMINDERS - < 6 Years
Normal – subglottic airway shows rounded shoulders
1. Croup• Loss of shoulders• Steeple sign
Subgottic narrowing
Epiglottis normal
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2. EPIGLOTTITIS• Thick epiglottis• Thumb sign
Thick epiglottis and aryepiglottic fold
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EXUDATIVE TRACHEITIS - 6 – 10 Years - Staph
• Trachea walls irregular• Normal epiglottis
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RETROPHARENGEAL CELLULITISA.• Retrofar. soft tissue swelling• More than vertebral body
B and C : CT with contrast• Low att. Mass• No rim enhancement
• Difficult to do Δ Δ from abscess – clue is gas [ cellulitis no gas ]
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RETROPHARENGEAL ABSCESS
A. Retrophareng – thick soft tissue B. CT with contrast
- Low att. mass- Rim enhancement
PSEUDORETROPHARENGEAL SOFT TISSUE THICKENING
A. Lat - thick retrophar soft tissue - image in flexion
B. Lat - no thickening - image in extension ( is the way)
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TB (SCROFULA) – TB glands
CT WITH CONTRAST• Bilat. necrotic lymph adenopathy• Usually no pulm TB
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TONSILS
Adenoid and palatine enlarged tonsils
T2 with fat saturation
Enlarged lingual tonsisls- T2 high
[Normal signalTonsils same as muscles of tongue]
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ADENOID TONSILS
A. Enlarged
T₂ Gradient echo (cine)
B. Expiration• Airway open
C. Inspiration• Collapse of airway
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Adenoid tonsils (T₂ with fat saturation – tonsil ↑ signal)• removed gives a V shaped appearance• absent at birth• Reach max size 2 – 10 years• After removal – commonly grows back
Ass with collapse of laringopharynx (stridor) with inspiration, because sup. obstruction cause negative pressure in laringopharynx
Bilat. palatine tonsils enlarged
- kissing tonsils- obstruction of airway
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PERITONSILLAR ABSCESS
CT WITH CONTRAST• ↓ Att• Rim enhance
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ANGIOEDEMA
• Diffuse edema around trachea (↓Att)• Pat. was on ACE-inhibitor for high BP
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GLOSSOPTOSIS – eg Down
Obstruction of airway
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LOWER AIRWAYS
EXTRINSIC
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NORMAL THYMUS
Infant – passed away - prominent size
Normal “sail” sign
CT• Quadrilat. in shape• Homogeneous att.• No compression of trachea or SVC
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BRONCHOGENIC CYST - COMPRESSING LEFT MAIN BRONCHUS
- 50% of intrathoracic cysts- Most asymptomatic- Location - Carina (most common) - Paratracheal (usually right) - Hila
B. - Low att. Mass - Adjacent to carina - compressing L main bronchus
A. LLL - Retrocardiac density - Asim. aeration of lungs
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LYMPHOMA – MOST COMMON ANT. MEDIAST. MASS IN CHILD
A - Wide mediast.
B and C - Trachea post displaced and compressed
C and D - SVC encased and compressed
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VASCULAR RINGS/SLING
• Some not found in 6 years• Some will not compress airways
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NORMAL ANATOMYLevel T₃ 9 : Trachea10 : Esophagus6,7 : R, L CCA5,8 : R, L SCA
Innominate art.(Br. ceph. truncus) - from right - passes just in front of trachea just inf. to level of thoracic inlet
Level T₄
4 : SVC3 : normal L aortic arch.
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VASCULAR ABNORM. ( RINGS AND PULM. SLING)DIAGRAMS COMPARED WITH LAT. CXR / FLUOROSCOPY
1. Double aortic arch
• Most common• Δ after birth• Both trachea and esoph. compressed• Both join desc. Aorta - additional compression in midline
2. Pulm. Sling• Only vasc abn that passes between esoph and trachea• L PA comes from R PA• Compress both (tracea/esoph)
3. Innominate art compression syndrome• Origin more to left and with large thymus, cause compression just below thoracic inlet• Highest vasc. abn
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4. R Arch with aberrant L SCA
Meg of airway compression• Kommerell diverticulum - dilation of aorta where L SCA starts• Lig. arteriosum completes ring as well• More midline desc. aorta
5. L Arch with aberrant R SCA
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DOUBLE AORTIC ARCH
Ba ⁺⁺ study: (Reverse S-shaped esoph.)• Bilateral extrinsic compressions on the esoph.
CT• Compress trachea ant.
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R AORTIC ARCH WITH ABERRANT L SCA
Ba⁺⁺ study: post compression of esoph.
A. CXR (AP) – clue of R arch - no knob L seen - trachea to leftB. CXR (Lat) – trachea ant. and compressedC. CT – R aortic arch with aberrant L SCAD. Midline desc. Aorta causes compression
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PULM. SLING
CT• L PA comes from R PA instead of MPA• Only vasc. abn that passes between esoph. and trachea
CXR • Above named cause compression of trachea and R main Bronchus – reason that aeration is less in R lung
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INNOMINATE ART. COMPRESSION SYNDROME
• Compresses the trachea – if trachea not round there is extrins. compression
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FOREIGN BODIESMore common in R main bronchus than upper airways
NON OPAQUE (80%)
INDIRECT SIGNSCXR PA – expiratory• L lung hyperlucent due to airtrapping • Normal dependent side will hypoaerate
Lat. decubitus• L lung will stay aerated
RADIO-OPAQUE (20%)• Button in subglottic area (round)• Bronchoscopy for removal
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RADIO-OPAQUE FB IN ESOPHAGUS vs TRACHEA
CXR LAT
• In esoph. – foreign body present - appears slim (like a pancake)
• In trachea – perpendicular (round)
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POST INTUBATION STRICTURE AND GRANULOMA
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SUMMARY
ETIOLOGY : STRIDOR IN 6 YEAR OLD
UPPER AIRWAYS LOWER AIRWAYS
Foreign bodiesInfections
ACUTE
CHRONICEnlarged tonsils
INTRINSICForeign bodies
EXTRINSIC – think ant. and middle mediastinumA. ANT – the T’sLymphoma (“terrible”) - most common ant. mass (older child)B. MIDDLENodes (lymphoma, TB, METS) – most common massC. POST – Neurogenic tumors Rare cause
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It has been said that one of the differentiating features between a pediatric and a general radiologist is that a pediatric radiologist remembers to look at the airway.
Problems with the airway are much more common in children than in adults.
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References
1. Yedururi S, Multimodality Imaging Of Tracheo Bronchial Disorders In Children Radiographics May 2008.2. Berrocal T, Cong. Anomalies Of Tracheobronchal Tree And Mediatinum: Radiology And Pathology Radiographics Nov. 2003.3. Ludwig B, Diagnostic Imaging In Nontraumatic Pediatric Head And Neck Emergencies, Radiographic 2010; 30: 781-799.4. Capps E, Emergency Imaging Assessment Of Acute Non Traumatic Conditions Of The Head And Neck Radiographics 2010; 30: 1335-1352.5. Gooding CA, Essentials Of Pediatric Radiology Cambridge 2010, 40-74.
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