NECK & AIRWAY NECK & AIRWAY EMERGENCIESEMERGENCIES

Carlos J. Sivit M.D.Carlos J. Sivit M.D.

NECK & AIRWAY NECK & AIRWAY EMERGENCIESEMERGENCIES

To identify the role of imaging in the To identify the role of imaging in the evaluation of N & A emergenciesevaluation of N & A emergenciesTo list normal variants that mimic diseaseTo list normal variants that mimic diseaseTo categorize emergent n & a conditions To categorize emergent n & a conditions including infections, masses, airway including infections, masses, airway foreign bodies & foreign bodies & tracheomalaciatracheomalacia

NORMAL VARIANTSNORMAL VARIANTS

Tracheal bucklingTracheal bucklingRetropharyngeal “Retropharyngeal “pseudomasspseudomass””

• Increased flexibility of thoracic trachea in young infant

• Cervical trachea fixed• Deviates away from arch

TRACHEALBUCKLING

RETROPHARYNGEAL PSEUDOMASS

• Pseudothickening of soft tissues• Airway not fully distended• Spine not fully extended

• True soft tissue swelling should result in anterior airway displacement

RETROPHARYNGEAL PSEUDOMASS

SPECTRUM OF SPECTRUM OF ABNORMALITIESABNORMALITIES

INFECTIONSINFECTIONSFOREIGN BODIESFOREIGN BODIESNECK & AIRWAY MASSESNECK & AIRWAY MASSESTRACHEOMALACIA / STENOSISTRACHEOMALACIA / STENOSIS

INFECTIONSINFECTIONS

Acute Acute LaryngotracheobronchitisLaryngotracheobronchitis (Croup)(Croup)Acute Acute EpiglottitisEpiglottitisRetropharyngeal abscessRetropharyngeal abscessInfectious MononucleosisInfectious Mononucleosis

CROUPCROUP

CLINICAL PRESENTATIONCLINICAL PRESENTATION< 2 y, < 2 y, inspiratoryinspiratory stridorstridor & barking cough& barking cough

EtiologyEtiologyParainfluenzaParainfluenza

Imaging findings Imaging findings SubglotticSubglottic tracheal narrowing “steeple sign”tracheal narrowing “steeple sign”InspiratoryInspiratory overdistensionoverdistension of of hypopharynxhypopharynx

““STEEPLE SIGN” STEEPLE SIGN” -- DDXDDX

CroupCroupEpiglottitisEpiglottitisVocal cord paralysisVocal cord paralysisLaryngeal webLaryngeal webCongenital Congenital subglotticsubglottic stenosisstenosis

EPIGLOTTITISEPIGLOTTITIS

CLINICAL PRESENTATIONCLINICAL PRESENTATION> 2 y, fever, sore throat, drooling & > 2 y, fever, sore throat, drooling & stridorstridor

ETIOLOGYETIOLOGYHemophilusHemophilus influenzainfluenza

IMAGING FINDINGS IMAGING FINDINGS Thickened epiglottis & Thickened epiglottis & aryepiglotticaryepiglottic foldsfoldsSubglotticSubglottic narrowing narrowing (variable)(variable)

RETROPHARYNGEAL RETROPHARYNGEAL ABSCESSABSCESS

CLINICAL PRESENTATIONCLINICAL PRESENTATION< 4y, prior URI, fever, neck pain, drooling< 4y, prior URI, fever, neck pain, drooling

ETIOLOGYETIOLOGYStaphylococcus or StreptococcusStaphylococcus or Streptococcus

IMAGING FINDINGSIMAGING FINDINGSPrevertebralPrevertebral soft tissue swellingsoft tissue swellingSoft tissue gas Soft tissue gas uncommonuncommon

INFECTIOUS INFECTIOUS MONONUCLEOSISMONONUCLEOSIS

CLINICAL PRESENTATIONCLINICAL PRESENTATION> 3y, fever, sore throat, > 3y, fever, sore throat, pharyngitispharyngitis & adenitis& adenitis

ETIOLOGYETIOLOGYEpstein Barr VirusEpstein Barr Virus

IMAGING FINDINGSIMAGING FINDINGSMassive Massive tonsillartonsillar & adenoidal enlargement& adenoidal enlargement+/+/-- PrevertebralPrevertebral soft tissue swellingsoft tissue swelling

AIRWAY FOREIGN AIRWAY FOREIGN BODYBODY

Symptoms depend on location & sizeSymptoms depend on location & sizeEndobronchialEndobronchial > > LaryngotrachealLaryngotrachealComplete Complete vsvs partial obstructionpartial obstruction

NonopaqueNonopaque > Opaque> OpaqueGreater morbidity w/ Greater morbidity w/ laryngotracheallaryngotracheal

AIRWAY FOREIGN BODYAIRWAY FOREIGN BODY IMAGING FDGSIMAGING FDGS

Filling defect in airwayFilling defect in airwayHyperinflation Hyperinflation -- diffuse, focaldiffuse, focalAtelectasisAtelectasis

INTRINSIC MASSESINTRINSIC MASSES

HEMANGIOMAHEMANGIOMAPAPILLOMAPAPILLOMAGRANULOMAGRANULOMA

SUBGLOTTIC SUBGLOTTIC HEMANGIOMAHEMANGIOMA

CLINICAL PRESENTATIONCLINICAL PRESENTATIONNeonatal period Neonatal period InspiratoryInspiratory stridorstridorDyspneaDyspneaCutaneousCutaneous hemangiomashemangiomas in 1/2in 1/2

SUBGLOTTIC SUBGLOTTIC HEMANGIOMA HEMANGIOMA

NECK RADIOGRAPHYNECK RADIOGRAPHYEccentric Eccentric subglotticsubglottic narrowingnarrowing

CT & MRCT & MRWell circumscribed Well circumscribed intraluminalintraluminal massmassUseful for preoperative planning w/ large Useful for preoperative planning w/ large massesmasses

EXTRINSIC MASSESEXTRINSIC MASSESINFANTS & YOUNG CHILDRENINFANTS & YOUNG CHILDREN

Cystic Cystic hygromahygroma -- ThyroglossalThyroglossal duct cystduct cystHemangiomaHemangioma -- FibromatosisFibromatosis collicolliBranchialBranchial cleft cystcleft cyst

OLDER CHILDREN OLDER CHILDREN LymphomaLymphoma -- BranchialBranchial cleft cystcleft cystRhabdomyosarcRhabdomyosarc -- ThyroglossalThyroglossal duct cystduct cyst

FIBROMATOSIS COLLIFIBROMATOSIS COLLI- Infants & neonates- Unilateral neck mass(R > L) or torticollis

- Pressure necrosis orvenous occlusion ofsternocleidomastoidfollowed by fibrosis

- Focal or diffuse - Variable echotexture

CYSTIC HYGROMA• Malformations of

lymphatic channels• Posterior to

sternocleidomastoid• 10% extend to mediastinum• Well circumscribed• Primarily cystic• May contain septa

BRANCHIAL CLEFT BRANCHIAL CLEFT CYSTCYST

-Failure of obliteration of cervical sinus of 1st or 2nd

clefts or pouches-Abnormalities include cysts, sinuses or fistulas-Cysts are the most common-Painless, nontender mass-Lateral to thyroid-Round or oval

THYROGLOSSAL THYROGLOSSAL DUCT CYSTDUCT CYST

-Persistence of thyroglossal duct

- 65% supra-, 20% infrahyoid & 15% at level of hyoid

- Midline or slightly off- midline

- Anechoic or hypoechoic

TRACHEOMALACIATRACHEOMALACIA

Weakness of tracheal wall 2Weakness of tracheal wall 2oo

abnormality of supporting cartilageabnormality of supporting cartilageNarrows during inspirationNarrows during inspirationExtrinsic > IntrinsicExtrinsic > IntrinsicFocal or generalizedFocal or generalizedPresent in neonatal period with Present in neonatal period with inspiratoryinspiratory stridorstridor & & dyspneadyspnea

TRTRACHEOMALACIAACHEOMALACIA DDXDDX

Extrinsic compressionExtrinsic compressionVascular ringVascular ring

Aberrant left Aberrant left subclaviansubclavian arteryarteryDouble aortic archDouble aortic archAberrant left pulmonary arteryAberrant left pulmonary artery

Dilated esophageal pouch in Dilated esophageal pouch in esophageal esophageal atresiaatresia

NECK & AIRWAY NECK & AIRWAY EMERGENCIESEMERGENCIES