Pediatric Airway

Question 1

Causes of upper airway obstruction above trachea

Answer 1

choanal atresia, rhabdomyosarcoma, infectious (peritonsillar abscess)

Question 2

Congenital occlusion of posterior nasal aperture(s)

Answer 2

choanal atresia; right side > left; bilateral cases have other anomalies; no communication between nasal cavity and nasopharynx

Question 3

Types of choanal atresia

Answer 3

osseous, membranous, mixed; most are mixed (70%)

Question 4

Choanal atresia findings

Answer 4

thickening of vomer, bowing of posterior maxilla/lateral nasal wall, air fluid level in nasal cavity; make sure to evaluate for associated head and neck anomalies (CHARGE)

Question 5

Ddx for choanal atresia

Answer 5

chonal stenosis (more common than atresia), pyriform aperture stenosis, nasolacrimal duct mucosele

Question 6

Chonal atresia presentation

Answer 6

respiratory distress in newborn if bilateral; chronic purulent unilateral rhinorrhea in older child

Question 7

Associations with bilateral choanal atresia

Answer 7

CHARGE syndrome: coloboma (gap in iris/retina), heart defects, atresia of choanae, retardation of development, GU anomalies, and ear anomalies

Question 8

Benign hamartomatous vascular lesion in adolescent males in the nasal cavity

Answer 8

JNA, juvenile nasopharyngeal angiofibroma

Question 9

Where does JNA originate?

Answer 9

posterior wall of nasal cavity off midline at margin of sphenopalatine foramen –> PPF

Question 10

Ddx for JNA

Answer 10

nasal rhabdomyosarcoma, nasopharyngeal carcinoma, antrochoanal polyp, esthesioneuroblastoma

Question 11

CT imaging findings of JNA

Answer 11

heterogenous vs diffuse, avid enhancement; bone remodeling and destruction (posterior wall of maxillary sinus is bowed anteriorly),

Question 12

MR findings of JNA

Answer 12

flow voids, intense enhancement, diffuse/heterogenous

Question 13

Angio findings of JNA

Answer 13

tumor blush during preop embolization; usually the internal maxillary branch of ECA

Question 14

JNA presentation

Answer 14

unilateral nasal obstruction with epistaxis

Question 15

What is the antral sign?

Answer 15

anterior bowing of the posterior wall of maxillary antrum; nonspecific sign from a slowly growing mass seen in JNA; erosion of pterygoid lamina may be pathognomic for JNA

Question 16

Most common childhood soft tissue sarcoma

Answer 16

rhabdomyosarcoma

Question 17

Ddx rhabdomyosarcoma

Answer 17

JNA, LCH, plexiform neurofibroma, infantile hemangioma, nasopharyngeal carcinoma, lymphoma, leukemia

Question 18

Pathology of rhabdomyosarcoma, tissue of origin

Answer 18

primitive mesenchymal cells (rhabdomyoblasts) commited to muscle differentiation

Question 19

Presentation for rhabdomyosarcoma

Answer 19

most under 12 years old; 40% in head and neck (orbit; best prognosis, parameningeal site); increase with p53 tumor suppressor gene mutation and in Noonan syndrome or secondary to radiation therapy

Question 20

Rhabdomyosarcoma CT findings

Answer 20

invasive soft tissue mass with variable enhancement, osseous erosion common

Best to evaluate for osseous erosion

Question 21

Rhabdomyosarcoma MR findings

Answer 21

T1 isointense, T2 hyperintense to muscle; variable enhancement, intracranial

Best for evaluating intracranila and perineural spread; distinguish between sinonasal tumor and inflammatory disease

Question 22

Pts who get epiglottitis

Answer 22

kids prior to H influenza immunization, immunocompromised (HIV, transplant)

Question 23

Imaging findings epiglottitis

Answer 23

thickening of epilottis on lateral view (thumprint sign); thickening of aryepiglottic folds

Question 24

Insipratory stridor and barking cough

Answer 24

Laryngotracheobronchitis (croup) ; exudative tracheitis can also present similarly

Question 25

Steeple sign

Answer 25

Croup; shouldering of subglottic trachea, ballooning of hypopharynx

Question 26

Aspirated foreign body, views

Answer 26

AP chest, decubitus views on obstructed side for persistent expansion/air trapping

Question 27

Ddx prevertebral soft tissue swelling

Answer 27

retropharyngeal abscess/cellulitis, lymphoma, foregut duplication cyst, pseudothickening from neck flexion,

Question 28

Exudative bacterial tracheitis presentation

Answer 28

fever, stridor, resiratory distress; older kids (S aureus) vs H influenza for epiglottitis

Question 29

Imaging exudative tracheitis

Answer 29

filling defects/membranes in the subglottic and cervical trachea

Question 30

Most common subglottic tracheal mass

Answer 30

subglottic hemangioma

Question 31

Imaging findings subglottic hemangioma

Answer 31

asymmetric narrowing of subglottic trachea on frontal view

Question 32

Laryngeal papillomatosis

Answer 32

HPV infection with multiple laryngeal nodules and thick/nodular vocal cords; increased risk for laryngeal SCC; can also cause multiple cavitary nodules

Question 33

Tracheobronchomalacia

Answer 33

airway collapse from weak cartilage (congenital, intubation, infection, inflammation)

Question 34

Vascular ring vs sling

Answer 34

ring: complete encircling of trachea and esophagus; sling: anomalous course of left pulmonary artery that traps trachea on 3 sides

Question 35

Vascular anomaly that causes stridor

Answer 35

pulmonary artery sling with a normal left aortic arch or right sided aortic arch with aberrant L subclavian, double aortic arch

Question 36

Most common vascular ring and symptoms

Answer 36

Double aortic arch; arches encircle both trachea and esophagus; cause stridor

Question 37

4 artery sign

Answer 37

Double aortic arch

Question 38

Second most common vascular ring

Answer 38

Right arch with aberrant left subclavan artery; arch indents trachea, left subclavian wraps around esophagus; ring completed by ligamentum arteriosum

Question 39

Ddx lateral esophagram with posterior indentation

Answer 39

double aortic arch, aberrant left subclavian with R arch

Question 40

Pulmonary sling

Answer 40

Anomalous L pulmonary artery from the right pulmoary artery; courses between trachea/esophagus; may also capture bronchus intermedius

Question 41

Only vascular cause of strider with L arch

Answer 41

pulmonary artery sling

Question 42

Associations with pulmonary artery sling

Answer 42

tracheal anomalies: tracheomalacia, bronchus suis or pig bronchus (RUL bronchus from trachea)

Question 43

Dysphagia lursoria association

Answer 43

L aortic arch with aberrant right subclavian artery; not ring/sling. Not associated with stridor , just dysphagia; posterior indentation of esophagus

Question 44

Innominate artery syndrome

Answer 44

large thymus pushes innominate artery against anterior trachea