Pediatrics: Airway

Question 1

What is the most common cause of acute upper airway obstruction in young children?

Answer 1

Croup (peak incidence is 6 months to 3 years)

Question 2

Neck radiographs showing the steeple sign (loss of the normal lateral convexities of the subglottic trachea)…

Answer 2

Croup (laryngotracheobronchitis)

Question 3

Seal barking cough…

Answer 3

Croup (laryngotracheobronchitis)

Question 4

Cause of croup

Answer 4

Viral infection (most often parainfluenza virus)

Question 5

Neck radiographs showing the thumbprint sign…

Answer 5

Epiglottitis

Note: Look for thickening of the aryepiglottic folds to distinguish from “omega epiglottis” which is just an artifact due to bad technique (oblique images).

Question 6

Cause of epiglottitis

Answer 6

H. influenza infection (most common)

Question 7

What age group is epiglottitis most common in?

Answer 7

Average 3.5 years of age (though recent increase in cases in teenagers)

Question 8

What is the cause of death in epiglottitis?

Answer 8

Asphyxiation due to airway closure from the aryepiglottic folds (not the inflamed epiglottis)

Question 9

Linear soft tissue filling defect within the airway of an 8 y/o…

Answer 9

Think exudative tracheitis (bacterial tracheitis)

Question 10

Cause of exudative tracheitis

Answer 10

Staph aureus infection (usually)

Question 11

Retropharyngeal soft tissue thickening in an 8 month old infant…

Answer 11

Think retropharyngeal cellulitis/abscess

Question 12

If you can’t tell whether there is real retropharyngeal thickening on a lateral radiograph or just poor technique (oblique, not true lateral), what is the next step?

Answer 12

Repeat lateral neck radiograph with neck extension

Question 13

Retropharyngeal cellulitis/abscess is most common in what age group?

Answer 13

6-12 months

Question 14

What is the most common soft tissue mass in the trachea?

Answer 14

Hemangioma (most commonly in the subglottic region)

Question 15

Radiographs show unilateral loss of the glottic shoulder…

Answer 15

Think subglottic hemangioma

Note: If this were symmetric, think steeple sign in croup (laryngotracheobronchitis).

Question 16

Subglottic hemangiomas are most common on the ____ side

Answer 16

left

Question 17

Subglottic hemangiomas are associated with…

Answer 17

• Cutaneous hemangiomas (50%)
• PHACES syndrome (7%)

Question 18

PHACES syndrome

Answer 18

PHACES:

• Posterior fossa (Dandy Walker)
• Hemangiomas
• Arterial anomalies
• Coarctation of the aorta
• Eye abnormalities
• Subglottic hemangiomas/Sternal cleft/Suproumbilical raphe

Question 19

During fluoroscopic swallow study of a kid you see a thin tract of contrast extending down the larynx/trachea, but there was no aspiration seen…

Answer 19

Think laryngeal cleft (a rare defect in the posterior wall of the larynx that communicates with the esophagus, allowing contrast to enter the trachea without laryngeal penetration/aspiration)

Question 20

Laryngeal clefts are associated with…

Answer 20

Other complex GI malformations

Question 21

If you see contrast appear in the trachea on fluoroscopy without aspiration and are thinking laryngeal cleft, what is the nest step?

Answer 21

Endoscopy for visual confirmation of the posterior laryngeal defect

Question 22

Lobulated, grape-like mass in the airway of a kid…

Answer 22

Think papilloma (especially if the lungs are full of solid and cavitating nodules)

Question 23

Airway papillomas are due to…

Answer 23

HPV infection (usually acquired during vaginal birth)

Question 24

Kid with MULTIPLE regions of air trapping and pulmonary nodules…

Answer 24

Think papillomatosis (HPV infection)

Note: If single region of air trapping, then obstruction from an aspirated foreign body or carcinoid tumor are more likely.

Question 25

If they show you a frontal neck radiograph of a kid, think…

Answer 25

• Croup (symmetric narrowing)
• Subglottic hemangioma (asymmetric narrowing)

Question 26

If they show you a lateral neck radiograph of a kid, think…

Answer 26

• Epiglottitis (thumbprint)
• Retropharyngeal abscess (Thickened pre vertebral soft tissues)
• Tonsilitis (Bulky posterior pharyngeal wall)
• Exudative tracheitis (linear tracheal filling defects)

Question 27

Next step if ED physician suspects epiglottitis…

Answer 27

STAT portable radiograph while waiting for anesthesia consult

Note: Do not bring this kid to the x-ray department, only portable. Keep the kid where they could get an emergency intubation, if needed.

Question 28

Next step if you see thickening of the retropharyngeal soft tissues on a lateral neck radiograph…

Answer 28

Neck soft tissue CT (to evaluate for retropharyngeal abscess and potential extension to the mediastinum via the danger space)