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Pediatric Airway and ChestUW Radiology Review 2015Jonathan Swanson, MD
Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
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Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
Case 1: 2 year old with stridor
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Case 1: 2-year-old with stridor
• What is the most likely underlying diagnosis?A. EpiglottitisB. Retropharyngeal AbscessC. Bacterial tracheitisD. CroupE. Laryngeal hemangioma
2 year old with Stridor
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Viral Croup• AKA acute laryngotracheobronchitis
• Peak Age: 6 month to 3 years
• Etiology: Parainfluenza• Mycoplasma and RSV, other etiologies
• Role of Imaging
Stridor• DDX:
• Infection • Croup• Epiglottitis• Retropharyngeal Abscess• Acute Bacterial Tracheitis
• Hemangioma
• Foreign body
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Normal Soft Tissue Neck
Epiglottitis
Images courtesy of Stephen Done, MD
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Acute Epiglottitis
• Etiology and Epidemiology:• Historic vs. Current
• Imaging Clues: • Enlarged epiglottis AND aryepiglottic
folds
• Required Reporting: Airway at risk
Omega epiglottis
http://en.wikipedia.org/wiki/Laryngomalacia
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6 year old with stridor and fever
http://erm.ersjournals.com/content/erm/ermre/1/SEC17/F36.expansion.html
Bacterial Tracheitis• Epidemiology:
• Typical age 6-10 years
• Imaging Clue:• Tracheal Membranes
• Reporting Responsibilities:• Requires emergent airway management• Endoscopy for definitive diagnosis
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9-year-old with Fever & Stridor
Retropharyngeal Abscess
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Retropharyngeal Abscess• DDX:
• Suppurative node, RTP edema, lymphatic malformation
• Complications:• Vascular• Embolic• Danger zone
• Reporting Responsibilities:• Extent of inflammation• Complications• Is there something to drain?
Phelgmon/Edema
Hoang JK et al. Multiplanar CT and MRI of collections in the RTP space: Is it an abscess. AJR 2011; 196: 426-432
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7 month old with persistent stridor
Subglottic Hemangioma
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Subglottic Hemangioma
• Epidemiology:• Infant less than 6 months• Cutaneous Hemangiomas in 50%• PHACES association
• Treatment options• Propranolol, steroids, surgical
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Case 2: 1-Year-Old with Stridor
Case 2: 1-Year-Old with Stridor
• Given these two views, which side of the esophagus is most likely to be injured?A. Right lateralB. AnteriorC. Left lateralD. Posterior
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1 Year Old with Stridor
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Button Battery
Button Battery Ingestion• 3 “N’s”: Negative – Narrow – Necrotic
• Size Matters: • 20 mm lithium most common to stick in
esophagus
• Imaging Protocol • Neck, esoophagus, and abdomen• See www.poison.org/battery/guideline.asp
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http://www.poison.org/battery/guideline.asp
Standard Coin
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Case 3: Sudden Onset of Wheezing and Tachypnea in a 20 month old
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What is the next step to work up possible foreign body?
A. Decubitus Chest Radiographs
B. Inspiration/Expiration
C. Fluoroscopy (diaphragm)
D. Bronchoscopy
E. Institution Dependent
Case 3: Sudden Onset of Wheezing and Tachypnea in a 20-month-old
Sudden Onset of Wheezing and Tachypnea in a 20 Month Old
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Airway Foreign Bodies• Age
• Range: 9m-13y• Peak: 1-3y
• Site• Right: 55%• Left: 33%• Bilateral: 7%• Trachea: 5%
Reed J. Can Assoc Radiol 28:111-113, 1977
• Types• Vegetable: 84%• Radiopaque: 11%• Others: 5%
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Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
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Case 4: Premature Newborn with Respiratory Distress
Case 4: Premature Newborn with Respiratory Distress
• What is the most likely diagnosis?A. Neonatal pneumoniaB. Respiratory distress
syndromeC. Transient tachypnea of the
newbornD. Meconium Aspiration
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Diffuse opacification in the Neonate Chest
• DDX:• Respiratory Distress
Syndrome• Neonatal Pneumonia• Meconium Aspiration• Transient Tachypnea of
the Newborn
The First Breath
Karlberg P, et al. J Pediatr,1960;56:585-604
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Case 4: Premature Newborn with Respiratory Distress
Respiratory Distress Syndrome• Early tachypnea, retractions
• Require prompt support
• Radiography:• Low, low-normal lung volume• Diffuse fine granularity• Air bronchograms• No pleural fluid• Detect complications
• Confused with: pneumonia, TTN
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Newborn with Transient Tachypnea
Transient Tachypnea of the Newborn (TTN)
• Tachypnea, ± cyanosis
• Accentuation of normal
• Radiography:• Normal to increased lung volume• Increase in linear markings• Fuzzy vessel margins• Pleural fluid
• Confused with: CHF, pneumonia
• Diagnosis: Clearing in 1-3 days
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Newborn with Mild TachypneaTTN
Day of Life 2
Day of Life 0
Newborn with Meconium aspiration
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Meconium Aspiration• Acute respiratory distress, hypoxia, hypercarbia pulmonary
hypertension
• Partial or complete airway obstruction
• Chemical pneumonia
• Radiography:• Patchy, heterogeneous opacities• Hyperinflation• Air leak is common
Neonatal Pneumonia
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Neonatal Pneumonia• Prenatal, perinatal and postnatal
• Pathogen: Viral, bacterial (Group B Strep)
• Imaging:• Patchy densities• May be RDS-like• Pleural fluid ±
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Case 5: 1-day-old with Respiratory Distress
What is the best test to confirm this critical finding?
A. Decubitus chest x-ray
B. Chest CT
C. Renal Ultrasound
D. Upper GI
Case 5: 1-day-old with Respiratory Distress
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1 day old with Respiratory Distress
Medial Pneumothorax
Moskowitz P, et al. Radiology1976
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Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
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Outline• Stridor and Foreign Bodies
• Neonatal Chest
• Pediatric Chest: Beyond the NICU
Case 6: 5-month-old with persistent tachypnea
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• What is the most likely diagnosis given this pattern on HRCT?A. Bronchiolitis obliteransB. Pulmonary interstitial
glycogenosis (PIG)C. ABCA3 Surfactant
deficiencyD. Neuroendocrine
hyperplasia of infancy (NEHI)
Case 6: 4-month-old with persistent tachypnea
Infant with persistent oxygen requirement
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4-month-old with NEHI
Same 4-month-old with NEHI
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Neuroendocrine hyperplasia of infancy (NEHI)
• Definition• Form of childhood ILD
• Clinical course• Prolonged with gradual improvement over time• Not improved by steroids
• Imaging Findings• GGO in perimediastinal distribution and in the
lingula and right middle lobe• Airtrapping
Bombesin Bombesin
Neuroendocrine hyperplasia of infancy
Courtesy of Gail Deutsch, MD, Dept of Pathology, Seattle Children’s Hospital
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Neuroendocrine hyperplasia of infancy
Courtesy of Gail Deutsch, MD, Dept of Pathology, Seattle Children’s Hospital
9-year-old with bronchiolitis obliterans
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Bronchiolitis obliterans
• Fibroblastic reparative response to small airways leads to luminal occlusion
• Etiologies:• Viruses – adenovirus, influenza• GVHD, Stevens-Johnson
• Imaging:• Mosaic attenuation, hyperlucency, pulmonary
vascular attenuation
Prior infection, persistent shortness of breath
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Swyer-James Syndrome
• Definition:• Variation of bronchiolitis obliterans• Results from viral injury to the developing lung
(before the age of 8)
• Imaging findings:• Unilateral transradiancy
• reflects a combination of hypoplasia of the pulmonary vasculature and obliterative bronchiolitis
• Bronchiolitis obliterans is bilateral, but asymmetric
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Case 7: 2-year-old with fever and weight loss
Case 7: 2-year-old with fever and weight loss
• In this pediatric patient, what is the most likely diagnosis?A. Congenital heart diseaseB. Normal thymusC. Anterior mediastinal massD. Neuroblastoma
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Case 7: 2-year-old with fever and weight loss
Normal Thymus
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Normal Pediatric Chest
Fever and Cough
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Case 8: 4 Year Old with Cough and Low Grade Fever
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The next best step in diagnosis for this patient is:
The next best step in diagnosis for thispatient is:
A. Follow-up chest x-ray
B. CT CAP
C. MRI of chest and spine
D. Bone Scan and MIBG
Case 8: 4 Year Old with Cough and Low Grade Fever
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Round Pneumonia
• Pseudotumor
• Usually in child < 8-10 years of age
• Clinically distinguishable - fever
• S. pneumoniae
• Imaging: Chest radiograph follow up to demonstrate expected evolution
What we learned• Stridor differential
• Button battery 3 N’s
• Neonatal diffuse lung disease – look for the effusion
• Specific patterns in pediatric HRCT
• Round pneumonia – image gently