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  • Dr. Elizabeth Sheffield

NECK RADIOGRAPHS: THE STRIDULOUS CHILD

Updated: Nov 3, 2023

Dr Elizabeth Sheffield Senior Registrar

Peer Reviewer: Dr David McCreary


CASE OF THE DAY:

It’s 23:00, when a 3-year old child is brought in by ambulance with a 2-hour history of noisy breathing, fever and cough.  On initial assessment she has inspiratory stridor, is miserable and sitting with her head in a sniffing position, without obvious drooling.  She’s previously fit and well, and parents tells you that immunisations are up-to-date.  You glance at her vitals and note she is febrile at 38.6, heart rate 180, respiratory rate 38 and oxygen saturations 98% room air. You prescribe your tried and tested cocktail of 0.6mg/kg dexamethasone and 5mls of 1:1000 adrenaline neb then stand triumphant at the foot of the bed basking in self-congratulation…unfortunately 15 minutes later the child is not running around the department in the throws of a steroid-induced mania and remains cuddled up to mum/dad displaying much the same picture as before.


WHAT IS THE HIGHEST PRIORITY DIAGNOSIS?

You can easily take your pick – but this is a toxic child. Sniffing position triggers an exam answer of retropharyngeal abscess – however epiglottitis and inhaled foreign body could certainly give this picture in the right circumstances. Although a bit young for the average bacterial tracheitis it’s definitely within the realm of possibilities.


You decide there is still ambiguity with regards to this patient’s diagnosis, and are looking for a handy way to screen for potential sinister causes that are quick, fast and non-distressing to the child.


So, behold the soft tissue x-rays.  This is a historical Part 2 Exam favourite cropping up every few years in some form or another.  Just to signpost, for what conditions might soft tissue neck x-rays be used with regards to acute diagnoses in the Emergency Department?

  • Epiglottis

  • Retropharyngeal abscess

  • Tracheobronchial or oesophageal foreign bodies

  • Bacterial tracheitis

  • Croup (to screen for alternative causes)

  • Neck tumours (although not usually emergent)


SO… WHAT MAKES KIDS AT RISK?

  • They lack all sense of self-preservation

  • They have some difficulty differentiating between “food” and “not food”

  • They LOVE to move. They pick-up everything and put in in the nearest orifice, which is (occasionally) their mouths…

  • They may be nonverbal, or at the very least unable to adequately communicate to caregivers that they have choked on a

  • They’re not just tiny adults: their trachea has a smaller diameter, with immature pliable tracheal rings which make them more prone to hyperflexion/extension and more at risk of airway occlusion from any inflammatory pathology. The epiglottis is large and floppy making direct intubation methods (straight blade) different, and also makes them more likely to choke on their own soft tissue… and their larynx is higher and more anterior (and smaller) so surgical cricothyroidotomy is out til about age 10.


LET’S TALK GENERAL AIRWAY ANATOMY.

Below is a refresher on anatomy of the head and neck...




And here we have the structures as seen on a normal neck x-ray: