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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