Pediatric Imaging Pearl of the Week

View the illustrated DDX of chronic upper airway obstruction

Infant with wheezing

Radiograph of airway foreign body — Lateral radiograph of the airway shows a subglottic soft tissue mass. Endoscopy showed a sunflower seed surrounded by granulation tissue.

The diagnosis was a chronic airway foreign body.

Teenager with fever, night sweats, weight loss, and stridor

CXR and CT of Hodgkins lymphoma — CXR shows diffuse narrowing of the trachea due to infiltrative adenopathy shown on the axial CT without contrast of the chest.

The diagnosis was Hodgkin lymphoma.

Toddler with a neck mass with overlying skin discoloration and stridor

Radiograph and CT of soft tissue hemangioma — Lateral radiograph of the airway and axial CT without contrast of the neck shows a large heterogenous mass that displaces and compresses the trachea.

The diagnosis was soft tissue hemangioma.

Newborn with prenatal diagnosis of neck mass who was delivered via an EX utero Intrapartum Treatment (EXIT) procedure

MRI of lymphatic malformation — Transverse (above) and sagittal (below) US of the neck and coronal (above) and axial T2 MRI without contrast of the neck shows an infiltrating multicystic mass of the neck surrounding the trachea that has minimal vascularity.

The diagnosis was lymphatic malformation.

Infant with stridor and a scalp hemangioma

Radiograph of subglottic hemangioma — Lateral radiograph of the airway shows a subglottic soft tissue mass.

The diagnosis was a subglottic hemangioma.

Former premature newborn with a history of long-standing endotracheal intubation who now has stridor

Radiograph of tracheal granuloma — Lateral radiograph of the airway shows a subglottic soft tissue mass.

The diagnosis was tracheal granuloma.

Teenager with stridor

Radiograph and CXR of tracheobronchial papillomatosis — Lateral radiograph of the airway shows multiple polypoid lesions in the trachea. CXR shows multiple cystic lesions in the chest.

The diagnosis was tracheobronchial papillomatosis.

Preschooler with stridor

Radiograph of aryepilottic fold cyst — AP and lateral radiographs of the airway shows a mass in the left aryepilottic fold.

The diagnosis was aryepilottic fold cyst.

Toddler with stridor

Radiograph of laryngomalacia — Lateral radiograph of the airway obtained in inspiration (left) and expiration (right) shows near-complete collapse of the larynx in expiration.

The diagnosis was laryngomalacia.

School ager with stridor

Radiograph and nuclear medicine scan of ectopic thyroid — Lateral radiograph of the airway (left) shows a mass at the base of the tongue that when overlaid / registered with a thyroid nuclear medicine scan (right) shows radiotracer uptake in the mass.

The diagnosis was ectopic thyroid.

Preschooler with stridor

US of thyroglossal duct cyst — Transverse (above) and sagittal (below) US of the neck shows a cyst in the midline of the neck that moved in relationship with tongue protrusion.

The diagnosis was thyroglossal duct cyst.

Toddler with stridor

Radiograph of epidermal inclusion cyst of tongue — Lateral radiograph of the airway shows a mass at the base of the tongue.

The diagnosis was epidermal inclusion cyst of tongue.

Toddler with stridor

Radiograph of Pierre Robin syndrome — AP + lateral radiographs of the airway shows a micronathia and posterior displacement of the tongue.

The diagnosis was Pierre Robin syndrome.

Teenager with epistaxis

CT and angiogram of juvenile nasopharyngeal angiofibroma — Axial CT without contrast of the face (above) shows a large left sided sinonasal soft tissue mass. Early (below left) and later (below right) lateral images from a carotid angiogram show the mass to be hypervascular.

The diagnosis was juvenile nasopharyngeal angiofibroma.

Newborn with hypoxia with feeding

Radiograph of choanal atresia — AP + lateral radiographs of the airway after the injection of contrast into the nares bilaterally shows no passage of contrast into the oropharynx with the obstruction at the level of the vomer.

The diagnosis was bilateral choanal atresia.

School ager with stridor

Radiograph of palatine tonsil hypertrophy — Lateral radiograph of the airway shows enlargement of the palatine tonsils.

The diagnosis was palatine tonsil hypertrophy.

Preschooler with stridor

Radiograph of lingual tonsil hypertrophy — AP + lateral radiographs of the airway shows enlargement of the lingual tonsils.

The diagnosis was lingual tonsil hypertrophy.

Our DDX For This Week Is

View the illustrated DDX of chronic upper airway obstruction

Preschooler with stridor

Radiograph of adenoid tonsil hypertrophy and palatine tonsil hypertrophy — Lateral radiographs of the airway shows enlargement of the adenoid tonsils and the palatine tonsils.

The diagnosis was adenoid tonsil hypertrophy.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of acute upper airway obstruction

Toddler with stridor

CXR and Upper GI of esophageal foreign body — Lateral spot images from an upper GI show fixed narrowing of the trachea (left + middle) with an esophageal perforation / fistula arising from the anterior wall of the esophagus (right). Endoscopy done earlier in the day removed a set of plastic wheels from a toy car which was felt to have been present for a long time as the esophagus was ulcerated and edematous in the area of perforation.

The diagnosis was esophageal foreign body.

Toddler with stridor with a history of ingestion

CXR of airway foreign body — CXR taken in inspiration (above) shows symmetrical aeration of the lungs. CXR taken in expiration (below) shows air trapping in the right lung.

The diagnosis was a non-radioopaque airway foreign body in the right mainstem bronchus.

Infant with stridor

Radiograph of normal airway — Lateral radiograph of the airway taken in expiration and flexion shows nearly 90 degree buckling of the trachea and massive thickening of the prevertebral soft tissues simulating a retropharyngeal abscess. Repeat radiograph obtained in inspiration and extension was normal.

The diagnosis was a normal airway.

Preschooler with stridor

Radiograph of retropharyngeal abscess — Lateral radiograph of the airway taken in inspiration and extension shows massive thickening of the prevertebral soft tissues.

The diagnosis was retropharyngeal abscess.