0:00

The next category we're gonna discuss is

0:03

large airway disorders.

0:05

We'll be talking about first,

0:07

what a normal airway looks like.

0:10

Then we'll talk about some congenital disorders,

0:13

infectious disorders, and finally, neoplastic disorders.

0:17

This first case

0:19

of a normal airway is fairly straightforward.

0:22

We can see that this is of an older child or adolescent,

0:25

and we can see on this frontal radiograph

0:27

of the neck a wide open trachea.

0:30

On the lateral. Correspondingly,

0:32

we can see a widely patent trachea

0:36

and there's no real question that this looks normal.

0:39

A couple things to point out.

0:41

Note the normal appearance of the epiglottis

0:44

and has a certain level of thickness that I want you

0:47

to keep in the back of your mind

0:49

because we'll talk about an abnormal epiglottis later.

0:52

Notice that you can see the vestibule here

0:55

and notice that the prevertebral soft

0:57

tissues are relatively thin.

0:58

It is typical below the level of C four

1:01

that they are thicker than higher up.

1:05

The next case of a normal airway looks a bit different,

1:08

and this is a really important thing

1:09

to understand about pediatric airways, particularly

1:12

of young children and toddlers.

1:15

I'm gonna zoom in on this frontal image of the neck,

1:19

and you'll notice here a couple of things.

1:22

One, you'll see that the airway starts here

1:25

and then seems to take a 90 degree turn

1:28

to the right before it goes down.

1:30

Again, that can seem jarring if you're not used to it.

1:34

This is actually quite normal in young children

1:36

who have more flexible tracheas.

1:39

When they're in expiration.

1:41

It can either turn quite a bit like this 90 degrees

1:44

or sometimes it has more of a bode appearance.

1:47

If the trachea looks like that

1:49

and it goes to the right, that's normal expiratory buckling.

1:53

If it goes to the left, that's not normal

1:56

and probably should be further investigated.

2:00

The reason it goes to the right and not to the left is

2:02

because normally the aortic arch sits on the left.

2:06

So this is a normal expiratory phase frontal radiograph

2:10

of a young child's airway.

2:12

Also, notice when an expiration, when the Gladys is closed,

2:17

there's narrowing at the glottis,

2:19

but immediately below the glottis, the subglottic trachea

2:22

has what's called normal shouldering.

2:25

What that means is immediately below the trachea, there's

2:28

what looked like shoulder pads that come out horizontally

2:31

before going inferiorly vertically,

2:35

and that happens on both sides.

2:36

So we see the normal shouldering

2:38

of the subglottic trachea in an expiratory view

2:42

of a young child's airway.

2:45

On the lateral, we can see that the patient's mouth is open.

2:49

That can be one of two things.

2:51

They may either be an inspiration and taking a breath in,

2:55

or they might be an expiration, they might be crying.

2:58

And you can see adult fingers are holding their head in

3:01

place and they might be an expiration.

3:03

If they're an expiration.

3:04

Sometimes you can see collapse of the airway

3:07

and it might look relatively narrow,

3:09

so you cannot rely on the lateral alone

3:12

to determine whether the airway is normal and caliber.

3:15

It just depends on what phase of expiration.

3:18

So in this case, looking at the frontal is quite reassuring

3:21

that this is a normal caliber airway.

3:25

Here is another patient showing similar

3:27

findings on the frontal.

3:29

We again, see as I zoom in here

3:32

and change my windowing, we see the patient's in expiration

3:36

with a closed glottis.

3:37

We see normal shouldering of the subglottic airway,

3:41

and we see some right word expiratory buckling all normal.

3:46

What I want to pay attention to in this case is

3:49

that we have two lateral views.

3:51

On the first one, we can see that the airway looks narrow.

3:56

It looks like there's soft tissue fullness in the

3:59

supraglottic region, and it looks like the prevertebral soft

4:02

tissues are quite thick.

4:05

What can be challenging here when you have a young child

4:07

who might not be able to follow directions is they may be in

4:10

the expiratory phase of respiration, which can make all

4:13

of these things happen

4:14

and they don't actually have anything wrong

4:16

with their airway or their soft tissues.

4:19

And so sometimes when people see a finding like this,

4:23

they might suggest to get a CT next to evaluate

4:26

for retro pharyngeal abscess.

4:28

If that fits the clinical picture, that's perfectly fine,

4:32

but if it doesn't fit the clinical picture

4:34

or if you're not convinced

4:36

that this was done in good inspiration, for example,

4:39

I can see this patient's lips are closed, so probably not,

4:42

then you can always just repeat the radiograph.

4:45

I often find that if I talk to my technologists

4:48

and ask them to use a few maneuvers to try

4:50

and help improve the chance of getting inspiratory

4:54

radiographs, we often can avoid getting the CT scan.

4:58

So if you look at the subsequent lateral that we got,

5:01

the picture looks much different.

5:03

The patient's mouth is open,

5:04

we can see the airway is much better expanded,

5:06

and the hypopharynx

5:08

and that prevertebral soft tissue thickening has resolved.

5:11

And this is all in a matter of minutes.

5:14

So this means that our technique has changed.

5:17

A couple things can help you with this.

5:19

One is that you want

5:20

to have the patient's head an extension.

5:23

So often the technologist will roll up a towel

5:25

and put it underneath their neck so

5:27

that their head can be bent back behind it.

5:30

Be careful that

5:31

that towel isn't placed too high up under their occiput

5:35

because if you do that, you'll have the opposite effect

5:38

where it's gonna push on the back of the head

5:40

and it'll actually put them into flexion.

5:42

So that will have the opposite of the intended effect.

5:45

Additionally, I talk to the text

5:47

and try to have them time taking the radiograph.

5:51

They try to time pushing the button in

5:54

between the patient's cries if they're crying.

5:56

So if they're crying and they're wailing, let them wail

6:00

one big breath out,

6:02

and then as they take a breath in to prepare

6:04

for their next whale, take the picture.

6:06

And so when you combine those things,

6:09

you can often get better inspiration

6:11

and we get better evaluation of the airway.

6:14

We can see that the sub gloc airway looks relatively

6:17

narrowed in this image just by chance.

6:20

But when we pair it with our original radiograph

6:22

or that part of the airway looked normal, we know

6:25

that's just related to some collapse of that airway

6:28

that happened in the course of taking this picture.

6:31

So the key things to take away here are when in doubt,

6:35

if you have a radiograph that looks abnormal on the lateral,

6:37

but you want to make sure that that's a real finding,

6:40

just repeat the lateral before going on to ct.

6:43

When you do that, you might be able

6:45

to resolve soft tissue thickening.

6:46

You might be able to better evaluate the airway for patency.

6:50

And remember, you can do this with the help

6:52

of getting the head in extension

6:55

and trying to get it during inspiration.

6:58

The final case I'll show of a normal airway

7:01

is a similar sort of idea.

7:03

We'll start with the frontal. I'm gonna zoom in here.

7:07

We nicely see the closed glottis

7:10

because this patient is an expiration.

7:13

The subglottic airway, the normal shouldering

7:16

of the subglottic airway

7:17

and some expiratory buckling of that trachea.

7:21

Now this patient has three different lateral radiographs

7:25

basically because we kept getting radiographs

7:27

where we weren't sure if the airway was normal or not.

7:31

So if we start with the first one that we have here,

7:35

you can see that the hypopharynx has some air,

7:38

but there's not really aeration in the subglottic region.

7:42

So there was concern that maybe this was

7:44

abnormally narrowed.

7:46

The prevertebral soft tissues look okay,

7:48

so then we got an additional radiograph.

7:51

And in this case, this is even worse.

7:53

The hypopharynx is not really aerated at all, so

7:55

that doesn't help us too much.

7:57

And on the final one, we got better inspiration.

7:59

We can see that there's air now throughout the airway

8:02

that subglottic region opened up.

8:04

And then paired with that frontal radiograph

8:05

that I showed you, this is all normal airway.

8:08

No need to get a CT scan.