Analysing lateral soft tissue neck radiographs.

A lateral soft tissue neck radiograph is a useful adjunct in diagnosing and managing the patient presenting with upper airway symptoms but is often inadequately reviewed. We present some common findings and robust systems to improve analysis of these radiographs.

Subglottic acute lymphoblastic leukaemia.

Acute lymphoblastic leukaemia (ALL) is one of the the most common malignancies of childhood and can occasionally present as acute airway obstruction. We present the unusual case of a 1-year-old boy who was referred to our Paediatric Otolaryngology (ENT) clinic with a recurrent history of croup. This is the first reported case of localised ALL presenting as a subglottic mass in a paediatric patient. It highlights the need to have a broader differential diagnosis in children presenting with 'recurrent croup' including extramedullary presentation of leukaemia and to have a low threshold for performing endoscopy in such cases.

Steeple sign: a case of croup.

Croup, or laryngotracheobronchitis, is a common viral respiratory tract illness seen in the pediatric population (). This article describes the case of a child who presents with croup and the characteristic "steeple sign" seen on the radiograph. The patient received a diagnosis of croup secondary to the parainfluenza virus infection. It is imperative for advanced practice nurses to recognize the signs and symptoms of croup when these patient present to emergency care settings. Advanced practice nurses must also consider possible differential diagnoses, accurately interpret the radiographs, and intervene according with supportive care and appropriate management.

Viral croup: current diagnosis and treatment.

Viral croup, a common illness in children, manifests with noisy, labored breathing. Parainfluenza viruses are the most common cause of croup; however, other causes including epiglottitis and bacterial tracheitis should be considered in the differential diagnosis. The diagnosis is primarily based on clinical findings; imaging studies may be useful in selected cases. Although most children recover from this self-limited illness with only minimal medical intervention, some are severely affected by laryngeal swelling and require respiratory support with analgesics, cool mist, corticosteroids, nebulized epinephrine, heliox, and, rarely, intubation. In this article, the current diagnostic and management strategies for viral croup are summarized.

Epidemiology of acute respiratory infections in young children from Thailand.

A prospective evaluation of the epidemiology and presentations of acute respiratory infections in children younger than 5 years of age admitted to Children's Hospital Bangkok (1988 to 1989) was supported by the World Health Organization. There were 226 patients with the inclusion criteria: 1 to 5 years of age; duration of illness less than 2 weeks; no prior antibiotic therapy; and low socioeconomic status. The disease categories included: croup, 19 cases; bronchiolitis, 60 cases; and pneumonia, 147 cases. Pathogens isolated were: respiratory syncytial virus (40); parainfluenza III (1); influenza B (1); and adenovirus (1); bacterial infections were proved in 23 cases. No significant differences in clinical features between bacterial and viral pneumonia were found. Interstitial radiographic patterns were more common in viral pneumonia whereas alveolar patterns were more common in bacterial pneumonia. However, 91% of mixed radiographic patterns (interstitial and alveolar) in chest films were from viral pneumonia.

Airway obstruction in pediatric patients. From croup to BOOP.

Causes for airways obstruction in infants and children vary considerably from those encountered in adult populations. The recent dissemination of rapid CT scan (helical and electron beam) has changed the diagnostic imaging approach in children with suspected airways obstruction. Fast CT scan not only detects the location of obstruction with high sensitivity but also frequently provides clues to specific pathologic diagnoses.

Management of children hospitalized for laryngotracheobronchitis.

During a 12-month period, 527 consecutive admissions for laryngotracheobronchitis (LTB) were reviewed to determine the epidemiology of hospitalized LTB patients and to better define patients who may benefit from therapy other than close observation. Viral cultures were obtained in 442 patients and were positive in 70%. Disease severity at the time of admission was unrelated to patient age or sex. Duration of hospitalization, however, was inversely related to age (p less than 0.001). Laboratory investigations were rarely abnormal or of therapeutic value. Patients who on admission had stridor without sternal and chest wall retractions recovered rapidly and spontaneously; they were frequently discharged within 48 hours and never required artificial airways. Children who had sternal and chest wall retractions on admission experienced longer hospitalizations, frequently received medical intervention such as aqueous mist therapy or racemic epinephrine, and had a 6% risk of requiring artificial airway support. This group of children should be studied selectively for the benefits of specific medical therapies and diagnostic evaluations.

Infectious adult croup.

From January 1980 to December 1987, seven patients with acute inflammatory swelling of the subglottic space were treated. Their ages ranged from 25 to 73 years. Medical history and symptomatology are similar to those characteristic of laryngotracheobronchitis (croup) in the pediatric age groups (i.e., an antecedent common cold followed by a barking cough and varying symptoms of upper airway obstruction). Physical findings before and after treatment were confirmed and documented by anteroposterior radiographs of the neck. Three patients required airway intervention but there were no deaths. To our knowledge there are no previous reports in the English literature describing this entity in adults. The purpose of this presentation was to introduce physicians, in general, and otolaryngologists, in particular, to this potentially serious infection. Our limited experience suggests that the pathogenesis and management of croup in adults are very similar to those in children.

Croup and epiglottitis: a radiologic study.

Because of the controversy regarding the benefits of the lateral neck and chest radiographs in the evaluation of croup and epiglottitis, a two-part retrospective study was initiated. Part I consisted of a retrospective chart review of 44 patients with a final diagnosis of croup and epiglottitis. Part II consisted of the 42 lateral neck and chest x-rays from patients in part I presented to six radiologists who knew only the patients age and the history of respiratory distress. Two hundred forty-six responses were obtained. The results of the part I study showed that 64% of patients with documented epiglottitis had a positive radiologic diagnosis. Only 33% of patients with croup had a positive radiologic diagnosis and importantly 27% had a diagnosis of possible epiglottitis. The results of part II showed 38% of the documented epiglottitis patients had a positive lateral neck radiograph. The croup patients had a lateral neck and/or chest x-ray positive in 38%. Of interest, 24% had readings consistent with possible epiglottitis. Based on this two-part study, it is our conclusion that the lateral neck and chest x-ray may be unreliable and inaccurate in the diagnosis of croup and epiglottitis. Caution and good clinical judgement should be utilized when interpreting these x-rays.

Utility of radiographs in the evaluation of pediatric upper airway obstruction.

The evaluation of children with airway obstruction always involves a history and physical examination. The definitive diagnosis is most often made with microlaryngoscopy and bronchoscopy (MLB), and in cases of extrinsic compression, information is gained from magnetic resonance imaging. Although plain radiographs of the airway are often used as a primary diagnostic modality in children with airway obstruction, the accuracy of plain radiographs in predicting specific airway abnormalities has not previously been evaluated. This study was designed to correlate the findings of plain airway radiographs with the diagnosis made at the time of MLB. Medical records from 1991 to 1996 were reviewed to identify patients that had MLB and airway radiographs within 2 days of one another. One hundred forty-four cases were identified and divided into diagnostic categories. Statistical analysis showed a high sensitivity (>86%) for the accuracy of the radiologic diagnoses of exudative tracheitis, airway foreign body, and innominate artery compression. Laryngomalacia and tracheomalacia had a much lower sensitivity (5% and 62%, respectively). We believe that plain radiographic evaluation of the airway provides important information to the diagnostician. However, plain radiographs can be inaccurate and must be considered along with a history, physical examination, and clinical suspicion. Microlaryngoscopy and bronchoscopy remains the ultimate diagnostic test for airway disorders.

Croup: pathogenesis and management.

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.

Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care.

OBJECTIVES: The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario. METHODS: We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied. RESULTS: From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24-0.95], 0.47 [95% CI 0.27-0.82], 0.13 [95% CI 0.02-0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20-1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16-3.53 [croup]; and OR 1.97, 95% CI 1.64-2.36 [asthma]). We found no association between clinical protocol use and radiograph rates. CONCLUSIONS: High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.

Variation and trends in ED use of radiographs for asthma, bronchiolitis, and croup in children.

OBJECTIVES: The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use. METHODS: A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. RESULTS: The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status. CONCLUSIONS: The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.