Lateral neck radiographs

1. LATERAL NECK
RADIOGRAPHS
A R U N N I T B O O N R O D

2. OUTLINE
• Normal anatomy
• Normal radiographs
• Must know diseases (Film reading and interpretation)
– Detection
– Localization
– Characterization

3. NORMAL ANATOMY

4. NORMAL ANATOMY
Nasopharynx
Oropharynx
Hypopharynx

5. N O R M A L T H I C K N E S S A N D A P P E A R A N C E O F T H E P R E V E R T E B R A L S O F T T I S S U E S O N M U L T I D E T E C T O R C T , R O J A S , A J N R , J A N 2 0 0 9

7. NORMAL
RADIOGRAPHS

8. NORMAL RADIOGRAPHS
• Prevertebral soft tissue:Variable with age and location.
• In adult
– At C3 < 7 mm. [usually <3mm. Or less than 1/3VB]
– At C6 < 21 mm. [less thanVB]
• In children
– At C3 < 7 mm.
– At C6 < 14 mm.

9. NORMAL RADIOGRAPHS
Analysing lateral soft tissue neck radiographs, Emerg Radiol, Jan 2012

10. NORMAL RADIOGRAPHS IN CHILDREN
• Adenoid are invisible until 6 months and regress after 6 years
• Improper position (should be head extend and full
inspiration) false positive
• Pseudosubluxation

11. FLEXION VS EXTENSION
Soft tissue lateral neck , W. Hering, www.learningradiology.com

12. PSEUDOSUBLUXATION
Soft tissue lateral neck , W. Hering, www.learningradiology.com
• Occur only in flexion
• If persist in extension  true subluxation
• Swischuk line
– Anterior border of posterior arch of C1 to
C3
– < 2 mm.  pseudosubluxation

13. MUST KNOW
DISEASES

14. MUST KNOW DISEASES
• Adult
– Foreign body
– Retropharyngeal abscess
• Children
– Foreign body
– Retropharyngeal abscess
– Epiglotitis
– Croup
– Adenoid hyperplasia.

15. A GENERAL APPROACH
1. Bony Alignment: Line up the anterior borders of the vertebral bodies, the posterior borders of
the vertebral bodies, the vertebral arches, and the spinous processes.
2. Height of the vertebral bodies and disk spaces.
3. Relationship of the odontoid (C2) and the atlas (C1).
4. Positioning of the neck: Is the neck in flexion, extension, or neutral.
5. Width of the prevertebral soft tissue space.This thickness is usually half the width of a vertebral
body and should not exceed the width of a vertebral body.
6. Epiglottis: Examine the shape of the epiglottis and the size of the pre-epiglottic space (vallecula).
7. Subglottic airway size.
https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c20.html

18. FOREIGN BODY
• 90% in the oropharynx (at the base of the tongue or tonsil bed)
• The commonest foreign bodies are fish or chicken bone in adults, whilst in children it
was ingested coins.

19. Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 26246

21. RETROPHARYNGEAL ABSCESS
• General information
– MC in children (75% < 5 years, and often in the first year of life)
– If in adult, iatrogenic or foreign body.
• Clinical sign and symptom
– Drooling, fever, neck swelling, and stridor.
• Radiographs
– Prevertebral soft tissue swelling.
– No gross bone destruction.

22. UPPER AIRWAY INFECTION IN
CHILDREN
• Epiglottitis
• Croup

23. C A S E C O U R T E S Y O F D R G A G A N D E E P S I N G H , R A D I O P A E D I A . O R G , R I D : 8 4 1 4

24. EPIGLOTITIS
• General information.
– Life-threatening condition caused by inflammation of the epiglottis and aryepiglottic folds.
– 3 to 6 years
• Clinical
– Fever, difficulty speaking, muffling or changes in the voice, inspiratory stridor, severe dysphagia
• Radiographs
– Lateral view: thickening of the epiglottis and aryepiglottic folds ( thumb sign) Hypopharynx may be
over-distended.

26. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 6258

27. CROUP
• General information.
– AKA acute laryngotracheobronchitis
– 6 months age up to 15 years but most commonly between 6 months to 3 years with the peak at 18
months.
• Clinical presentation
– Barking cough and inspiratory stridor due to mucosal oedema resulting in tracheal narrowing.
• Radiographic features
– Not always required, as the diagnosis is often made clinically.
– AP film: Steeple sign = uniform narrowing of the subglottic airway; also referred to as a wine bottle sign
– Lateral film: Hypopharynx over-distension, narrowing of the subglottic region, a normal epiglottis.

29. A GENERAL APPROACH
1. Bony Alignment: Line up the anterior borders of the vertebral bodies, the posterior borders of
the vertebral bodies, the vertebral arches, and the spinous processes.
2. Height of the vertebral bodies and disk spaces.
3. Relationship of the odontoid (C2) and the atlas (C1).
4. Positioning of the neck: Is the neck in flexion, extension, or neutral.
5. Width of the prevertebral soft tissue space.This thickness is usually half the width of a vertebral
body and should not exceed the width of a vertebral body.
6. Epiglottis: Examine the shape of the epiglottis and the size of the pre-epiglottic space (vallecula).
7. Subglottic airway size.
https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c20.html

41. TAKE HOME MESSAGES
• Normal anatomy
• Normal radiographs
• Must know diseases (Film reading and interpretation)
– Detection
– Localization
– Characterization

42. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 46366
1
2 34
5
6

44. T H A N K Y O U F O R Y O U AT T E N T I O N

45. REFERENCES
• Atlas of Human Anatomy, 6th edition, Netter
• NormalThickness and Appearance of the Prevertebral SoftTissues on Multidetector CT, Rojas,
AJNR, Jan 2009
• Analysing lateral soft tissue neck radiographs, Emerg Radiol, Jan 2012
• Lateral neck soft tissue radiographs, learningradiology.com
• https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c20.html
• www. Radiopaedia.org