Lish James,  Richardson Randy,  Lin Alice

Final Pr. ID: Poster #: CR-015

Traumatic laryngotracheal transection is an uncommon occurrence most often secondary to blunt trauma to the neck. The most commonly described mechanism is a “clothesline” injury or strangulation, involving high speed impact of the neck across a chain, rope, chord, or strap, usually associated with the use of a motor or recreational vehicle. It is often instantaneously fatal, and those who survive may have severe respiratory compromise requiring immediate advanced airway placement, or astonishingly, they may be asymptomatic. Tracheal transection may be identified when laryngoscopic intubation fails, during the placement of a surgical airway, or during initial CT or bronchoscopic evaluation.

We describe an 8-year-old male who experienced blunt neck trauma and was intubated successfully in the pre-hospital setting. Initial radiographic evaluation was significant for severe subcutaneous emphysema and pneumomediastinum. Bilateral thoracostomy tubes were placed. Initial CT evaluation again showed extensive pneumomediastinum without pneumothorax. Four days after initial hospitalization the patient was extubated without difficulty. Post-extubation chest x-ray showed irregular tracheal borders with focal hyperlucency adjacent the mid-cervical trachea in the former position of the endotracheal tube cuff. Repeat CT of the chest showed complete tracheal transection of the mid-cervical trachea. The patient subsequently underwent surgical repair and was discharged without complication. This is the first reported case of traumatic tracheal transection not identified on initial CT examination secondary to the position of the endotracheal balloon, with subsequent discovery of the complete transection on the post-extubation radiograph.

There is 1 reported case of tracheal transection identified on initial CT evaluation in the presence of a well-positioned endotracheal tube. Additionally, there is 1 reported case of tracheal transection not identified on initial CT evaluation, however the patient was not intubated and had minimal symptoms. Tracheal transection was confirmed via bronchoscopy in that case.

Tracheal transection is rare traumatic injury that can be difficult to identify. High clinical suspicion and careful examination with multiple modalities is often necessary to make a definitive diagnosis. Read More

Authors:  Lish James , Richardson Randy , Lin Alice

Keywords:  tracheal resection, neck trauma, airway

El Hawari Mohamad,  Joshi Akash,  Zarchan Adam,  Dobbs-desilet Debbie,  Ornelas Samuel

Final Pr. ID: Poster #: EDU-101

Congenital high airways obstruction sequence (CHAOS) refers to a relatively rare fetal anomaly caused by high airway obstruction (tracheal or laryngeal) caused by atresia or stenosis. Similar imaging findings can be seen with airway obstruction due to oropharyngeal or neck masses such as teratoma. Antenatal imagining findings include but not limited to dilated fluid filled trachea and proximal bronchi, bilateral enlarged echogenic lungs with relative small sized midline heart, flattening or eversion of the diaphragm, feta ascites and anasarca and polyhydramnios. The prognosis is overall poor, however it is improved after planning for delivery and performing EXIT procedure (ex utero intrapartum treatment) with tracheostomy.
We present a case of a 20-year-old female G1P0 at 25 weeks of gestation diagnosed with Congenital high airways obstruction sequence (CHAOS) with typical features on prenatal ultrasound and fetal MR. Delivery was planned and an EXIT procedure was performed and the newborn survived. Read More

Authors:  El Hawari Mohamad , Joshi Akash , Zarchan Adam , Dobbs-desilet Debbie , Ornelas Samuel

Keywords:  Congenital High Airway Obstruction Sequence, Ultrasound, MRI

Suryaningrat Windu,  Amal Mohamad,  Sekarsari Damayanti

Final Pr. ID: Poster #: CR-031

The bridging bronchus is a rare bronchus anomaly which mostly found in infants and children. Aberrant bronchus that arises from either right or left main bronchus and crosses the mediastinum to supply the collateral lung lobe has come to the term of bridging bronchus. The diagnosis is often challenging as the bridging bronchus itself can be asymptomatic or presented by recurrent respiratory distress, but the use of right protocol in cross-sectional imaging is helpful enough to find the bridging bronchus.
This case report aims to present a case of a 5-month-old boy with recurrent pneumonia. He experienced episodes of severe dyspnea, fever, and desaturation, with negative PCR for covid-19. His echocardiography showed a moderate ventricular septal defect (VSD), worsening his dyspnea episodes which were accompanied by the decrease of oxygen saturation to 92% in room air. He underwent VSD closure procedure, which omitted the desaturation episodes, yet still experienced recurrent episodes of dyspnea and fever within 4 months of follow-up. In each episode, he had to be hospitalized and received conventional therapy by using antibiotics, bronchodilators, corticosteroids. Computed tomography (CT) scan of thorax using the pediatric radiation dose was done to evaluate the cause of recurrent pneumonia. Imaging findings in post-contrast slices (taken in inspiration phase) showed no connection between right lower lobe and left main bronchus, which was then suspected as esophageal bronchus. Then, in pre-contrast slices (taken in expiration phase) showed branch of the trachea into a right main bronchus and a stenotic aberrant bronchus (bridging bronchus, type 2) to the left hemithorax, and branching as right lower lobe bronchus and left main bronchus. Further evaluation of all slices in CT scan of thorax showed the stenotic bridging bronchus occluded in post-contrast slices, which were accidentally taken in inspiration phase. The occluded bridging bronchus led to non-optimal ventilation of the left lung lobes and right lower lobe, causing an imbalance of mucus clearance. Thus, increases the risk of mucus accumulation and rise the bacterial risk of infection which manifests as recurrent pneumonia in this patient. Nevertheless, within four months of follow up the patient was discharged with stable condition and symptoms-free. Read More

Authors:  Suryaningrat Windu , Amal Mohamad , Sekarsari Damayanti

Keywords:  bridging bronchus, congenital airway anomaly, airway anomaly

Khumalo Zonah

Final Pr. ID: Poster #: EDU-061

Disorders of the large airways occur frequently in the pediatric population.
Affected pediatric patients typically present with symptoms related to airway obstruction, including stridor, wheezing and dyspnea.
Infants and children are particularly vulnerable to respiratory compromise because of the smaller size of their airways.
As radiologists, we are pretty good at commenting on the lungs, pleural spaces and cardiomediastinal contours, but we often neglect or forget to take a look at the airways.

By definition, the upper airways are the air passages from the nasal cavity to the cervical trachea above the thoracic inlet. The lower airways begin below the thoracic inlet and include the thoracic trachea and bronchi. The spectrum of airways disorders is vast and includes both upper and lower airways anomalies, which can be congenital or acquired.

This educational exhibit will review the imaging findings of congenital lower airways anomalies, both on conventional radiography and cross-sectional imaging. I will also highlight radiographic features suggesting large airway pathology.

The following congenital lower airways anomalies will be reviewed:

Laryngeal cleft
Tracheal bronchus
Congenital tracheal stenosis
Congenitally short trachea
Congenital bronchial stenosis
Tracheobronchomalacia
Bronchial agenesis/hypoplasia/aplasia Read More

Authors:  Khumalo Zonah

Keywords:  congenital, lower, airways

Zhu Xiaowei,  Silvestro Elizabeth,  Andronikou Savvas

Final Pr. ID: Paper #: 019

Dynamic 4D CT (D4DCT) can replace bronchography in the assessment of tracheobronchomalacia (TBM) but setting up a new D4DCT service for infants with TBM poses unique challenges due to their venerability. Simulation prior to implementation is essential as D4DCT involves continuous volumetric CT scanning through the breathing cycle, potentially delivering high radiation doses. Radiation dose, gantry rotation and scan dynamics can be customized.
Our purpose is to describe the development and implementation of CT dynamic airway protocol using a 3D printed Infant Dynamic Airway Phantom (phantom) for simulation of D4DCT in tachnypnoea and collapsible airways, thereby validating image quality and estimating radiation dose prior to clinical implementation. Read More

Authors:  Zhu Xiaowei , Silvestro Elizabeth , Andronikou Savvas

Keywords:  dynamic airway, infant, D4DCT

Tang Elizabeth,  Menashe Sarah,  Romberg Erin,  Perez Francisco,  Otjen Jeffrey

Final Pr. ID: Poster #: EDU-070

CT with 4D cine imaging can non-invasively and dynamically characterize airways for various pathologies, such as airway caliber fluctuations in tracheobronchomalacia, intermittent compression by cardiovascular or other mediastinal structures, or constriction from anatomic anomalies like those associated with craniofacial syndromes. However, optimal interpretation of dynamic airway CT studies requires an understanding of the impact of such extrinsic factors as the presence of support apparatus (e.g., endotracheal tube, enteric tube), level of required respiratory support (e.g., positive end-expiratory pressure), and differences in positioning (e.g., with jaw thrust). We have performed more than 100 pediatric cases of dynamic airway CT under a variety of conditions, in patients who range from free-breathing to ventilator-dependent, and for a variety of pathologies. In this educational exhibit, we will consider how to balance and tailor extrinsic factors when using dynamic CT for the guidance of airway management, in order to meet diagnostic considerations and supplement other cardiopulmonary investigations, including cases with bronchoscopic and surgical correlates. Read More

Authors:  Tang Elizabeth , Menashe Sarah , Romberg Erin , Perez Francisco , Otjen Jeffrey

Keywords:  Airway, Cine, CT

Shah Jignesh,  Chauhan Ankita,  Sandhu Preet

Final Pr. ID: Poster #: EDU-082

1. To discuss etiologies of unilateral hyperlucent hemithorax in children.
2. To discuss radiographic and cross-sectional imaging features of various conditions leading to unilateral hyperlucent hemithorax. Read More

Authors:  Shah Jignesh , Chauhan Ankita , Sandhu Preet

Keywords:  Unilateral hyperlucent hemithorax, congenital lobar overinflation, congenital pulmonary airway malformation

Ksiazek Kathleen

Final Pr. ID: Poster #: EDU-016 (T)

Medical imaging of the soft tissue of the neck or airway is one of the most common, and sometimes challenging, exams performed at a pediatric hospital. Imaging of the airway can help identify enlarged adenoids, the presence of a foreign body, an abscess, pathology or anatomical abnormality. It is crucial to understand the proper technique, breathing instructions and positioning in order to obtain optimal imaging for correct diagnosis. Different radiographic findings will be presented with examples of incorrect positioning, grid usage, exposure factors, artifacts and ways to improve the image quality. This poster will also provide technologists with tips and recommendations to help them to feel prepared and confident to work with all pediatric patients. Read More

Authors:  Ksiazek Kathleen

Keywords:  Airway, Soft tissue of neck

Das Prasnjeet,  Thomen Robert,  Halula Sarah,  Woods Jason,  Fleck Robert

Final Pr. ID: Poster #: SCI-082

CT is often performed and advocated in patients with risk factors for or symptoms of tracheomalacia (TM). However, TM is traditionally defined as a 50% decrease in the cross-sectional area of the airway during a forced expiratory maneuver. This basis for detecting TBM was never meant for use in CT and leads to the under diagnosis of TM in young children by CT and typically requires inspiratory/expiratory CT (IECT). Additionally, some pictures archiving systems do not have tools to measure area. The aim of this investigation is to show that TM is under diagnosed by IECT relative to bronchoscopy and to develop a “view box” parameter to improve sensitivity while maintaining specificity in identifying the trachea as normal or affected by TM.
Read More

Authors:  Das Prasnjeet , Thomen Robert , Halula Sarah , Woods Jason , Fleck Robert

Keywords:  Bronchoscopy, trachea, bronchomalacia, airway, dynamic CT

Elma Alexander,  Bates Alister,  Xiao Qiwei,  De Alarcon Alessandro,  Fleck Robert

Final Pr. ID: Poster #: CR-046

Large airway obstruction, subglottic stenosis, tracheal narrowing, and tracheomalacia are common morbidities associated with prematurity secondary to prolonged intubation. Laryngotracheoplasty is often required to alleviate subglottic stenosis and allow a patient to be decannulated from their tracheostomy. Patients will often have continued airway and voice issues despite being able to live without a tracheostomy. The clinical conundrum in treating this patient is whether vocal folds can be surgically moved closer together to improve vocalization without compromising the airway further and increasing resistance. Here we demonstrate how this clinical conundrum can be informed by CT-derived CFD modeling in a 15-year-old male former 31-week preterm infant with dysphonia and subglottic airway narrowing at the cervical trachea and narrow vocal cords. Read More

Authors:  Elma Alexander , Bates Alister , Xiao Qiwei , De Alarcon Alessandro , Fleck Robert

Keywords:  compurtational fluid dynamics, airway modeling, subglottic stenosis

Aljallad Mohammed,  Dunoski Brian

Final Pr. ID: Poster #: SCI-001

Balancing PEEP settings in mechanically ventilated premature infants to maximize air exchange while minimizing barotrauma is typically evaluated using bronchography. A 4D dynamic airway computerized tomography protocol (4D CT) was developed as a less invasive method to evaluate large and small airways collapse at variable PEEP settings. Our purpose was to evaluate the radiation dose from 4D CT and to demonstrate the number of cycles impact on the radiation dose. Read More

Authors:  Aljallad Mohammed , Dunoski Brian

Keywords:  Dynamic Airways, Effective Dose, Skin Dose

Maier Pia,  Alam Aisha,  Acord Michael,  Cahill Anne Marie,  Vatsky Seth

Final Pr. ID: Paper #: 036

Evaluate patient demographics, current imaging patterns, extent of disease, and tumor types in pediatric patients with mediastinal masses to assist with developing an imaging algorithm to streamline patient care. Read More

Authors:  Maier Pia , Alam Aisha , Acord Michael , Cahill Anne Marie , Vatsky Seth

Keywords:  Mediastinal Mass, Airway

Maier Pia,  Alam Aisha,  Acord Michael,  Cahill Anne Marie,  Vatsky Seth

Final Pr. ID: Poster #: SCI-034

Evaluate patient demographics, current imaging patterns, extent of disease, and tumor types in pediatric patients with mediastinal masses to assist with developing an imaging algorithm to streamline patient care. Read More

Authors:  Maier Pia , Alam Aisha , Acord Michael , Cahill Anne Marie , Vatsky Seth

Keywords:  Mediastinal Mass, Airway

Rubio Eva,  Blask Anna,  Loomis Judyta,  Bulas Dorothy

Final Pr. ID: Poster #: EDU-077

The purpose of this exhibit is to depict the prenatal imaging features of isolated intra-oral lesions, describe delivery course, and correlate with final diagnoses. Read More

Authors:  Rubio Eva , Blask Anna , Loomis Judyta , Bulas Dorothy

Keywords:  Oral, airway, fetal

Whitehead Mark,  Whitehead Matthew

Final Pr. ID: Poster #: SCI-045

The human airway is fundamental to respiratory gas transmission and oxygen exchange. The pediatric upper airway is subject to a number of specific age and location related disease processes that can cause alarming morbidity and could be deadly by impairing normal air movement. In this exhibit, we guide the learner on a fantastic journey thorough the pediatric upper airway from nose to cords illustrated thorough neuroimages. Congenital and acquired anatomic and pathologic barriers to airflow will be reviewed. Read More

Authors:  Whitehead Mark , Whitehead Matthew

Keywords:  Airway, Sinus, Pharynx

El-ali Alexander,  Davis James,  Otero Hansel,  Biko David,  Rapp Jordan

Final Pr. ID: Paper #: 030

Dynamic Airway CT (DACT) has risen in popularity in recent years, however, studies of Tracheobronchomalacia (TBM) are hindered by inconsistent definitions which variously rely on airway area, airway diameter, and qualitative measures. We explore the interrater reliability of these measures. Read More

Authors:  El-ali Alexander , Davis James , Otero Hansel , Biko David , Rapp Jordan

Keywords:  dynamic airway imaging, CT, tracheobronchomalacia

Somasundaram Elanchezhian,  Brady Samuel,  Crotty Eric,  Trout Andrew,  Anton Christopher,  Towbin Alexander,  Coley Brian,  Dillman Jonathan

Final Pr. ID: Paper #: 032

At our institution, airway radiographs are routinely checked by the radiologist to ensure diagnostic image quality prior to the technologist completing the examination. These checks interrupt the workflow for both the technologist and radiologist. In this study, we develop and validate a deep learning algorithm to detect non-diagnostic lateral airway radiographs. Read More

Authors:  Somasundaram Elanchezhian , Brady Samuel , Crotty Eric , Trout Andrew , Anton Christopher , Towbin Alexander , Coley Brian , Dillman Jonathan

Keywords:  Deep learning, Airway, Xray

Epps Caleb,  Cassady Christopher,  Ketwaroo Pamela

Final Pr. ID: Poster #: CR-004

A 33-year-old presented for fetal MRI at 22 weeks 2 days gestation following pre-natal ultrasound that demonstrated findings suspicious for congenital high airway obstruction syndrome (CHAOS). Findings were characteristic of CHAOS and included focal narrowing of the cervical trachea, pulmonary hyperexpansion, tracheobronchomegaly, everted hemi-diaphragms, and abdominal free fluid. However, follow-up MRI at 27 weeks 3 days gestation showed decreased pulmonary hyper-expansion and abdominal free fluid. Diagnosis of atypical congenital high airway obstruction (aCHAOS) was suggested. Further improvement was noted on fetal MR at 31 weeks 2 days gestation and the diagnosis of aCHAOS was reinforced.

CHAOS represents a rare, life-threatening fetal airway anomaly characterized by complete or incomplete obstruction of the upper airway. Prenatal imaging findings of classic CHAOS have been well described and include hyperexpanded lungs with everted diaphragms, tracheobronchomegaly, and hydrops. Our experience at quaternary referral centers is that this applies to a particular subset of patients with complete laryngotracheal obstruction without a pathway of fluid egress, and that there is a spectrum of more subtle but equally critical large airway obstructions. This can be in the form of either incomplete large airway obstruction or complete large airway obstruction with a decompression route such as coexisting tracheoesophageal fistula.

Accurate characterization by fetal imaging has increased in importance as treatment options have expanded, including fetal airway management and ex utero intrapartum treatment (EXIT). There is a paucity of literature regarding the characterization of CHAOS variants and their natural history. However, improved understanding is important as it is unknown whether outcomes between classic CHAOS and aCHAOS may differ. Findings on prenatal imaging of aCHAOS are more subtle, and the diagnosis requires nuance and a high index of suspicion. Close follow up is required in fetal life, as a lack of proper preparation risks near-certain neonatal death. Diagnoses that mimic aCHAOS, such as bilateral congenital lung malformation, should be considered and excluded. We present the current case along with companion cases to expand the spectrum of prenatal imaging appearances in congenital large airway obstruction. Read More

Authors:  Epps Caleb , Cassady Christopher , Ketwaroo Pamela

Keywords:  Congenital High Airway Obstruction Syndrome, Atypical CHAOS, Fetal MR