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What is the MC cause of upper airway obstruction in kids?
Enlargement of the palatine tonsils and adenoids.
What are the major classifications of lower airway obstruction and examples of each? What do you recommend next?
- Intrinsic- Arising from within airway... Foreign body, tracheal malacia, intrinsic mass.
- Further mx is bronchoscopy.
- Extrinsic- External compression... vascular ring, -other extrinsic mass
- Further mx is cross-sectional imaging.
What are the classically described vascular causes of extrinsic lower airway compression?
- Double aortic arch
- Anomalous left pulmonary artery
- innominate artery compression syndrome
- other causes also, but less classic.
Vascular rings on lateral radiograph...
A. Indentation of anterior trachea & posterior esophagus?
B. Indentation of anterior trachea only?
C. Indentation of posterior esophagus only?
D. Indentation of posterior trachea & anterior esophagus?
- A. Double aortic arch
- B. Innominate artery compression
- C. Left arch with aberrant right subclavian artery or Right arch with aberrant left subclavian artery
- D. Aberrant left pulmonary artery ("pulmonary sling")
What is the MC symptomatic vascular ring?
Double aortic arch
What is a "pulmonary sling?"
- The left pulmonary artery arises from the right pulmonary artery and passes between the trachea and esophagus causing indentations on the posterior trachea and anterior esophagus.
- It is the only vascular abnormality that crosses between the trachea and esophagus.
What is the only vascular anomaly to cross btw the trachea and esophagus?
"Pulmonary sling" aka aberrant left pulmonary artery arising from the right pulmonary artery.
What is the only vascular anomaly associated with asymmetric lung volumes on chest radiography?
"Pulmonary sling" (aberrant left pulmonary artery from the right pulmonary artery).
What are two associations with pulmonary sling that can also contribute to respiratory complaints?
- Congenital heart disease
- Complete tracheal rings
What are the 3 MC soft tissue masses of the trachea? Where do they MC occur?
Hemangiomas, tracheal papilloma, & tracheal granuloma
Hemangiomas are MC subglottic
What is the key radiographic feature of a bronchial foreign body?
Lack of change in lung volume demonstrated at different phases of the respiratory cycle.
What are radiographic findings of bronchial foreign body?
- asymmetric lung aeration
- lung consolidation
What % of bonchial foreign bodies are nonradiopaque?
97% are nonradiopaque
DDx for asymmetric lucent lung?
- Bronchial foreign body
- Swyer-James syndrome
- Pulmonary hypoplasia
DDx of perihilar streaky opacities with high lung volumes? Term or preterm?
- Meconium aspiration
- Neonatal pneumonia
DDx for granular opacities and low lung volumes? Term or preterm?
- Surfactant deficiency
- Beta-strep pneumonia
What is a characteristic feature of meconium aspiration? What is a common complication? How often?
20-40% are complicated by PTX.
Radiograph with nml to increased lung volumes, airspace opacification, coarse interstitial markings, prominent or indistinct pulmonary vasculature, fluid in fissures, pleural effusion, and cardiomegaly.
What does this most likely represent?
- Mild to severe pulmonary edema
What is the MC cause of death in newborns?
- Surfactant-deficiency Dz
- aka respiratory distress, hyaline membrane dz
Low lung volumes with bilateral granular opacities with prominent air bronchograms is most likely?
Surfactant deficiency disease
Beta strep pneumonia and surfactant deficiency can have similar appearance on radiographs. Describe these findings? How can you distinguish these two processes?
Low lung volumes and bilateral granular opacities.
Pleural effusion is present in up to 2/3 of beta strep cases but is uncommon in surgactant deficiency
UAC catheter tip should not be positioned between what levels? Why?
- UAC catheter tip should NOT be btw T10-L3 because these are the origins of the celiac, SMA, IMA and can become thrombosed from the thrombogenic potential of the catheter tip.
- Keep it high or leave it low.
Pulmonary interstitial edema and bronchopulmonary dysplasia have similar radiographic appearances. How are they described? How can you differentiate them?
PIE usually occurs the first week of life and occurs abruptly.
BPD usually occurs after two weeks of life and occurs gradually.
Who usually get PIE?
Newborns in the first week of life on ventilatory support. PIE is pulmonary interstitial emphysema which results from alveolar perforation secondary to high pressures in noncompliant lung.
DDx for acute diffuse pulmonary consolidation in neonates?
- Edema due to PDA
- Hemorrhage (can occur with surfactant administration)
- Diffuse microatelectasis - artifactual consolidation
- worsening surfactant def. (first days of life only).
development of coarse lung markings and diffues bubble-like lucencies in a 28 day old is most likely what?
What is Wilson-Mikity Syndrome?
Development of BPD in the absence of mechanical ventilation.
DDx for focal lung lesions in the neonate? What two categories?
- Lucent lung lesions
- Persistent PIE
- Congenital diaphragmatic hernia
Solid lung lesions
- Pulm sequestration
- Bronchogenic cyst
Why is CCAM typically resected?
- Increased risk of infection
- Rare development of rhabdomyosarcoma
Congenital Diaphragmatic Hernia is usually due to what? What side?
Posterior diaphragmatic defect (Bochdalek hernia).
What is the MC presentation of pulmonary sequestration? What is the characteristic feature? MC location? MC radiographic appearance in newborn?
MC presents with h/o recurrent PNA in late childhood.
Characteristic anomalous arterial supply to the abnormal lung via a systemic artery arising from the aorta.
MC in LLL and appears as a solid mass because air has not yet been introduced into the lesion.
How are pulmonary sequestrations classified? Why does it matter? How is this distinction made?
Intralobar - no associated anomalies
Extralobar (pleural covering separate from nml lung) - 65% assoc with other anomalies
distinction made surgically. Can't be made with imaging.
What is the MC of large pleural effusion in a newborn? Treatment?
Chylothorax. Most are in term neonates with shortness of breath a few days after birth. Most resolve with thoracentesis and need no further treatment.
Round PNA usually occurs in what age group?
Swyer-James syndrome is characterized by what on radiographs?
Unilateral lung lucency thought to be due to virally induced necrotizing bronchiolitis iwth xray having hyperlucent and enlarged lung with static lung volume. Pulmonary vessels are also decreased compared to the normal side.
Lung consolidation with unilateral lymphadenopathy and/or pleural effusion in child that is not acutely ill should be strongly suspicious for what?
Sickle cell patient presents with fever, chest pain, and hypoxia. CXR shows pulmonary opacities. What does this child have?
Acute chest syndrome.
What is the radiographic appearance of CF?
- May be nml in young children.
- Otherwise... hyperinflation, increased peribronchial markings, mucous plugging and bronchiectasis. Hilar areas are often prominent resulting from lymphadenopathy (from infection) and enlarged central pulmonary areteries (from pulmonary artery htn).
How long may it be before pulmonary injury from hydrocarbon ingestion is seen?
Up to 12 hours. If the CXR is nml at 24 hours, then there is no significant hydrocarbon ingestion.
What are the 3 MC anterior mediastinal masses in kids?
- 1. Nml thymus mistaken as a mass
- 2. Lymphoma
- 3. Teratoma
What are the 3 MC tumors in children?
- 1. Leukemia
- 2. Brain tumors
- 3. Lymphoma
2 MC causes of middle mediastinal masses in kids?
- Lymphadenopathy (from a variety of conditions - inflammatory vs neoplastic)
- Duplication cysts (bronchogenic, enteric, or neurogenic) are well circumscribed.
Neurenteric cysts, by definition, have assoc vertebral anomalies.
DDx for posterior mediastinal masses in kids?
- Neural crest tumors
- Lateral meningocele
- Extramedullary hematopoiesis
- Neuroblastoma is the working dx for a posterior mediastinal mass until proven otherwise.
What is the working dx for a posterior mediastinal mass in a kid, until proven otherwise?
What are the neurogenic tumors of the mediastinum that commonly occur in children?
What are 3 primary malignant dz that occur in the chest wall of kids? What is MC? What do these look like on cross-sectional imaging?
- 1. Ewing Sarcoma
- 2. Askin tumor (primitive neuroectodermal tumor of the chest wall)
- 3. Osteosarcoma (less common)
The MC is actually mets from neuroblastoma, lymphoma, or leukemia.
They are all aggressive with poorly defined margins, bony destruction, and pleural involvement.
On US where will the germinal matrix hemorrhage be found (what anatomic location)?
The choroid plexus can be seen sonographically at the level of the caudothalamic groove and have the appearance of an intraventricular hemorrhage. T/F?
False. If there is something at the level of the caudothalamic groove then it is either hemorrhage or abnormal choroid.
What disease has the classic triad of seizures, mental retardation, and adenoma sebaceum? What is the MC imaging finding?
- Tuberous Sclerosis. AD-inh.
- MC neuroimaging finding are tubers appearing as a subependymal mass, typically along the lateral ventricles. Tubers usually don't enhance.
- A tuber is called a "Giant Cell Tumor" when it occurs near the foramen of Monroe and will frequently lead to hydrocephalus.
What other findings are commonly seen in Tuberous Sclerosis?
Visceral manifestations include renal cysts, renal angiomyelofibromas, cardiac rhabdomyoma, and hamartomas of other organs.
CT examination shows serpiginous calcification, abnormal enhancement, and atrophy of the involved gyri. There is thickening of the overlying calvarium. Pt may have seizures, mental retardation, and hemiparesis. What is the most likely diagnosis?
What direction does myelination occur in a child? When does it complete?
- Myelination progresses caudally to cranially.
- Myelination completes by 18-24 months.
What is the MC TORCH infection involving the CNS? What are the imaging findings?
- Findings include perventricular calcifications, migrational abnormalities (cortical dysplasia), cerebellar hypoplasia, and ventricular enlargement.
What TORCH infection has the following findings... perventricular calcifications, migrational abnormalities (cortical dysplasia), cerebellar hypoplasia, and ventricular enlargement.
Clinical presentation in a newborn with microcephaly, hearing impairment, mental retardation, and developmental delay. What TORCH infection?
What is the 2nd MC TORCH infection involving the CNS?
MRI on a child with a recent viral infection or immunization, shows increased T2 signal in the white matter, brain stem, and cerebellum. What is the likely dx? What is the tx?
- Likely dx is ADEM, acute disseminated encephalomyelitis.
- Tx - steroids
What are posterior fossa tumors in childhood?
- cerebellar astrocytoma
- brainstem glioma
What is the MC posterior fossa tumor in childhood? What are some of its imaging characteristics?
- Cerebellar astrocytoma.
- Cystic or solid
- Commonly has mural nodule when cystic.
- 4th ventricle displaced anteriorly
- No calcs or hemorrhage
This posterior fossa tumor arises from the roof of the 4th ventricle, is poorly defined, and has homogeneous signal on MR. It will also commonly metastasize through CSF. What is it?
Which posterior fossa tumor shows circumferential enlargement or an exophytic mass of the brainstem (MC the pons), is nonenhancing, and pushes the 4th ventricle anteriorly?
Which posterior fossa tumor arises from the floor of the 4th ventricle, has a poorly defined interface, is heterogeneous on CT & MR due to hemorrhage & necrosis, has lobulated margins, and commonly contains calcifications (70% of cases)?
Which tumor has the best prognosis of any CNS malignancy in childhood? What is tx?
- Cerebellar astrocytoma (pilocytic subtype).
- Most require surgical excision only
"Enhancing mural nodule" in a cystic posterior fossa mass. Dx? What else should you see?
The 4th ventricle is pushed anteriorly. There should not be any calcs or hemorrhage.
What is the most malignant posterior fossa tumor in childhood? Where does it rank in frequency of occurence? What type of tumor is it?
Medulloblastoma is most malignant and 2nd in frequency.
It is a primitive neuroectodermal tumor.
This poorly defined posterior fossa tumor arises from the floor of the 4th ventricle and obliterates the 4th ventricle. It has a tendency to metastasize via the CSF to intraspinal spaces.
This tumor tends to present with cranial nerve abnormalities, pyramidal tract signs, or cerebellar dysfunction. What is the tumor and tumor type? What is the primary treatment?
Brainstem glioma (MC astrocytoma).
Primary therapy is radiation therapy. Complete surgical excision is generally not possible due to its location.
This tumor MC arises from the 4th ventricle and is a relatively slow-growing benign tumor. What happens with growth in these tumors? What should you look for on imaging?
Tumor may fill and grow out of the 4th ventricle via the foramina into the cisterna magna and spinal canal.
They are heterogeneous on CT & MR. 70% have calcifications on CT. Lesion has well defined lobulated margins.
4th ventricle is pushed anteriorly by which tumors? Posteriorly by which tumors? Obliterated by?
- Anterior - Cerebellar astrocytoma
- Posterior - Brainstem glioma
- Obliterated - Medulloblastoma & Ependymoma
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