ECR 2014 - C-1394 - Identifying Ingested Foreign Bodies in Lateral Neck Radiograph of Adult Patients at Asia-Pacific Region

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POSTERSECTIONSCoverpageLearningobjectivesBackgroundFindingsandproceduredetailsConclusion
PersonalinformationReferences
ECR2014/C1394
IdentifyingingestedforeignbodiesinlateralneckradiographofadultpatientsatAsiaPacificregion.
Thisposterispublishedunderanopenlicense.Pleasereadthedisclaimerforfurtherdetails.
Congress: ECR2014
PosterNo.:
C1394
Type: EducationalExhibit
Keywords: Calcifications/Calculi,Diagnosticprocedure,Conventionalradiography,Headandneck,Foreign
bodies
Authors: V.Krishnan,A.Chawla,K.Chokkappan,M.SubramanianSingapore/SG
DOI: 10.1594/ecr2014/C1394
DOILink: http://dx.doi.org/10.1594/ecr2014/C1394
Findingsandproceduredetails
Fig.6:Illustrationoflaryngealcartilagesthatcancalcifyandmimicforeignbodies....
Fig.7:Calcificationofposteriormarginoflamina,inferiorcornuaandpartof...
Fig.8:Calcificationpredominantlyinvolvingposteroinferiorthyroidcartilage(arrow)...
Fig.9:Calcificationofmostofthyroidcartilage(arrow),superiormarginand...
Fig.10:Specificanatomicalfociandcalcificationsthatmimicforeignbodiesin...
Fig.11:Calcificationofposteriorverticallamina(arrowhead)andsuperiormargin...
Fig.12:Calcificationofbaseofarytenoid(arrow)mimickingforeignbody.Notethe...
Fig.13:Calcificationofposterioraspectofthyroidcartilage(arrow)mimickingforeign...
Fig.14:Calcificationofstylohyoidligament(arrow)mimickingforeignbodyatbaseof...
Fig.15:Prevertebralosteophyte(arrow)atC4C5mimickingaforeignbody.Notethe...
Fig.16:Identificationofforeignbodyinlateralneckradiograph.
Fig.17:Foreignbody(arrow)attheregionofvallecula.
Fig.18:Foreignbody(arrow)intheuppercricopharyngealregion(C5C6).
Fig.19:Foreignbody(arrow)attheregionofcervicalesophagus(C7T1).
Fig.20:Morphologicalpatternsofimpactedfishboneinlateralneckradiograph.
Fig.21:Curvilinearappearanceoffishboneatthelevelofvallecula(arrow)and...
Fig.22:Straightwithtaperingend(arrow)appearanceoffishboneatthelevelofC7C8
Fig.23:Branchingappearanceoffishbone(arrow)atthelevelofC4C5
Fig.24:Backboneappearance(arrow)offishboneatthelevelofC5C7
Fig.25:Impactedlalabeehoonseashell(arrow)atC5C6level.
Fig.26:Impactedduckbone(arrow)atC6level.
Fig.27:PrevertebralsofttissueswellingatC5C7levels.Foreignbody(arrow)canbe...
Fig.28:Softtissueswellingatbaseofthetongue.Notetheforeignbody(fishbone)...
Fig.29:Impactedchickenbone(arrow)atT1levelwhichperforatedesophagus.Note...
Fig.30:Patientpresentedwithsymptomsimmediatelyafterforeignbodyingestion....
Fig.31:EnhancedappreciationofforeignbodyatC6level(arrow)afterpropercontrast...
Fig.32:Enhancedappreciationofforeignbody(porkbone)atC6C7level(arrow)after...
Fig.1
Fig.33:ThisisannotatedimageofFigure2.
Fig.4
BASICANATOMY
Laryngealcartilages:
Thereare3unpaired(thyroid,epiglottisandcricoid)and3paired(arytenoid,cuneiformandcorniculate)
laryngealcartilages.Thyroidcartilageconsistsoftwolaminaethatmeetatmidlineanteriorly.Posteriorlythey
aredrawnupanddownformingsuperiorcornuaandinferiorcornuarespectively.Inferiorcornuaarticulatewith
cricoidcartilageinferiorly.Cricoidisasignetringshapedcartilagethatliesbelowthelevelofthyroidcartilage.
Itconsistsofposteriorlaminaandanarrowanteriorarch.Arytenoidcartilagesaresmallpairedcartilagesthat
arepresentsuperiortocricoidcartilage.Thebaseofthearytenoidsrestoncricoidcartilage[4].
Triticeouscartilagesaresmallelasticcartilagesthatlieatthyrohyoidmembrane[5,6].

Thyroid,cricoidandmostofthearytenoidcartilagesarehyalinecartilagesthatundergoenchondralossification
overaging.Apicesofarytenoids,epiglottis,corniculateandcuneiformcartilagesareelasticcartilagesthatwill
notcalcify[4,7].Theydontcausemuchhindrancetoforeignbodydetectioninneckradiograph.Triticeous
cartilagesarevariablesmallelasticcartilagesthatcalcify[5,6].
Figure6illustratesvariouslaryngealcartilagesthatcancalcify.
Fig.6:Illustrationoflaryngealcartilagesthatcancalcifyandmimicforeignbodies.1.Thyroidcartilage.2.
Superiorcornuaofthyroidcartilage.3.Inferiorcornuaofthyroidcartilage.4.Cricoidcartilage.5.Arytenoid
cartilage.6.Trtiticeouscartilage.
References:DepartmentofDiagnosticRadiology,KhooTeckPuatHospital,Singapore.
Calcificationpatternsoflaryngealcartilages:
Bothmalesandfemalesshowvariablefrequenciesofthyroidandcricoidossificationwithfrequencyofthyroid
ossificationbeingmorethancricoidinbothsexes.Beinghyalinecartilages,thyroid,cricoidandmostpartsof
thearytenoidcartilagesundergoenchondralossificationoveragingandsimulateforeignbody[8].
Thyroidcartilagecalcification/ossificationstartsby2025yrsofage.Itstartsatposteroinferiorpartoflamina
andinferiorcornua(Fig7).Thenitprogressesupwardsandanteriorly.Soitisunusualtoseeisolatedsuperior
laminaorsuperiorcornuaossification.Eventuallymalethyroidcartilagecompletelyossifieswhereasinfemales
theanterioraspectleftunossified[4,9].
Cricoidandarytenoidcartilagescalcifyatthirddecadeaswell,butsomewhatlaterthanthyroidcartilage.[10,
11,12].Superiormarginandlaminaofcricoidossifiesearlythanotherparts[6](Fig8).Ossificationofcricoid
canbeidentifiedeveninpresenceofthyroidcartilageossification.Arytenoidcalcificationstartsfromthebaseof
arytenoidssittingonupperaspectofcricoidlamina[6].Whencompletelycalcified,itproducesLshaped
appearance(Fig9,12).
Triticeouscartilagesarevariable.Whenpresentandcalcified,theycanbeseenalongthelinebetweensuperior
cornuaofthyroidandposteriorpartofgreatercornuaofhyoid[5,6](Fig7,9).
Fig.7:Calcificationofposteriormarginoflamina,inferiorcornuaandpartofsuperiorcornuaofthyroid
cartilage(arrow)ina24yearfemale.Smallroundedossifiedtriticeouscartilage(arrowhead)isalsoseen.
Fig.8:Calcificationpredominantlyinvolvingposteroinferiorthyroidcartilage(arrow)andpartialcalcification
involvingsuperiormargin(curvedarrow)andposteriorlamina(arrowhead)ofcricoidin54yearmale.
Fig.9:Calcificationofmostofthyroidcartilage(arrow),superiormarginandposteriorlaminaofcricoid
(hollowarrow)in53yearsoldmale.TypicalLshapedcalcificationofarytenoidcartilage(curvedarrow)and
smallroundedtriticeouscartilage(arrowhead)areseenaswell.Ontheright:Diagrammaticrepresentationofthe
same.
Eventhoughcommonpatternsandappearancesofcalcificationhavebeendescribedabove,sometimesthe
patternandrateofcalcification/ossificationgrosslyvariesamongdifferentindividualsandunpredictable[5].
Theycanappearinunexpectedanddisorderedpatternaswell.Calcificationbecomesdenserfromearlylinear
appearanceasageadvances.Soknowledgeofexpectedanatomicallocation,patternofcartilagecalcificationat
particularlevels(levelC3C5forthyroid,C6forcricoid)andcloserelationshipofanisolatedfocalcalcification
ofparticularcartilagewithcalcificationofothercartilagesaremosthelpfuldeterminantsofidentifyingforeign
bodiesthanorderofappearanceofcalcifications.
Styloidprocessandstylohyoidligament:
Styloidprocessesarepairedbonyprojectionsthatcanbeseeninlateralradiographaslinearbonyopacities
extendingjustanteriortomastoidandtowardshyoid.Stylohyoidligamentextendsfromtipofstyloidtolesser
hornofhyoidbone.
Hyoidbone:Thehyoidboneiscloselyrelatedfunctionallyandanatomicallytotheskeletonofthelarynx.
Typicalappearanceandlackofvariabilityamongindividualsmakesidentificationofhyoidboneeasierwhich
doesnotcreatemuchdiagnosticconfusionexceptwithveryinexperiencedeyes.
Prevertebralcalcification/ossification:Prevertebralosteophytesoccurinoldageduetodegeneration.
Anteriorlongitudinalligamentossificationisseenascontinuouslinearbandofossificationandincloserelation
toanteriorvertebralbodymargins.Lymphnodesincervicalandprevertebralregiongetenlargedduetovarious
pathologiesthatcancalcify.
TECHNIQUE
Weusedigitalradiographyforlateralnecksofttissueradiographsinourdepartment.
View:Lateralview
Position:Erectposition,Patientinfullinspirationwithneckextension(tocoverC7/T1).
Exposure:about60kVp(adjustedaccordingtopatientbodyhabitus),6mAs.
CentralRay:Atthelevelofthethyroidcartilage(C4).
Artifactproducingsubstanceslikeearringsandshirtswereremovedbeforeexam.
WeevaluatedalllateralneckradiographsfromJanuary1,2013toNovember25,2013,takenforthepurposeof
detectingforeignbodies.Therewere44positivecasesconfirmedbyfollowup.
IDENTIFICATIONOFFOREIGNBODYMIMICS
Fig.10:Specificanatomicalfociandcalcificationsthatmimicforeignbodiesinlateralneckradiograph.
Superiormarginofcricoidlamina(Fig11)ossifiesearlyandformshorizontallinearopacitywhichis
commonlymistakenasforeignbody.Itcanbeidentifiedbyitslocationattheexpectedlevelofcricoid,andits
inferiorrelationshipwithadjacentthyroidcartilagecalcification.
Theposteriorverticallaminaofcricoidcalcification(Fig11)isalsocommonlymistakenasforeignbody.
Typicalverticalorientationwithsubtleanteriorconcavityandinferiorrelationshiptothyroidcartilagelocation
helpsinidentifyingit.
Fig.11:Calcificationofposteriorverticallamina(arrowhead)andsuperiormargin(arrow)ofcricoid
mimickingforeignbodies.Notethesubtleanteriorconcavityofverticallaminacalcification.Ontheright:
Diagrammaticrepresentationofthesame.Calcificationismarkedinred.
Isolatedlinearcalcificationofthebaseofarytenoidcartilage(Fig12)oftenmimicshorizontallyplaced
foreignbody.Ahorizontallyplacedcurvilinearopacitywithconvexsurfacejustabovecricoidlaminaindicates
baseofarytenoidcalcification.Whencompletelycalcified,itproducesLshapedappearance.
Fig.12:Calcificationofbaseofarytenoid(arrow)mimickingforeignbody.NotethetypicalLshaped
calcification.Ontheright:Diagrammaticrepresentationofthesame.Calcificationismarkedinred.
Ossificationoftriticeouscartilage(Fig9)areclassicallyseenassmallroundedopacitieslocatedbetween
superiorcornuaofthyroidcartilageandposteriorendofgreaterhornofhyoid.
Posterioraspectofthyroidcartilageossification(Fig13)canbeidentifiedasverticalcalcificationwith
classicaldirectionalonginferiorcornuafollowedbysuperiorcornua.Inferiorcornuaofthyroidcartilageare
pairedtubularlinearstructurescoursingverticallydownwardsfrominferioraspectofthyroidcartilagethat
tapersinferiorly.Superiorcornuaofthyroidcartilageareagainpairedtubularlinearstructuresthattapers
superiorlyandtipcoursingposterosuperiorlyfromtheexpectedlocationofupperaspectthyroidcartilage.
Fig.13:Calcificationofposterioraspectofthyroidcartilage(arrow)mimickingforeignbody.Ontheright:
Diagrammaticrepresentationofthesame.Calcificationismarkedinred.
Elongatedstyloidprocess/stylohyoidligamentcalcification(Fig14)canbeidentifiedanddifferentiatedfrom
fishbonesastheyarepairedstructuresandfollowexpecteddirectionandanatomicallocationpairedtubular
taperingstructuresthatstartjustanteriortomastoidandcoursinganteroinferiorlytowardslesserhornofhyoid,
withvariablelength.
Fig.14:Calcificationofstylohyoidligament(arrow)mimickingforeignbodyatbaseoftongue.Notethetypical
directionandcontinuitywithsuperiorlyplacedstyloidprocess.
Prevertebralosteophytes(Fig15)canbeidentifiedbytheirlocationatoradjacent(ifdetached)tothemargin
ofvertebralbodiesandcharacteristictriangularshapecoursinganteriorlyandobliquelytowardsdiscspace.
Associateddegenerativechangesofcervicalspinemaybeseen.Anteriorlongitudinalligamentcalcificationis
seenascontinuouslinearbandofossificationandincloserelationtoanteriorvertebralbodymargins.
Fig.15:Prevertebralosteophyte(arrow)atC4C5mimickingaforeignbody.Notethetypicalcourseacrossdisc
spaceandattachmentwithvertebralmargins.
IDENTIFICATIONOFFOREIGNBODY:
Fig.16:Identificationofforeignbodyinlateralneckradiograph.
Expectedlocations:
Commonlocationsofimpactionsarevallecula(Fig17),cricopharyngealregion(Fig18)anduppercervical
esophagus(Fig19)withsuprahyoidlocationbeingthecommonest[5,13].Wealsoencounteredsamecommon
locations,howeverthecommonestbeinginfrahyoidlocationinourseries.Eventhoughitcanoccuranywhere,
knowledgeofcommonlocationsofimpactionwillcreateahighindexofsuspicionandtherebyincreases
diagnosticaccuracy.
Fig.17:Foreignbody(arrow)attheregionofvallecula.
Fig.18:Foreignbody(arrow)intheuppercricopharyngealregion(C5C6).
Fig.19:Foreignbody(arrow)attheregionofcervicalesophagus(C7T1).
Morphology:
Fishbonewasthemostcommonlyseeningestedandimpactedsymptomaticforeignbodyofneckinourseries.
Wefoundthefollowingmorphologicalpatternsofforeignbodies:
Fishbone:Curvilinear,straightwithtaperingend,branching,backboneappearance(Fig20,21,22,23,24)

Fig.20:Morphologicalpatternsofimpactedfishboneinlateralneckradiograph.
Theycanbeidentifiedasradioopacitieswiththeabovementionedmorphologiesinthebackgroundofupper
aerodigestivetractlucencyorprevertebralsofttissueopacity,withtheirdensityslightlylesserthanadjacent
vertebralbody.Expectedphysiologicalradioopacitiesshouldbeexcluded.
Fig.21:Curvilinearappearanceoffishboneatthelevelofvallecula(arrow)andprojectinginferiorlyoverthe
epiglotticshadow.
Fig.22:Straightwithtaperingend(arrow)appearanceoffishboneatthelevelofC7C8
Fig.23:Branchingappearanceoffishbone(arrow)atthelevelofC4C5
Fig.24:Backboneappearance(arrow)offishboneatthelevelofC5C7
Restoftheforeignbodies:Otherlesscommonforeignbodiesweencounteredinourserieswerechicken
bone,porkbone,duckboneandseashell.Theyhavevariableappearancesanddensity.Theirdensities
maybelowerthan,equaltoormorethanadjacentvertebralbody.Again,expectedphysiologicalradio
opacitiesshouldbeexcluded.
Fig.25:Impactedlalabeehoonseashell(arrow)atC5C6level.
Fig.26:Impactedduckbone(arrow)atC6level.
Secondarysigns:
Sometimessecondarysignsinsofttissuemaybehelpfulinappropriateclinicalsettings.Impactedfish
bonemaycausesecondarysignslikewideningofprevertebralsofttissue,swellingatbaseoftongueor
epiglottisaccordingtoitslocationandstreakylucencies(incaseofperforation).
Prevertebralsofttissueswelling:
Upperlimitofnormalwidthforprevertebralsofttissueis5mmatC2level,7mmatC3C4level,and20
mmbelowC4[14].IfthesofttissueequalsorexceedsthewidthofvertebralbodyatorbelowC4,
pathologyshouldbesuspected.Impactedforeignbodymaycausewideningofsurroundingsofttissuedue
toinflammation.Therewillbeswellingofprevertebralsofttissue(Fig27),baseoftongue(Fig28)or
epiglottisshadowaccordingtothelocationofimpaction.
Fig.27:PrevertebralsofttissueswellingatC5C7levels.Foreignbody(arrow)canbeidentifiedwithin
theswellingoncloseinspection.
Fig.28:Softtissueswellingatbaseofthetongue.Notetheforeignbody(fishbone)withtaperingend
(arrow).
Airstreaksinprevertebralsofttissue(Fig29,30):Thisisanimportantsignthatindicatesperforationof
upperaerodigestivetractbyanimpactedforeignbody.
Fig.29:Impactedchickenbone(arrow)atT1levelwhichperforatedesophagus.Notestreaksofairin
prevertebralsofttissuesurroundingtheforeignbodyatC7T1level.
Fig.30:Patientpresentedwithsymptomsimmediatelyafterforeignbodyingestion.Foreignbodyisnot
visualized.However,streaksofairinprevertebralsofttissuearenotedatC2toC7level(arrowheads)
andalsoprojectingoverlowertrachealaircolumnsuggestingperforatedandmigratedforeignbody.

IMPORTANCEOFCONTRASTADJUSTMENT:
Evenwithadequatecenteringandproperexposure,narrowingthewindowlevelandproperadjustment
ofcontrastaccordingtothegivenradiographisessentialpartofproperidentificationofforeignbodies
anadvantageofdigitalradiographyoverconventionalplainfilmradiographywhereadjustmentcannot
bemade.Foreignbodiesthataredifficulttomakeoutingivenimagescanbemadevisiblebyproper
adjustmentofwindowlevel(Fig31,32).
Fig.31:EnhancedappreciationofforeignbodyatC6level(arrow)afterpropercontrastadjustmentwith
reducedwindowlevel.
Fig.32:Enhancedappreciationofforeignbody(porkbone)atC6C7level(arrow)afterpropercontrast
adjustmentwithreducedwindowlevel.
LIMITATIONS
1)Radiolucentforeignbodies,especiallywithopacitylowerthansurroundingsofttissuemaybemissedin
radiographs.Inthesecases,nextlineofinvestigationslikeCTscanwillbeuseful,providedthereisstrong
clinicalsuspicion.
2)ObscurationofcervicalesophagusatC7/T1levelbysurroundingskeletalshadowsmayoccurdueto
improperpositioningoruncooperativepatient.Inthesecasesimpactedforeignbodiesmaybemissed.
3)Radiographsobtainedwithflexedneckpositionmayspuriouslyincreasetheprevertebralsofttissue
widthandmisleadtheradiologists.

ANSWERSTOPREREADINGQUIZ
QUIZ1:
Fig.1
ANSWER:Noforeignbody.TheradioopacityatthelevelofC4representsossifiedarytenoidcartilage.
QUIZ2:
ANSWER:Foreignbody(arrow)atthelevelofC5.Notethetypicalcurvilinearappearance.Eventhough
itslocationiscloselyrelatedtoexpectedarytenoidcartilageossification,thecurvilinearappearance
insteadofhorizontal/Lshapedappearanceofexpectedarytenoidossification,helpstoidentifythe
foreignbodyaccurately.
Imageonright:Radiographafterremovalofforeignbody.
QUIZ3:
ANSWER:Curvilinearforeignbodyseenatthelevelofvallecula(arrow).Eventhoughthisforeignbody
isverysubtleinthisradiograph,itsimpactioninoneofthecommonlyexpectedlocations,helpstoidentify
thisforeignbodyaccuratelybycreatinghighindexofsuspicioninthisparticularlocation.
QUIZ4:
Fig.4
ANSWER:Noforeignbody.TheverticalradioopacityatthelevelofC6representscalcificationof
posterioraspectofcricoidlamina.
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