Soft Tissue Neck XRay

Aka: Soft Tissue Neck XRay, Soft Tissue Neck Radiograph, XRay Soft Tissue Neck

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II. Technique

  1. Technically difficult to obtain an adequate film in children (requires cooperation)
  2. False Positive prevertebral widening may occur with less ideal films
    1. Good image requires patient cooperation
    2. Should be a true lateral position film
      1. Neck rotation can exaggerate the size of the epiglottis
    3. Should be an inspiratory film (expiratory films exaggerate prevertebral space)
    4. Neck neutral to neck extension
    5. Crying may also cause a False Positive widening
  3. Abnormal or non-diagnostic findings may prompt advanced imaging
    1. CT Soft Tissue Neck with contrast
      1. First-line study in adults (and second-line study to XRay in children)

III. Interpretation: Findings

  1. Croup
    1. "Steeple" sign on PA Neck XRay (40-50% of croup cases)
    2. Narrowing of subglottic region from mucosal edema
    3. XRay does not correlate with croup severity
    4. Dilated hypopharynx (most sensitive finding)
    5. Images
      1. RadCroupMedPix1246.jpgFrom MedPix with permission.
  2. Epiglottitis
    1. Thickened, thumb shaped epiglottis (swollen supraglottis)
    2. Diminished or loss of the vallecula air space
    3. Thickened aryepiglottic folds
    4. Distended hypopharynx
    5. Cervical Spine may demonstrate straightening or reversal of cervical lordosis (as with Retropharyngeal Abscess)
    6. Test Sensitivity 44-76% (but >96% specific)
  3. Retropharyngeal Abscess
    1. Bulging of posterior pharyngeal wall
    2. Loculated soft tissue gas may be seen in severe cases
    3. Widening retropharyngeal soft tissue (prevertebral space)
    4. Prevertebral soft tissue width increased (Mnemonic 6 at 2, and 22 at 6)
      1. C2 level prevertebral space >7 mm (adults and children) or more than half Vertebral body width
      2. C6 level prevertebral space >14 mm (children) or >22 mm (adults) or more than a full Vertebral body width
    5. Cervical Spine may demonstrate straightening or reversal of cervical lordosis
  4. Bacterial Tracheitis
    1. Thickened trachea
    2. Tracheal pseudomembrane
    3. Necrotic epithelium subdivides trachea lumen
    4. Croup findings (e.g. steeple sign) may coexist, as it may have preceded Bacterial Tracheitis

IV. References

  1. Tubbs and Janicki (2025) Mastering Emergency Imaging, CCME, accessed 6/12/2026

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