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Background
The pediatric lateral neck radiograph is frequently utilized for the evaluation of common neck pathology including adenoid and tonsillar hypertrophy, airway impingement, sleep apnea, epiglottitis, retropharyngeal abscesses, localization of foreign bodies. Without proper technique, distorted structures can easily obscure findings. We review a standard, simplified technique that can be easily taught to technologists including those who are not pediatrics trained. We also review key landmarks for interpreting common pediatric pathologies on lateral neck radiographs.

Educational Goals / Teaching Points
After reading this exhibit, the radiologist will be able to describe a standardized technique for lateral neck radiographs including technical aspects, patient positioning, and best practices. They will also be able to recognize key anatomy and anatomic variations that can be mistaken for pathology, and how these vary by age. Finally, they will be able to discuss common technical limitations and how best to avoid these.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Review a standardized technique for soft tissue necks including photos showing patient positioning and centering. Lateral neck should be taken at 72” with neck extension. Film should be taken during inspiration with mouth closed and use of grid. Use of bolsters, collimation, removal of earrings, etc., will be described. Description of modifications for patients with suspected epiglottitis will be included. Techniques for positioning in small children who may not comply with instructions will be described. Age-based dose settings will be discussed. Description and differentiation of the nasopharynx, oropharynx, hypopharynx and the epiglottis, glottis and subglottis on anatomy drawing correlated to radiograph. Detailed radiograph examples showing soft tissue structures (earlobe, soft palate, tonsils/adenoids, tongue, etc.), spaces (vallecula, laryngeal ventricle, pyriform sinuses, etc), and osseous structures including hyoid bone and various regions of potential ossification such as thyroid and cricoid cartilage, stylohyoid ligament). Systematic approach to interpreting soft tissue neck radiographs will be reviewed. Errors and limitations of the normal pediatric lateral neck radiograph is prone to errors of parallax and poor control of patient positioning. Inadequate image will include examples such as poor distention of the pharynx, incomplete extension of the neck, incomplete coverage of anatomy, poor collimation, opposition of the soft palate and adenoids, apparent thickening of the prevertebral soft tissues, under/overpenetration Discussion of when a tech should repeat an exam will be included.

Conclusion
The pediatric lateral soft tissue neck radiograph is a cheap, readily available tool that is valuable in assessing pathology of the upper aerodigestive tract. Recognizing and teaching proper technique and interpretation will improve lateral neck radiograph interpretation.