oslo4 hn emergenciesfh24-files.s3.amazonaws.com/110213/692971-xulem.pdf · neck infection imaging...

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Kathleen R. Fink, MDUniversity of Washington5th Nordic Emergency Radiology Course

May 21, 2015

+ Disclosure

My spouse receives research salary support from:

Bracco

BayerHealthcare

Guerbet

May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology

+ Outline

Case-based review of head and neck emergencies:

1. Foreign body

2. Neck infection focusing on complications

3. Sinus infection

4. Acute orbital abnormalities

5. Mastoid infections


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+ CT: Dysphagia after eating chicken casserole last night


Foreign body—in esophagus.

Are we done?

Pearl: esophageal foreign body: looks for signs of perforation

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+ CT: Esophageal foreign body


Esophageal wall edematous and enhancing.

Fat stranding in visceral space surrounding the esophagus

No extraluminal gas and FB appears confined to lumen

Endoscopy is therapeutic (object retrieval) and diagnostic (perforation)

In this case, esophageal wall irritated, but not perforated.

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+ Foreign body: Aspirated insulin cap


Patient with neurodegenerative disease arrived to ER, worried he had swallowed the cap to an insulin syringe.

But what would that look like? Could you see a plastic cap on CT?

Aha! Savvy resident, Lauren Toney, decided to image the patient with a second syringe cap on the skin surface so she would know what to look for.

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May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyPitfall: Appropriate window and level vital to find subtle foreign body

+ Foreign body: disk/button battery


Vital to diagnosis FB as battery due to possibility of erosive changes from: Electrolyte leakage

Alkali produced in situ

Mercury toxicity (if Hg battery) - theoretical

Pressure necrosis -theoretical

Batteries can become lodged many places:

Esophagus Nasal cavity

Ear

Lin et al, Int J Pediatr Otorhinolaryngol 68:4, 473-9. 201

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From: Lin, Daniel and PapsinInt J Pediatr Otorhinolaryngol 68:4, 473-9

Differentiating battery from coin can be difficult.

Raise the possibility!

Look for double ring sign.


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Foreign bodyHelpful to know what you are looking for.

Appropriate window/level.

Main concern: airway obstruction

Beware of disk batteries: regardless of location.


+ Neck Infection

Odontogenic abscess

Tonsillar abscess

Abscess versus phlegmon

Complications


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+ CT: facial swelling and pain


+ CT: cellulitis


Soft tissue thickening (cellulitis)

Submandibular space

Stranding Sublingual space

Thickening of mylohyoid muscle and platysma (myositis)

No ring enhancing collection.

Subcutaneous edema and skin thickening

Treated with antibiotics

Pearl: If there is no enhancing mass or collection, the term cellulitis is appropriate

+ CT: One week later, worsened swelling


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+ CT: Phlegmon/Abscess


Low density collection with surrounding enhancement.

Phlegmon: Enhancing inflammatory mass preceding abscess

Abscess: Ring enhancing fluid.

Here: Aspirated 10 ml pus

+ CT: companion case


Phlegmon! No pus on I&D

Pitfall: There is an imaging overlap between abscess and phlegmon

+ Differentiating cellulitis/phlegmon from abscess Important distinction because abscess requires

surgical I&D but cellulitis/phlegmon may be successfully treated with antibiotic therapy alone.

CT has limitations: Positive predictive value for abscess versus cellulitis: 71 -94% Negative predictive value 26-53%

Imaging criteria for abscess: Area of decreased attenuation with complete rim of contrast

enhancement. If no well definite rim, diagnosed “cellulitis”

Accuracy increased when correlated with clinical examination

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyVural, et al, Am J Otolaryngol 24:3, 143-8, 2003. Rosenthal et al, J Oral Maxillofac Surg 69:6, 1651-6 2011

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+ CT: “Slam dunk” abscess


Pearl: Look at teeth on bone windows if you see abscess or cellulitis involving submandibular or sublingual spaces

+ CT: Maxillary teeth can also be involved.


+ Odontogenic abscess


Often involves submandibular space

May involve sublingual space if anterior teeth are involved.

Look for cortical dehiscense of alveolar ridge

Look for dental disease: Periapical abscess Severe dental caries

Evaluate bone changes for osteomyelitis: Permeative bone lesion Osseous destruction Periosteal reaction

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+ CT: Sore throat and swelling


+ CT Tonsillitis:


Unilateral enlarged tonsil

No low density collections

May be edematous with a striated appearance

May see bilaterally enlarged tonsils

“Kissing tonsils”

Lymphoid hyperplasia is the differential

+ CT: Sore throat


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+ CT: Tonsillar abscess


Findings:

Low density well circumscribed collection in palatine (faucial) tonsil

Fat stranding in parapharyngeal space but no frank abscess extension

Pus aspirated

+ CT: Parapharyngeal space.


+ CT: Tonsillar versus peritonsillar abscess


Tonsillar abscess versus peritonsillar abscess terminology used loosely!

Definition 1: Peritonsillar abscess extends through fibrous tonsillar capsule but may still be bounded by the superior constrictor muscle (CT cannot distinguish)

Definition 2: Peritonsillar abscess refers to extension into surrounding spaces, usually submandibular or parapharyngeal (CT can distinguish)

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+ Peritonsillar abscess

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyPearl: Always look carefully at fat-containing parapharyngeal space with tonsillar infections



Definite extension into parapharyngeal space, masticator space, and carotid space

Note mucosal edema of uvula and narrowing of oropharynx

Consider infectious complications!



Definite extension into parapharyngeal space, masticator space, and carotid space

Note mucosal edema of uvula and narrowing of oropharynx

Consider infectious complications!

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+ Neck Infection: Complications

Thrombophlebitis

Lemierre Syndrome

Arteritis

Mediastinitis


+ CT: Neck swelling after IVDA


+ Complications: thrombophlebitis

Because of antibiotic therapy, septic thrombophlebitis is increasingly uncommon after typical head and neck infections

Certain risk factors

Intravenous drug use

Central venous catheterization

Malignancy/neck dissection

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyLin et al, Laryngoscope 114:1, 56-60 2004

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+ Complications: Pulmonary abscesses


Lemierre syndrome (postanginal septicemia or necrobacillosis)

Originally reported after odontogenic, tonsillar or peritonsillar abscess, mastoiditis, other infections

“Metastatic abscesses”

- Lung abscess

- Pulmonary Empyema

- Liver or renal lesions

- Septic arthritis

Lemierre, Lancet 227:5874, 701-703 1936

Increasingly rare due to antibiotic treatment

Several days of progressive left ear pain, neck stiffness and developing area of redness over left neck and ear.


Involves retropharyngeal space


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Involves carotid space


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+ Complication: Carotid artery pseudoaneurysm

Pseudoaneurysm is a rare but potentially life threatening complication of neck infection.

Left untreated, may increase in size and/or rupture.

Arterial narrowing/spasm from arteritis should also be specifically evaluated


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Progressive dysphagia and sore throat


Involves multiple spaces:Pharyngeal mucosal space and parapharyngeal space

Submandibular space

Carotid space

Retropharyngeal space

Visceral space



Where does the collection end?

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+ Complications: Mediastinitis


Uncommon but important complication of retropharyngeal infection due to high mortality (20-40%)

Retropharyngeal space extends from skull base to mediastinum (T3 or so)

Provides a path of infection from neck to chest

Important to recognize to allow early debridement, which requires involvement of thoracic surgeons.

Sandner et al J Oral Maxillofac Surg 65:4, 794-800 2007

Right mandibular pain, treated with antibiotics. Returned to ED with progressive swelling and taken urgently to OR


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+ Special case: Ludwig’s angina


Rapidly progressive infection of the floor of mouth, usually of odontogenic origin

Hallmarks:

Extension across midline, into deeper cervical spaces

Cellulitis/soft tissue edema without liquefaction

Airway compromise is the main clinical concern.

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Neck infectionImaging overlap between phlegmon and abscess

Complete ring enhancement increases likelihood of abscess

Evaluate for complications

Extension into adjacent cervical spaces

Image entire involved area

Vascular involvement


+ Sinus infection: bacterial

Presume Acute bacterial sinusitis if: Symptoms last longer than 10 days

Worsened symptoms within 10 days after an initial improvement (viral to bacterial transition).

No need for imaging.

Consider imaging if Suspect alternative diagnosis

Treatment failure


Rosenfeld et al. Otolaryngol Head Neck Surg 137:3 Suppl, S1-31 2007

+ CT signs of acute bacterial sinusitis.Imaging findings correlating with acute bacterial sinusitis include:

Sinus opacification

Air-fluid level

Moderate to severe mucosal thickening.

CT better than radiographs

Evaluate for complications:

Orbital, intracranial, deep face extension

MRI is only indicated for suspected complications of acute rhinosinusitis.

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyRosenfeld et al. Otolaryngol Head Neck Surg 137:3 Suppl, S1-31 2007

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+ Sinus infection: fungal

Multiple subtypes:


Invasive Noninvasive

Acute invasive fungal sinusitis

Allergic fungal sinusitis

Chronic invasive fungal sinusitis

Fungal mycetoma

Chronic granulomatous invasive fungal sinusitis (rare in US)

Aribandi et al. Radiographics 27:5, 1283-96 2007

+ Acute invasive fungal sinusitis

Patients at risk: Immunocompromised Poorly controlled diabetes

High mortality

Painless necrotic usually nasal septal ulcer sinusitis rapid orbital and intracranial spread death

Angioinvasion and hematogenous dissemination


+ Acute invasive fungal sinusitis

Imaging: Hypoattenuating mucosa or

small area of soft tissue attenuation in lumen of nasal cavity or sinus.

Subtle mucosal thickening with bone erosion

Check fat planes along sinuses carefully!

Early MRI to eval for intracranial and intraorbital extension.

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyMucormycosis

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+ Fungal sinusitis running amok

May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology Woman with CLL and facial pain

+ Fungal sinusitis: vascular complications Expanded nonenhancing left

cavernous sinus

Cavernous sinus thrombosis

Loss of left cavernous carotid enhancement

Carotid occlusion


+Invasive fungal sinusitis: Hallmarks

Early invasion

Vascular invasion

• Venous thrombosis

• Arterial involvement• Aneurysms

• Infarcts


Basilar artery aneurysm due to sphenoid sinus aspergillus infection

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+ Sinus Infection: complications

Orbital extension

Soft tissue extension (Pott’s puffy tumor)

Subdural empyema, epidural abscess

Venous sinus thrombosis

Intracerebral abscess


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FLAIR

Complications: Orbital and Epidural extension


T2

T1 post

+ Complications: Subdural empyema and Potts’ puffy tumor

May 21,2015Fink: 5th Nordic Course in Emergency Radiology

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+

SinusitisBacterial sinusitis is a clinical diagnosis.

Imaging is to evaluate for complications: Orbital extension Intracranial extension Venous sinus thrombosis

In immunocompromised patients, always look for invasive fungal sinusitisHallmarks: bone erosion and involvement of adjacent fat planes


+ Acute orbital abnormalities

Abscess: Preseptal/postseptal

Hemorrhage Vitreous

Choroid

Retinal


+ Orbital inflammatory disease, Chandler classification*Classification Category Description

Stage 1 Pre-septal Eyelid or skin swelling

Stage 2 Orbital cellulitis Orbital fat involvement, proptosis

Stage 3 Subperiosteal abscess Pus beneathperiosteum of bony orbit

Stage 4 Orbital abscess Pus within the orbit

Stage 5 Cavernous sinus thrombosis

May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology*Chandler et al The Laryngoscope 80:9, 1414-1428. 1970

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+ Preseptal cellulitis:

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyFrom: Matthew et al. Br J Radiol 87:1033, 20130503. 2014

Pearl: Always look carefully retrobulbar fat to determine post septal involvement. Reformats helpful.

Preseptal: Cellulitis limited to eyelid and periorbital soft tissue.

*

Preseptal

Postseptal

+ Postseptal cellulitis


Preseptal

Postseptal

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Post septal cellulitis often results from sinus disease, particularly from ethmoids through lamina papyracea

May cause:

Increased intraorbital pressure

Central retinal artery or vein occlusion

Optic nerve stretching or damage

Contrast enhanced study may help evaluate for abscess.

Importance of post septal involvement:


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+ Importance of post septal involvement:


Extraconal and intraconal involvement

+ Retinal hemorrhage

Retinal hemorrhage/detachment

- Hyperdense material in V shape with apex at optic nerve head


+ Choroidal hemorrhage

Choroidal hemorrhage/detachment

- Hyperdense material in concave shape, often bilateral

Be aware: some globe surgeries can result in an appearance of choroidal hemorrhage.


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+ Vitreous hemorrhage/Globe rupture Hyperdense material in the

vitreous chamber.

Here see associated loss of globe shape and volume loss Globe rupture.

Be aware: some retinal re-attachment procedures can result in an appearance of vitreous hemorrhage.


+ Lens dislocation

Hyperdense material in vitreous chamber looks really concave.

Lens dislocation Occurs with disruption of

zonular fibers of ciliary body

Dislocation usually posterior

If bilateral, think connective tissue disorder such as Marfan’s


+Acute orbital abnormalitiesInfection:

Important to determine whether there is post septal involvement

Evaluate for signs of increased intraocular pressure

Orbits are a radiology blind spot. Don’t forget to look!


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+ CT: Red swollen mass behind ear


+ CT: Otomastoiditis


Fluid opacification of middle ear and mastoids

Antibiotics have dramatically decreased the incidence acute mastoiditis and complications.

Coalescent mastoiditis: Erosion of mastoid air cells.

Bezold abscess*: extension to the soft tissues of the neck, usually through erosion through the mastoid tip

*Nelson: Am J Emerg Med 31:11, 1626.e3-4 2013

+ Mastoiditis:


Same patient: associated gas in epidural space. Contrast clearly demonstrates the associated epidural abscess

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+ Mastoiditis: Complications


Complications include:

Sigmoid sinus thrombosis

Empyema

Subdural abscess

Epidural abscess

Luntz Laryngoscope 122:12, 2813-7 2012

+ Mastoiditis: Complications

May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyFrank cerebral abscess

Left transverse and sigmoid sinus thrombosis

Pearl: Always remember to check venous sinuses!

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MastoiditisOften treated before complications occur.

Evaluate for

Intracranial extension

Venous sinus thrombosis

Extracranial soft tissue extension (Bezold abscess)


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+ Outline

Case-based review of head and neck emergencies:

1. Foreign body

2. Neck infection focusing on complications

3. Sinus infection

4. Acute orbital abnormalities

5. Mastoid infections


Thank you!Kathleen [email protected]

Hard rain comes down on the University of Washington, Seattle campus. February 18th, 2014. Photo by Katherine B. Turner

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