plain radiology of the neck
TRANSCRIPT
Prof.Prof. Hossam Thabet, M.DHossam Thabet, M.D..
Otolaryngology-Head & Neck Otolaryngology-Head & Neck Surgery DepartmentSurgery Department
Alexandria UniversityAlexandria University
Plain Imaging Of The Neck
Plain Imaging of H&N
Neck Lateral Soft Tissue AP Soft Tissue Cervical Spine
1. Lateral (Flexion & Extension)2. AP3. Right Lateral Oblique4. Left Lateral Oblique5. Odontoid View, Open Mouth
Hyoid Bone
Ventricle
Tracheal Airway
Cricoid Cartilage
Aryepiglottic FoldEpiglottis
Base Of Tongue
Prevertebral Space C2
Prevertebral Space C6
Vallecula
Nasopharynx
Neck Soft Tissue Lateral View
Prevertebral space
Anatomically; it is defined by the anterior part of the cervical spine and the deep layer of the deep cervical fascia running between the transverse processes of the spine. Extends along entire vertebral columnalong entire vertebral column
Radiologically; it is defined posteriorly by the Radiologically; it is defined posteriorly by the anterior surface of the cervical spine and anterior surface of the cervical spine and anteriorly by the pharyngeal & tracheal wallsanteriorly by the pharyngeal & tracheal walls
Cervical FasciaVisceral SpaceVisceral Space
Retropharyngeal Retropharyngeal SpaceSpace
Alar SpaceAlar Space
Prevertebral SpacePrevertebral Space
Vascular SpaceVascular Space
Perivertebral SpacePerivertebral Space
The prevertebral space contains1. The prevertebral muscles (longus colli and longus
capitis) 2. Vertebral vessels 3. Scalene muscles 4. Phrenic nerve 5. proximal part of the brachial plexus.
Prevertebral space
Prevertebral space Causes of widening of the prevertebral space:1. Retropharyngeal infection (Cellulitis/Abscess)2. Postcricoid carcinoma 3. Posterior pharyngeal wall carcinoma4. Trauma of cervical spine 5. Pott’s disease of cervical spine6. Vertebral osteomyelitis 7. Spondylodiscitis 8. Vertebral metastasis. 9. Posterior spread of H & N tumor 10.Primary tumors arising within this space.
Hodgkin lymphoma Chordoma Lipoma
Lateral Neck Soft Tissue
Screening examination Mainly for Prevertebral Space & Airway Normal Prevertebral Space:
7mm at C-2, 14mm at C-6 ( kids) 22mm at C-6 (adults)
Technique dependent (Extension& Inspiration) Sensitivity 83%, compared to CT 100%
Step off sign
Normal Prevertebral Space:At C3= <3 mm (< 1/3 AP diameter)At C6 = < AP width of C6 vertebral body At C2 = 7mmAt C6 = 14 mm (kids) = 22mm (Adults)
True widening of prevertebral space
False +ve widening of prevertebral space
Adenoid Hypertrophy Pediatric Sleep Apnea
Pediatric Sleep Apnea
Lingual tonsillitis causing stridor
Ludwig’s angina(Sublingual cellulitis)
Cervical Spine
Lateral (Flexion & Extension) AP Right Lateral Oblique Left Lateral Oblique Odontoid View, Open Mouth
Cervical Spine AP
Cervical Spine AP
Cervical Spine AP
Cervical Spine Lateral
Cervical Spine Lateral
F - facet joint SP - spinous process L - lamina Od - odontoid
Right Lat. ObliqueLeft Lat. Oblique
Right Lat. ObliqueLeft Lat. Oblique
Odontoid View, Open Mouth
Odontoid View, Open Mouth
Odontoid View, Open Mouth
Fish Bone vallecula
F.B Upper Esophagus
Coin In the Upper Esophagus
Bottle Cap
Facts about Button Battery Ingestions
Ingested lithium cells pose a higher risk due to their larger diameter which makes them more likely to lodge in the esophagus and their greater voltage which generates more local hydroxide when lodgement occurs
Emergency NaOH, KOH, mercury
1 hour – mucosal damage 2 - 4 hours – muscular layers 8 - 12 hours – perforation
Esophagoscopy Observation for gastric location for 4-7
days Laparotomy for bowel perforation
Facts about Button Battery Ingestions
Disc batteries lodged in the esophagus can potentially cause serious problems in 3 ways:
1) Direct pressure necrosis (similar to coins or other inert F.B.).
2) Caustic injury due to the leakage of sodium or potassium hydroxide from a leaking battery.
3) Injury from low voltage burns from a disc battery that still has a charge.
For these reasons, all disc batteries lodged in the esophagus should be removed expeditiously to avoid these injuries.
Facts about Button Battery Ingestions
Impacted Esophageal F.B. Commonly impacted just below
cricopharyngeous (70%) Another 20% impact at the level of the aortic arch Another 10% at EG junction Once past the esophagus, most F.Bs will pass
through the GI tract
Plain films usually do not demonstrate all FB but are still obtained first If negative, then either contrast esophagram or CT if
high index of suspicion
Impacted Esophageal F.B. Food or true F.B.
Chicken bones (opaque), fish bones (non-opaque(
Coins, toy trucks Chicken bones are usually opaque Fish bones contain less calcium and
usually are not
The black arrow is pointing to stylo-hyoid ligament calcification .
The grey arrow is the hyoid bone
The white arrow is the thyroid cornu
Ossified stylohyoid ligament
Impacted Esophageal F.B.
Lateral X-ray of the neck demonstrates a linear density in the proximal esophagus (arrow) consistent with an impacted F.B. (a chicken bone (
chicken bone (arrowed)stuck in the pharynx
Impacted Esophageal F.B.
A faint irregular mottled density in the oesophagus with an A/F level superior to this density (arrowed).
The mottled density is assumed to be the meat
Air in oesophagus can be a normal finding associated with air swallowing.
An air-fluid level is suggestive of obstruction in the oesophagus.
Impacted Esophageal F.B.
Impacted Esophageal F.B.
The arrowed structure is food in a Zenker diverticulum.
Sea food shell in the pharynx at the origin of the oesophagus (arrowed(
F.B. stuck in the patient's esophagus ( arrow), a tablet which is still in its foil packaging.
There is some soft tissue swelling associated with the foreign body
Impacted Esophageal F.B.
Impacted esophageal Fish bone.
•Chicken bones are usually opaque •Fish bones contain less calcium and usually are not
Stone
Fish bone
Radio-opaque shadow in the prevertebral space opposite to C5
Edema & obliteration of the Rt. Pyriform sinus and PGS with a F.B. in the prevertebral space
Esophageal Fish bone migrating to the neck
Posttonsillectomy ECA embolization for recurrent
severe 2ry bleeding, F29y
Aspirated F.B.Common aspirated objects(Choke
Hazard) Latex Balloons (29% of choking deaths) Marbles, Balls (19% of choking deaths ( Peanuts Popcorn Hot dogs Other foods Plastic or metal toy objects
Metallic wire larynx
Aspirated F.B.
F.B. Button in the larynx
Aspirated F.B.
Aspirated F.B.
Infected TGDC
Infected TGDC with subcut. Edem (white arrow), edema of the preepiglottic space (black arrows) & arytenoid edema ( blue arrow)
The Big Two Croup Epiglottitis
Upper Airway Infections
Croup Croup - Scottish for barking cough Laryngotracheobronchitis 6 months to 3 years old (rare<1y) Younger than epiglottitis Usually viral (Parainfluenza types 1 & 2)
Upper Airway Infections
Croup URI symptoms Difficult to distinguish from early
retropharyngeal abscess Barking cough & hoarseness Inspiratory or biphasic stridor Low-grade fever
Upper Airway Infections
Croup Four major findings
Distension of the hypopharynx
Distension of the laryngeal ventricle
Haziness or narrowing of subglottic space –
(AP neck - “Steeple sign” “ Pencil tip”)
Normal Epiglottis
Upper Airway Infections
(AP neck - “Steeple sign” “ Pencil tip”)
Epiglottitis Haemophilus influenzae type B most
common Peak incidence : 6-7 years
Croup occurs from 6 months to 2 years Lateral radiograph -- Erect position only
Supine position may close off airway
Upper Airway Infections
EpiglottitisKey Findings ‘Toxic’ Child X-ray findings
‘Thumbprint’ Dilated
hypopharynx(Children) ‘Cherry Red’ Epigottis
Upper Airway Infections
Epiglottitis Radiological Key Points1.Swollen Epiglottis (Thumb print appearance)2.Thickened edematous AEF3.Swollen edematous
arytenoids4.Dilated hypopharynx5.Obliterated vallecula6.Normal subglottis7.Loss of cervical lordosis8.Associated pneumonia in 25
%
Upper Airway Infections
Epiglottitis Ballooning of the
hypopharynx is a finding in children with croup, and sometimes those with epiglottitis,
A rare radiographic finding in adults.
Ballooning is caused by sucking air through an open mouth against an obstruction
Upper Airway Infections
Congenital Cervical Lung Herniation
The least common location of lung herniation. Patients <3 years of age Unilateral or bilateral
Bilateral Laryngoceles
Bilateral laryngoceled
DysphagiaCricophgaryngeus Spasm The cricopharyngeus
muscle (the upper esophageal sphincter) lies at about the level of C5-C6
A prominent cricopharyngeus, however, can be seen on barium swallows in about 5-10% of asymptomatic individuals
63 year-old with dysphagia
Prominent Cricopharyngeus The cricopharyngeus muscle is normally
contracted at rest Upon the initiation of swallowing, the
normal cricopharyngeus muscle relaxes in anticipation of the bolus and helps to form part of the pharyngeal peristaltic wave
Therefore, the cricopharyngeus muscle is usually not seen on a barium swallow
Dysphagia
Posterior hypopharyngeal wall carcinoma
Postcricoid CaPost.Ph. W. Ca
Vallecular Spindle Cell carcinoma
Extensive papillary caecinoma with retrophartngeal
extension & calcifications (black arrows)
Extensive papillary caecinoma with retrophartngeal extension,dysphagia , V.C paralysis and aspiration (red arrow)
Left: Lateral neck radiograph showing a large mass in theretropharyngeal space, extending from the nasopharyngeal roof to
the level of the 4th cervical vertebra, narrowing the upper airway.Right: axial CT at the level of the palate showing a homogeneous and hypodense mass with multiple intrinsic septa.
Weixi Gong MS et al. A Retropharyngeal Lipoma Causing Obstructive Sleep Apnea in a Child Journal of Clinical Sleep Medicine, Vol. 2, No. 3, 2006
Retropharyngeal abscessRetropharyngeal abscess
Suppuration of the retropharyngeal, danger or prevertebral spaces –collectively RPA
The 2nd most common DNSI in children
Almost all occur before age 6 50% between 6-12 months In adults, usually 2ry to trauma to
oropharynx, Iatrogenic or FB
Retropharyngeal SpaceRetropharyngeal Space Posterior to pharynx & esophagusPosterior to pharynx & esophagus Anterior to alar layer of deep Anterior to alar layer of deep fasciafascia Extends from skull baseExtends from skull base to T1-T2to T1-T2 Midline raphe connects superior Midline raphe connects superior constrictor to the deep layer of deep constrictor to the deep layer of deep C.F.C.F. Contains retropharyngeal nodes.Contains retropharyngeal nodes.
Retropharyngeal abscessRetropharyngeal abscess
• Children 3m-3y Children 3m-3y (<5y) (<5y) • CausesCauses1.Suppuration in 1.Suppuration in lymph nodes of lymph nodes of HenleHenle2. Nose, adenoids, 2. Nose, adenoids, nasopharynx, & nasopharynx, & sinus infectionssinus infections
• AdultsAdults• CausesCauses1.Ttrauma, F.B, 1.Ttrauma, F.B, instrumentationinstrumentation2.Extension from 2.Extension from adjoining deep adjoining deep neck spaceneck space
PathogenesiPathogenesiss
Retropharyngeal abscessRetropharyngeal abscess
Lateral Cervical Radiographs Swelling: Diffuse →cellulitis/Focal →
abscess Widened prevertebral space, slightly
thicker than width of vertebral body Reversal of normal lordosis Air/fluid levels Vertebral body destruction Foreign body
Retropharyngeal abscessRetropharyngeal abscess
A tenA ten--Y/O boy with fever& neck pain due to posttrumatic Y/O boy with fever& neck pain due to posttrumatic
(F.B.)(F.B.)
Retropharyngeal abscessRetropharyngeal abscess
18 year male with post traumatic retroph. abcess
Retropharyngeal abscessRetropharyngeal abscess
Retropharyngeal abscessRetropharyngeal abscess
Retropharyngeal abscessRetropharyngeal abscess
Retropharyngeal abscessRetropharyngeal abscess
Retropharyngeal abscessRetropharyngeal abscess
Retropharyngeal Retropharyngeal AbscessAbscess
Retropharyngeal Retropharyngeal AbscessAbscess
Cervical Spondylolethesis
55 Y/O female child with torticollis to left side, fever , Y/O female child with torticollis to left side, fever , dysphagia, neck pain. X-ray neck shows loss of lordosis, dysphagia, neck pain. X-ray neck shows loss of lordosis, reversed lordosis.reversed lordosis.CT shows enlarged adenoid, lt retropharyngeal & CT shows enlarged adenoid, lt retropharyngeal & parapharyngeal abscess extending downward to the parapharyngeal abscess extending downward to the visceral space & left thyroid regionvisceral space & left thyroid region
Danger SpaceDanger Space Anterior border-alar layer of deep Anterior border-alar layer of deep fasciafascia Posterior border-prevertebral layerPosterior border-prevertebral layer Extends from skull base to diaphragmExtends from skull base to diaphragm Contains loose areolar tissueContains loose areolar tissue Little resistance to spread of infectionLittle resistance to spread of infection
Retropharyngeal abscessRetropharyngeal abscess
Danger SpaceDanger Space AA potential space composed of loose potential space composed of loose aereolar tissue & fat, extends down to aereolar tissue & fat, extends down to mediastinummediastinum. .
Nearly identical presentation to RPANearly identical presentation to RPA Cause: Extension from retropharyngeal, Cause: Extension from retropharyngeal, prevertebral or parapharyngeal spaceprevertebral or parapharyngeal space Cannot be distinguished by imaging Cannot be distinguished by imaging from retropharyngeal space.from retropharyngeal space.
Retropharyngeal abscessRetropharyngeal abscess
Prevertebral SpacePrevertebral Space Anterior border - prevertebral fasciaAnterior border - prevertebral fascia Posterior border-vertebral bodies & deep Posterior border-vertebral bodies & deep N.msN.ms Lateral border – transverse processesLateral border – transverse processes Extends along entire vertebral columnExtends along entire vertebral column Infection tends to be localized due to Infection tends to be localized due to dense fibrous attachmentsdense fibrous attachments between fascia between fascia & deep muscles& deep muscles
Retropharyngeal abscessRetropharyngeal abscess
Prevertebral SpacePrevertebral Space
Mostly originates from the cervical spineMostly originates from the cervical spine Cause: Pott’s abscess, trauma, osteomyelitis, Cause: Pott’s abscess, trauma, osteomyelitis, extension from retroph. & danger spacesextension from retroph. & danger spaces Back, shoulder, neck pain made worse by Back, shoulder, neck pain made worse by deglutitiondeglutition Dysphagia or dyspneaDysphagia or dyspnea
Retropharyngeal abscessRetropharyngeal abscess
Diffuse Idiopathic Skeletal Hyperostosis (DISH(
Often confused radiographically with ankylosing spondylitis, as bridging osteophytes are seen in both conditions. However, the lack of facet joint arthritis and fusion, sacroiliitis, and syndesmophytes in DISH help to confirm the diagnosis.
Diffuse Idiopathic Skeletal Hyperostosis (DISH(
A generalized spinal & extraspinal articular disorder that is characterized by ligamentous calcification and ossification
The definitive criteria for the diagnosis :1. Flowing calcification or ossification along the
anterolateral aspect of at least 4 contiguous vertebral bodies.
2. Relative preservation of intervertebral disc height of the involved segments
3. Lack of associated signs of disc degeneration
Lateral view of the cervical spine showing
1. Loss of cervical lordosis.
2. Mild prominence of prevertebral soft tissues
3. Presence of calcification at level of C2.
Rodríguez JR et al, Applied Radiology 2004
(A and B) Axial CTCE images soft tissue and bone windows,respectively. An area of calcification is seen in the retropharyngeal space with prominence of this region. The scans exhibit low attenuation with no abnormal enhancementRodríguez JR et al, Applied Radiology 2004
37 Y/O man with an 8 day history of low grade fevers, neck stiffness, & odynophagia. unremarkable medical history. O/E Decreased cervical range of motion upon flexion and extension, with marked paraspinous muscle spasm. There is no spinal tenderness or meningismus. Laboratory evaluation reveals a WBC of 8.3 and an ESR of 56.
(A) amorphous calcification anterior to the C1 and C2 vertebrae (yellow arrow) with marked prevertebral soft tissue swelling (red arrow). (B) higher magnification
The appearance of the calcification varies from punctuate to a dense, prominent concretion
Axial CT scan at the level of 3rd &4th cervical vertebra shows fluid collection (arrow) in the retropharyngeal space .
Acute Calcific Tendinitis of The Longus Colli
Idiopathic noninfectious inflammation of tendinous insertion of longus colli muscle with deposition of calcium hydroxyapatite crystals, confused with retropharyngeal abscess .
Sagittal reformat shows tapering of the
fluid (arrowheads) superiorly &
inferiorly in the typical pattern
T2MRI shows the effusion (straight arrows) tapering to a point inferiorly (curved arrow) at the level of C5. The level of attachment of the longus colli is at the anterior arch of the atlas (open arrow).
Acute Calcific Tendinitis of The Longus Colli
The longus collis muscle originates from the C1 to T3 vertebrae and consists of vertical, inferior oblique, and superior oblique fibers.
The superior oblique fibers originate from the transverse processes of C3 to C5 and fuse into a tendon that inserts onto the anterior tubercle of the atlas and is most vulnerable to calcific deposits
Acute Calcific Tendinitis of The Longus Colli
Pathology Inflammation of tendinous insertion of longus
colli muscle with deposition of calcium hydroxyapatite crystals
Oblique fibers of muscle are involved Effusion can extend from prevertebral space
into retropharyngeal space Abnormality begins in prevertebral space
rather than in retropharyngeal space, edema or fluid collection may surround part of muscle, particularly superiorly
Acute Calcific Tendinitis of The Longus Colli
The exact cause of crystal deposition is unknown.
There seems to be a genetic and metabolic predisposition associated with chronic trauma, inflammation, and tendon degeneration.
Acute symptoms develop when these contained deposits rupture, provoking an acute inflammatory process that usually lasts 2 to 3 weeks and responds to the administration of nonsteroidal anti-inflammatory medication
Acute Calcific Tendinitis of The Longus Colli
Clinical Presentation Mimics retropharyngeal abscess, but
patient is less febrile May have normal white blood cell count Illness is self-limited, responds to either
steroids or nonsteroidal anti-inflammatory drugs
Acute Calcific Tendinitis of The Longus Colli
Diagnosis Middle-aged patients with no gender predilection. No history of trauma or history of minor trauma Neck pain, limited range of motion, & odynophagia. Tender neck muscles over the transverse
processes of the higher cervical vertebrae In 50% of cases, there may be a low-grade fever Normal WBC or Mild leukocytosis Elevation of CRP & ESR
Acute Calcific Tendinitis of The Longus Colli
Diagnosis A plain lateral neck film - an amorphous
calcific deposit below the arch of C1 and anterior to the body of C2 with associated swelling of the prevertebral soft tissue from C1 to C4.
CT is more sensitive for depiction of intratendinous calcifications, showing also the edema of the retropharyngeal space.
MRI is excellent to identify soft tissue edema or fluid collection
Acute Calcific Tendinitis of The Longus Colli
Differential Diagnosis retro- or naso-pharyngeal abscess acute thyroiditis occult C-spine fracture malignancy calcific tendonitis accessory ossicle (appear osseous with a
demarcated cortex, without soft tissue swelling) calcified stylohyoid ligament
Acute Calcific Tendinitis of The Longus Colli
Prognosis The natural history of this condition is
spontaneous resolution. Symptomatic support with analgesia
and anti-inflammatories is useful; symptoms improve over a 1 to 2 week period.
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
TB Retropharyngeal Abscess & Multineck abscesses
T.B. Of the Prevertebral Space (Pott’s Disease)
Prevertebral SpacePrevertebral Space
Complicated retropharyngeal abscess (White Complicated retropharyngeal abscess (White arrow)/arrow)/(asterisk) extending to the prevertebral extending to the prevertebral space & the neural canal (Black arrow)space & the neural canal (Black arrow)
Lateral cervical radiograph. Note the presence of permeative lytic areas involving spinous processes of C4-5 vertebrae with widening of prevertebral soft tissue and presence of posterior cervical soft tissue shadow
CT. Multiple lytic areas seen involving bodies and posterior elements
Epidural Extension Of Actinomycosis in HIV infected immunocompromised 30ymale
Lateral cervical spine film shows widening of the prevertebral space and destruction of C5 and C6 vertebrae
Sagittal MRI showing the abscess opposite C4-C5. Destruction of C5 and C6, collapse of the intervertebral space and posterior extension of the abscess into the spinal canal.
Prevertebral Abscess with Osteomyelitis of the Cervical Vertebrae and Spinal Compression
High risk patients for cervical osteomyelitis:
1. Trauma to the pharynx or cervical spine2. Near by cervical infection3. IV drug abusers4. D.M.5. Immunocompromize, HIV infection6. Chronic renal failure7. Elderly
Retropharyngeal abscessRetropharyngeal abscess
Causes 1.1. Pharyngeal PerforationPharyngeal Perforation Trauma to esophagus or
trachea Penetrating injuries from
weapons Perforation from within
Chicken bone Mediastinal emphysema tracking
into neck Surgery Retropharyngeal abscess Retropharyngeal abscess
(gas(gas--forming organismforming organism ))Pharyngeal perforation with extensive surgical emphysema
Retropharyngeal Retropharyngeal EmphysemaEmphysema
Imaging findings Streaks of air in soft
tissues of neck Anterior displacement of
pharynx Associated pneumothorax
possible Cervical or mediastinal air
in 60% of cases of ruptured esophagus
Pharyngeal PerforationPharyngeal Perforation