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Head &Neck 911Imaging of Neck & Airway Emergencies
Michelle A. Michel, M. D.Professor of Radiology and Otolaryngology
Medical College of Wisconsin, Milwaukee, WI
Disclosure of Commercial Interest• Neither I nor my immediate family (that
would be my Bichon Frise “GoGo”) have
a financial relationship with a
commercial organization that may have
a direct or indirect interest in the content
of this presentation.
Illustrations courtesy Elsevier & Amirsys, Inc.
A big thanks to Drs. Philip Chapman, Rebecca
Cornelius, Bernadette Koch, C. Douglas Phillips, &
Deborah Shatzkes for case material!!!
Neck & Airway EmergenciesObjectives
• Review emergent, non-
traumatic adult conditions of
the neck
• Emphasize imaging findings to
make the correct diagnosis,
identify secondary findings,
and recognize potential
complications
• Topics
• Neck space
infection/inflammation
• Conditions affecting the airway
• Non-traumatic vascular lesions
Neck & Airway EmergenciesOverview
• What constitutes a H&N
Emergency?• Condition is life threatening
• Condition could cause loss of function
• Condition causes severe pain or distress
• Condition that if not identified early may result
in a situation that is life-threatening, causes
loss of function or severe pain/distress
• Vital anatomy in the H&N• Airway, vasculature, neural elements
• In close proximity
• Big problems if findings missed or
misinterpreted!Jean-Baptiste Marc Bougery
(1831-1854)
Neck & Airway EmergenciesImaging Approach
• Conventional radiographs & MRI
have little role in acute setting
• CT is primary imaging modality
in emergent H&N conditions
• Fast image acquisition
• Relatively insensitive to patient
motion
• Large FOV & high spatial resolution
• Reformatted images from single
acquisition
• Widely available
• Benefits in emergent setting outweigh
risks of radiation exposure
• Dose-limiting technologies
• Role of imaging
• Identify location &
source
• Assess anatomic
extension – pattern of
spread
• Orbit, intracranial, airway,
vessles, thoracic cavity
• Detect complications
• Guide drainage
Neck & Airway EmergenciesNeck Space Infection & Inflammation
Neck & Airway EmergenciesNeck Space Infection & Inflammation
• Glandular “emergencies”
• Tonsillitis & peritonsillar
abscess
• Acute calcific prevertebral
tendonitis
• Odontogenic infection
• Floor of mouth infection
(Ludwig angina)
• Deep neck space infection
• Necrotizing fasciitis
57 year old male with left neck swelling & pain
Neck & Airway EmergenciesGlandular “Emergency”
Acute Submandibular Sialolithiasis-adenitis
Neck & Airway EmergenciesAcute Sialoadenitis
• Facial swelling & tenderness
↑ by oral intake
• Parotitis – CN7 paresis
• Obstructing sialolith
• 80-90% of acute cases
• SMG (70-80%)
• Large, ascending duct & small
papillary orifice, ↑ secretion
viscosity & slow flow rate
• No stone?...look for anterior
FOM mass!
Acute on Chronic
Sialolithiasis/Sialoadenitis
Neck & Airway EmergenciesSialoadenitis
63 year old male with tongue pain and neck swelling
Sialoadenitis 2° Tongue/FOM SCCa
Courtesy C. Douglas Phillips, MD
Neck & Airway EmergenciesGlandular Emergency
Acute Sialolithiasis and SMG Abscess
Neck & Airway Emergencies
18 & 19 year old females with sore throat
Tonsillitis without Intratonsillar Abscess
Neck & Airway EmergenciesTonsillitis & Tonsillar Abscess
Intratonsillar Abscesses
• Young patients with sore
throat, trismus, tonsillar
enlargement & erythema
• EBV > Staph, Strep
• Imaging in severe cases
• Evaluate for abscess & extent
• Tonsillitis
• Enlarged, “kissing” in midline,
striated enhancement pattern
• Intratonsillar vs. peritonsillar
abscess
• Intratonsillar• Liquefaction contained by
capsule, enhancing rim
• No extension posterior to ICA/IJV
• Peritonsillar• Extends beyond capsule
into connective tissue between tonsil & superior constrictor ring
• Airway compromise
• Cellulitis in PPS, MS, RPS, PVS
Neck & Airway EmergenciesIntratonsillar vs. Peritonsillar Abscess
Confusing!
Courtesy C. Douglas Phillips, MD
41 year old female with sore throat & dysphagia
Acute Calcific Prevertebral Tendonitis
with RPS Effusion
Neck & Airway Emergencies? Tonsillitis
• Relatively rare &
underdiagnosed
• Tonsillitis mimic
• Adult (30-60 yrs)
• Stiff neck, sore throat, no
infection or dental disease
• No or low-grade fever,
minimal ↑ WBC, ↑ ESR
• Crystal deposition in longus
colli tendons & inflammatory
tendonitis & RPS effusionCourtesy C. Douglas Phillips, MD
Neck & Airway EmergenciesAcute Calcific Prevertebral Tendinitis
33 year old female with facial swelling & trismus
Odontogenic Masticator Space Abscess
Neck & Airway Emergencies
• Odontogenic abscess
• From molar tooth infection or following dental procedure
• 2nd or 3rd molar teeth
• Roots below mylohyoid
– SMS
• Adjacent to posterior body and ramus
• +/- Osteomyelitis
• Changes therapy
Neck & Airway EmergenciesMasticator Space Infection
84 year old female with cheek swelling & erythema
Neck & Airway EmergenciesMasticator Space Infection
Maxilllary Odontogenic Abscess with SZMS Extension
Neck & Airway Emergencies
46 year old male with progressive anterior
neck swelling and erythema
Courtesy Mauricio Castillo MD
“Ludwig Angina”
Neck & Airway EmergenciesFloor of Mouth Infection – Ludwig Angina
• “Angina Ludovici”, “angina maligna”, “morbusstrangularis”
• Potentially life-threatening floor of mouth (SLS) cellulitis
• ± Abscess
• Adults with dental infection > complicated SMG infection
• Canine, premolar, 1st molar• Roots above mylohyoid (SLS)
• Airway compromise• OP or pretracheal ST Wilhelm Friedrich von Ludwig
1790-1865
Neck & Airway EmergenciesFloor of Mouth Infection
Courtesy C. Douglas Phillips MD
69 year old male with fever & dysphagia
Retropharyngeal & PVS Abscess 2°
Cervical Osteodiscitis
Neck & Airway Emergencies
• RPS between buccopharyngeal fascia & alar fascia
• Clivus to T3 level
• Danger space between alar fascia & prevertebral fascia
• Clivus to above diaphragm
• Conduit to mediastinum
• Potential spaces &
indistinguishable on imaging
BPF AF
PVF
Neck & Airway EmergenciesDeep Neck Space Infection
Retropharyngeal & Danger Space Anatomy
Neck & Airway EmergenciesRetropharyngeal & Danger Space
Lateralized >
Lymph Node
Midline >
Effusion/Abscess
• Most common in children < 6 years• Ruptured suppurative LN
or penetrating FB
• Less common in adults• Immunocompromised or
diabetic
• Cervical osteodiscitis or post-spine surgery
• Imaging features• Tense fluid collection
• Wall enhancement / gas
• Image inferior extent!Courtesy Bernadette Koch, MD
Neck & Airway EmergenciesRetropharyngeal Abscess
Neck & Airway EmergenciesRetropharyngeal/Danger Space
Screw Extrusion with RPS/PVS Abscess
71 year old male post cervical fusion with fever & dysphagia
Neck & Airway EmergenciesDeep Neck Space Infection
Multispatial, Retropharyngeal & PVS Abscess
54 year old male with fever, neck pain, dysphagia,
and difficulty breathing
Surgical drainage performed…
1 week post RPS-PVS abscess drainage presented
with ↑ neck pain & paresthesias
Cervical Osteodiscitis with PVS → Epidural Abscess
Neck & Airway EmergenciesDeep Neck Space Infection
56 year old male with tonsillar abscess
RPS & DS Extension with Descending Mediastinitis
Neck & Airway EmergenciesDeep Neck Space Infection
• Mediastinitis 2° H&N infection > 1 °• RPS infection permeates
the alar fascia
• Infection spreads to danger space & with gravity extends into mediastinum
• Potentially life-threatening• Severe sepsis
• Cardiovascular collapse
Neck & Airway EmergenciesDescending Mediastinitis
Lee MK, et al. BMC Infectious
Diseases 2013 13:475
Neck & Airway Emergencies
Courtesy Philip Chapman, MD
50 year old patient post XRT for HP SCCa. Presents with sore
throat, difficulty swallowing, neck swelling, and sepsis
Radionecrosis of the Hyoid Bone and Thyroid Cartilage
…but there’s more…
Neck & Airway Emergencies
Courtesy Philip Chapman, MD
Necrotizing Fasciitis
• Rare, but ↑ incidence
• Patients immune-compromised, DM, EtOH-ic
• Inciting condition
• Pharyngitis, odontogenic most often
• Symptoms and signs deceptively benign
• Polymicrobial
• Anaerobes & other
• Bacterial enzymes & exotoxins destroy tissue
• Mortality: ~ 25%
• Sepsis, mediastinitis, carotid erosion, venous thrombophlebitis, aspiration pneumonia, airway compromise
• Multiple debridements often required
Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis
http://www.arquivosdeorl.org.br
nycems.blogspot.com
Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis
• Imaging features• Cellulitis: skin thickening,
reticulation of fat
• Fasciitis: thickening & enhancement of fascia
• Myositis: swelling & enhancement of muscles
• Multispatial fluid collections• Necrotic tissue > abscesses
• Gas collections (65-75%)
• Imaging role for surgery• Vascular complication
• Descending mediastinitis
• Collection > 3 cm, involving > 2 spaces, or involving CS, PVS, VS
Courtesy C. Douglas Phillips, MD
Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis
Courtesy Deborah Shatzkes, MD
65 year old diabetic male with worsening posterior neck pain
& bloody drainage
46 year old female with sore throat & dysphagia
Courtesy Phil Chapman, MD
Neck & Airway EmergenciesAirway Emergencies
Supraglottitis
• Potentially life threatening
infection/ inflammation of
supraglottic larynx in adult with
sore throat & dysphagia
• Pharyngeal > laryngeal symptoms
• Thickened epiglottis, AEF,
obliterated preepiglottic fat,
mucosal enhancement
• Often involves tonsils and base
of tongue
• Abscess formation more
common in adults
Neck & Airway EmergenciesEpiglottitis & Supraglottitis
Courtesy Deborah Shatzkes, MD
40 year old female with intermittent right neck
swelling; follow up 18 months later
Laryngocele → Laryngopyocele
Neck & Airway EmergenciesAirway Emergencies
• Thin walled air or fluid-
filled cystic lesion
communicating with
laryngeal ventricle
• Types:
• Internal
• Mixed (external)
• Secondary laryngocele
• Laryngopyocele
Neck & Airway EmergenciesLaryngopyocele
Neck & Airway EmergenciesAirway Emergencies
67 year old female with rapid onset of tongue swelling &
difficulty breathing; Tx with ACE inhibitor x 1 year for HTN
Courtesy Philip Chapman, MD
ACE Inhibitor-Induced Angioedema
Neck & Airway EmergenciesLaryngotracheal Angioedema
Thyroiditis & Laryngeal Edema
• Generalized inflammation of
mucosa & submucosa
• Varying airway narrowing &
respiratory compromise
• Minor Δ in luminal size →
significant impact on airflow
• ↓ Diameter by ½ = ↑ airway
resistance 16x
• Etiologies: Drugs (ACE inh),
anaphylaxis, XRT, cellulitis
• Tx aimed at underlying
condition, airway protection
Neck & Airway EmergenciesVascular
• Jugular vein
• Thrombosis
• Thrombophlebitis
• Arterial
• Dissection
• Carotid
pseudoaneurysm
• Carotid “blowout”
Neck & Airway EmergenciesVascular
59 year old with lupus and renal failure developed neck
swelling after subclavian CVL placement
Courtesy Philip Chapman, MD
Jugular Vein Thrombosis
Neck & Airway EmergenciesVascular
Internal Jugular Vein Thrombophlebitis
20 year old female post removal of CVL 17 year old with sore throat, left neck swelling,
& respiratory distress
Neck & Airway EmergenciesVenous Thrombophlebitis
Courtesy C. Douglas Phillips, MD
Neck & Airway EmergenciesVenous Thrombophlebitis
17 year old with sore throat, left neck swelling,
& respiratory distress
Courtesy C. Douglas Phillips, MD
Neck & Airway EmergenciesVenous Thrombophlebitis
17 year old with sore throat, left neck swelling,
& respiratory distress
Courtesy C. Douglas Phillips, MD
Lemierre Syndrome
• Lemierre was a French
bacteriologist
• In 1936, published 20
cases of throat infections
followed by anaerobic
septicemia
• 18 patients died
• Septic thrombosis of facial,
EJ, or IJ veins following
suprahyoid neck infection
Neck & Airway EmergenciesLemierre Syndrome
Andre-Alfred Lemierre
1763-1820
Neck & Airway EmergenciesLemierre Syndrome
• Young patients
• Toxic, febrile (“picket fence”
fevers) 1 week post tonsillitis
• Fusobacterium necrophorum
• Neck tenderness
• May have respiratory distress
due to septic pulmonary
emboli from clot propagation
•Large joints 2nd most site of
emboli > septic arthritis
•Very high mortality
Courtesy Philip Chapman, MD
#1
#2
#3
Neck & Airway EmergenciesVascular
Carotid Artery “Blowout” (Pseudoaneurysm)
69 year old male 1 week post carotid endarterectomy
Neck & Airway EmergenciesVascular – Carotid “Blowout’
Patient post neck
dissection & XRT for SCCa
Courtesy Rebecca Cornelius MD
• Semi-contained
rupture/pseudoaneurysm
• Prior surgery, XRT >
carotid space infection,
vasculitis, trauma, tumor
invasion
• XRT damages vaso vasorum
• Can lead to exanguination,
emboli/ischemia
• Endovascular repair vs.
sacrifice
Neck & Airway EmergenciesSummary & Key Points
• CT is modality of choice for imaging of neck
emergencies
• Our role: Identify source, extent, & complications
• ? Orbital, intracranial, or thoracic spread
• ? Airway compromise, venous or arterial involvement
• Do not mistake RPS effusion for abscess
• Assess inferior extent of collections in the RPS & for
epidural extension if process involves the PVS
• Consider less common entities in the appropriate
setting
• Acute calcific prevertebral tendonitis, necrotizing fasciitis,
Lemierre syndrome
Thank You!
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