Kathleen R. Fink, MD Virginia Mason Medical Center. 6 th Nordic Emergency Radiology Course 2017

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1 Kathleen R. Fink, MD Virginia Mason Medical Center 6 th Nordic Emergency Radiology Course 2017

2 Disclosure My spouse has a financial relationship with a commercial organization that may have a direct or indirect interest in the content as follows: Guerbet

3 Outline Case-based review of head and neck infections: 1. Neck infection focusing on complications 2. Sinus infection 3. Orbital infection 4. Skull base infection

4 Neck infection Focusing on complications

5 CT: facial swelling and pain

CT: cellulitis Treated with antibiotics Soft tissue thickening (cellulitis) Submandibular space Stranding Sublingual space Thickening of mylohyoid muscle and

6 CT: cellulitis Treated with antibiotics Soft tissue thickening (cellulitis) Submandibular space Stranding Sublingual space Thickening of mylohyoid muscle and platysma (myositis) Subcutaneous edema and skin thickening No ring enhancing collection. If there is no enhancing mass or collection, the term cellulitis is appropriate

7 CT: One week later, worsened swelling

8 CT: Phlegmon/Abscess Low density collection with surrounding enhancement. Phlegmon: Enhancing inflammatory mass preceding abscess Abscess: Ring enhancing fluid. 10 ml pus aspirated

9 CT: companion case Phlegmon! No pus on I&D Pitfall: There is an imaging overlap between abscess and phlegmon

10 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 Vural, et al, Am J Otolaryngol 24:3, 143-8, Rosenthal et al, J Oral Maxillofac Surg 69:6,

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

12 CT: Maxillary teeth can also be involved.

13 Summary: 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 lucency Severe dental caries Evaluate bone changes for osteomyelitis: Permeative bone lesion Osseous destruction Periosteal reaction

14 CT: Sore throat and swelling

15 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

16 Striated tonsils: tonsillitis

17 CT: Sore throat * *

18 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

19 CT: Parapharyngeal space.

20 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)

21 Peritonsillar abscess Always look carefully at fat-containing parapharyngeal space with tonsillar infections

22 Peritonsillar abscess Definite extension into parapharyngeal space, masticator space, and carotid space

23 Peritonsillar abscess Definite extension into parapharyngeal space, masticator space, and carotid space Note mucosal edema of uvula and narrowing of oropharynx Consider infectious complications!

24 Neck Infection: Complications Thrombophlebitis Lemierre Syndrome Arteritis Mediastinitis

25 CT: Neck swelling after IVDA

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

26 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 Lin et al, Laryngoscope 114:1,

abscess, mastoiditis, other infections Metastatic abscesses - Lung abscess -

27 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,

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

29 Involves retropharyngeal space

30 Involves carotid space

32 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

33 Progressive dysphagia and sore throat

34 Involves multiple spaces: Pharyngeal mucosal space and parapharyngeal space Submandibular space Carotid space Retropharyngeal space Visceral space

35 Where does the collection end?

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)

36 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,

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

38 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 often without liquefaction Airway compromise is the main clinical concern.

39 Neck infection Imaging 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

40 Sinus infection Role of imaging

41 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, S

CT signs of acute bacterial sinusitis. Imaging findings correlating with acute bacterial sinusitis include: Sinus opacification Air-fluid level Moderate to severe mucosal thickening.

42 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. Rosenfeld et al. Otolaryngol Head Neck Surg 137:3 Suppl, S

43 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 Aribandi et al. Radiographics 27:5,

44 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

45 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. Mucormycosis

46 Fungal sinusitis, advanced Woman with CLL and facial pain

47 Fungal sinusitis: vascular complications Expanded nonenhancing left cavernous sinus Cavernous sinus thrombosis Loss of left cavernous carotid enhancement Carotid occlusion

48 Invasive fungal sinusitis: Hallmarks Early invasion Vascular invasion Venous thrombosis Arterial involvement Aneurysms Infarcts Basilar artery aneurysm due to sphenoid sinus aspergillus infection

49 Sinus Infection: complications Orbital extension Soft tissue extension (Pott s puffy tumor) Subdural empyema, epidural abscess Venous sinus thrombosis Intracerebral abscess

50 Companion case:

51 Complications: Orbital and Epidural extension T1 post T2 FLAIR T2

52 Epidural abscess Imaging: Stays in epidural space Adjacent brain usually appears normal Enhancing epidural collection Associated sinusitis/mastoiditis In this case, note extension From maxillary sinus (*) To subperiosteal space of the orbit (+) + *. To epidural space (arrow)

53 Complications: Subdural empyema and Potts puffy tumor H&N

54 Sinusitis Bacterial 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 sinusitis Hallmarks: bone erosion and involvement of adjacent fat planes

55 Orbital infection

56 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 beneath periosteum of bony orbit Stage 4 Orbital abscess Pus within the orbit Stage 5 Cavernous sinus thrombosis *Chandler et al The Laryngoscope 80:9,

57 Preseptal cellulitis: Pearl: Always look carefully retrobulbar fat * to determine post septal involvement. Reformats helpful. Preseptal Postseptal Matthew et al. Br J Radiol 87:1033,

58 Postseptal cellulitis Preseptal Postseptal

cause: Increased intraorbital pressure Central retinal artery or vein occlusion

59 Importance of post septal involvement: 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.

60 Importance of post septal involvement: Extraconal and intraconal involvement

61 Skull base infection

62 Otomastoiditis Fluid opacification of middle ear and mastoids Evaluate mastoid air cells for erosion: Coalescent mastoiditis (Not present here) Noncontrast head CT

Post contrast Complications include: Sigmoid

63 Evaluate for complications Low density epidural collection with gas Rim enhancing Noncontrast Post contrast Complications include: Sigmoid sinus thrombosis Empyema Subdural abscess Epidural abscess

64 Bezold abscess: Red swollen mass behind ear Abscess in soft tissues adjacent to mastoid tip, from rupture of otomastoiditis through mastoid bone T1 Post contrast F. von Bezold: Deutsche medicinische Wochenschrift, Berlin, 1885, 7:

65 Petrous Apicitis CT: Opacification of the petrous apex air cells May be coalescent MR: Fluid in air cells Remember, petrous apex is variably pneumatized. NECT T2 Normal comparison Case courtesy of Roberta Dalley, MD, Univ Washington

66 Petrous Apicitis T1 pre T1 post Enhancing material Case courtesy of Roberta Dalley, MD, Univ Washington

67 Gradenigo syndrome Petrous apicitis + T1 pre Clinical syndrome 1. Otomastoiditis 2. Deep facial pain (CN V) 3. Lateral rectus palsy (CN VI) T1 post Enhancing material Case courtesy of Roberta Dalley, MD, Univ Washington

68 Outline Case-based review of head and neck infections: 1. Neck infection focusing on complications 2. Sinus infection 3. Orbital infection 4. Skull base infection

69 Thank you! Kathleen Fink

11 May Disclosure. + Outline. Case-based review of head and neck emergencies: Kathleen R. Fink, MD University of Washington. 1.

11 May Disclosure. + Outline. Case-based review of head and neck emergencies: Kathleen R. Fink, MD University of Washington. 1. + Kathleen R. Fink, MD University of Washington 5 th Nordic Emergency Radiology Course May 21, 2015 + Disclosure My spouse receives research salary support from: Bracco BayerHealthcare Guerbet + Outline