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

Size: px

Start display at page:

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

Eleanor Small
5 years ago
Views:

1 + Kathleen R. Fink, MD University of Washington 5 th Nordic Emergency Radiology Course May 21, Disclosure My spouse receives research salary support from: Bracco BayerHealthcare Guerbet + 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 1

2 + CT: Dysphagia after eating chicken casserole last night Foreign body in esophagus. Are we done? Pearl: esophageal foreign body: looks for signs of perforation + + 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. 2

+ Foreign body: Aspirated insulin cap Patient with neurodegenerative disease arrived to ER, worried

surface so she would know what to look for.

disk/button battery Vital to diagnosis FB as battery due to possibility of erosive changes from:

3 + 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. + Pitfall: 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,

From: Lin, Daniel and Papsin Int J Pediatr

Differentiating battery from coin can be

4 From: Lin, Daniel and Papsin Int J Pediatr Otorhinolaryngol 68:4, Differentiating battery from coin can be difficult. Raise the possibility! Look for double ring sign. + Foreign body Helpful 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 4

mylohyoid muscle and platysma (myositis)

5 + 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 5

+ CT: Phlegmon/Abscess Low density collection with surrounding enhancement.

Here: Aspirated 10 ml pus + CT: companion case Phlegmon!

cellulitis/phlegmon from abscess Important distinction because abscess requires surgical I&D but cellulitis/phlegmon

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

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

7 + 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 7

8 + 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 8

+ CT: Tonsillar abscess Findings: Low density well circumscribed collection in palatine (faucial) tonsil Fat stranding in parapharyngeal space but no frank

+ CT: Tonsillar versus peritonsillar abscess Tonsillar abscess versus peritonsillar abscess terminology used loosely!

9 + 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) 9

+ Peritonsillar abscess Pearl: Always look carefully at fat-containing parapharyngeal

parapharyngeal space, masticator space, and carotid space Note mucosal edema of uvula

+ Peritonsillar abscess Definite extension into 10

10 + Peritonsillar abscess Pearl: Always look carefully at fat-containing parapharyngeal space with tonsillar infections + Peritonsillar abscess Definite extension into parapharyngeal space, masticator space, and carotid space Note mucosal edema of uvula and narrowing of oropharynx Consider infectious complications! + Peritonsillar abscess Definite extension into parapharyngeal space, masticator space, and carotid space Note mucosal edema of uvula and narrowing of oropharynx Consider infectious complications! 10

+ Neck Infection: Complications Thrombophlebitis Lemierre Syndrome

Complications: thrombophlebitis Because of antibiotic therapy, septic

infections Certain risk factors Intravenous drug use Central venous

11 + 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 Lin et al, Laryngoscope 114:1,

+ Complications: Pulmonary abscesses Lemierre syndrome (postanginal septicemia or necrobacillosis) Originally reported after odontogenic, tonsillar or peritonsillar abscess, mastoiditis, other

12 + 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 Increasingly rare due to antibiotic treatment Lemierre, Lancet 227:5874, Several days of progressive left ear pain, neck stiffness and developing area of redness over left neck and ear. Involves retropharyngeal space 12

Involves carotid space * * + Complication: Carotid artery pseudoaneurysm Pseudoaneurysm is a rare but potentially life threatening complication of

13 Involves carotid space * * + 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 13

14 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? 14

+ Complications: Mediastinitis Uncommon but important complication

Retropharyngeal space extends from skull base to mediastinum (T3

to recognize to allow early debridement, which requires

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

Returned to ED with progressive swelling and taken urgently to OR

the floor of mouth, usually of odontogenic origin Hallmarks:

15 + 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, Right mandibular pain, treated with antibiotics. Returned to ED with progressive swelling and taken urgently to OR * + 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. 15

+ 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

16 + 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 + 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. 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

+ Sinus infection: fungal Multiple subtypes: Invasive Acute invasive fungal sinusitis Chronic invasive fungal sinusitis Chronic granulomatous invasive fungal sinusitis (rare in US) Noninvasive

17 + Sinus infection: fungal Multiple subtypes: Invasive Acute invasive fungal sinusitis Chronic invasive fungal sinusitis Chronic granulomatous invasive fungal sinusitis (rare in US) Noninvasive Allergic fungal sinusitis Fungal mycetoma Aribandi et al. Radiographics 27:5, 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. Mucormycosis 17

+ Fungal sinusitis running amok Woman with CLL and

Expanded nonenhancing left cavernous sinus Cavernous

enhancement Carotid occlusion + Invasive fungal

Venous thrombosis Arterial involvement Aneurysms

18 + Fungal sinusitis running amok 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 18

19 + Sinus Infection: complications Orbital extension Soft tissue extension (Pott s puffy tumor) Subdural empyema, epidural abscess Venous sinus thrombosis Intracerebral abscess + Complications: Orbital and Epidural extension T1 post FLAIR T2 + Complications: Subdural empyema and Potts puffy tumor Fink: 5th Nordic Course in Emergency Radiology 19

20 + 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 + 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 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,

+ Preseptal cellulitis: * Pearl: Always look carefully

Reformats helpful. Preseptal Postseptal From: Matthew et al.

2014 Preseptal: Cellulitis limited to eyelid and periorbital

+ Postseptal cellulitis Preseptal Postseptal + Importance of

from sinus disease, particularly from ethmoids through lamina

21 + Preseptal cellulitis: * Pearl: Always look carefully retrobulbar fat to determine post septal involvement. Reformats helpful. Preseptal Postseptal From: Matthew et al. Br J Radiol 87:1033, Preseptal: Cellulitis limited to eyelid and periorbital soft tissue. + Postseptal cellulitis Preseptal Postseptal + 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. 21

nerve head + Choroidal hemorrhage Choroidal hemorrhage/detachment - Hyperdense material in

22 + 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. 22

+ Vitreous hemorrhage/globe rupture Hyperdense material in the vitreous chamber.

Be aware: some retinal reattachment procedures can result in an appearance of vitreous hemorrhage.

Lens dislocation Occurs with disruption of zonular fibers of ciliary body Dislocation usually posterior If bilateral,

23 + 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 reattachment 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 abnormalities Infection: 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! 23

mastoids Antibiotics have dramatically decreased the

Coalescent mastoiditis: Erosion of mastoid air cells.

the neck, usually through erosion through the

e3-4 2013 + Mastoiditis: Same patient: associated

24 + 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.e Mastoiditis: Same patient: associated gas in epidural space. Contrast clearly demonstrates the associated epidural abscess 24

+ Mastoiditis: Complications Complications

Complications Pearl: Always remember to check

Frank cerebral abscess Left transverse and

25 + Mastoiditis: Complications Complications include: Sigmoid sinus thrombosis Empyema Subdural abscess Epidural abscess Luntz Laryngoscope 122:12, Mastoiditis: Complications Pearl: Always remember to check venous sinuses! Frank cerebral abscess Left transverse and sigmoid sinus thrombosis + Mastoiditis Often treated before complications occur. Evaluate for Intracranial extension Venous sinus thrombosis Extracranial soft tissue extension (Bezold abscess) 25

26 + 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 Fink Hard rain comes down on the University of Washington, Seattle campus. February 18th, Photo by Katherine B. Turner 26

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

Kathleen R. Fink, MD Virginia Mason Medical Center 6 th Nordic Emergency Radiology Course 2017 Disclosure My spouse has a financial relationship with a commercial organization that may have a direct or