Nontraumatic Head and Neck Injuries: a Clinical Approach. Part 2 183
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Radiología. 2017;59(3):182---195
www.elsevier.es/rx
UPDATE IN RADIOLOGY
Nontraumatic head and neck injuries: A clinical
ଝ approach. Part 2
∗
B. Brea Álvarez , L. Esteban García, M. Tunón˜ Gómez, Y. Cepeda Ibarra
Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
Received 3 May 2016; accepted 16 February 2017
KEYWORDS Abstract Nontraumatic emergencies of the head and neck represent a challenge in the field of
Emergencies; neuroradiology for two reasons. As explained in the first part of this update, these entities affect
Neck injuries; an area where the thorax joins the cranial cavity and can thus compromise both structures;
Orbital diseases; second, they are uncommon, so they are not well known.
Diseases of the Maintaining the same approach as in the first part, focusing on the clinical presentations in the
paranasal sinus; emergency department rather than on the anatomic regions affected, we will study the entities
Sialadenitis; that present with two patterns: those that present with a combination of cervical numbness,
Cellulitis; dysphagia, and dyspnoea and those that present with acute sensory deficits. In the latter group,
Diagnostic imaging; we will specifically focus on visual deficits, because this is the most common symptom that calls
Computed for urgent imaging studies.
tomography; © 2017 SERAM. Published by Elsevier Espana,˜ S.L.U. All rights reserved.
Magnetic resonance
imaging
PALABRAS CLAVE Urgencias no traumáticas de cabeza y cuello: aproximación desde la clínica. Parte 2
Urgencias;
Resumen Las urgencias no traumáticas de cabeza y cuello son un reto en el campo neurorra-
Lesiones del cuello;
Enfermedades diológico por los motivos referidos en la primera parte: su área de afectación, en la encrucijada
orbitarias; del tórax y la cavidad craneal, y su baja incidencia en la urgencia, lo que supone que sean poco conocidas.
Enfermedades del
Manteniendo el mismo enfoque que en la actualización previa, a partir de las formas clínicas
seno paranasal;
Sialadenitis; de presentación en el ámbito de la urgencia, en lugar de la división por regiones anatómicas
ଝ
Please cite this article as: Brea Álvarez B, Esteban García L, Tunón˜ Gómez M, Cepeda Ibarra Y. Urgencias no traumáticas de cabeza y
cuello: aproximación desde la clínica. Parte 2. Radiología. 2017;59:182---195. ∗
Corresponding author.
E-mail address: [email protected] (B. Brea Álvarez).
2173-5107/© 2017 SERAM. Published by Elsevier Espana,˜ S.L.U. All rights reserved.
Nontraumatic head and neck injuries: A clinical approach. Part 2 183
estudiaremos las entidades que se presentan con patrones que combinan tumefacción cervical,
Cellulitis; disfagia y disnea, y los déficits agudos de los sentidos. Dentro de este último grupo, el síntoma
Imagen diagnóstica; al que haremos referencia específica será el déficit visual, puesto que es el que de forma más
Tomografía frecuente requiere estudio radiológico urgente.
computarizada; © 2017 SERAM. Publicado por Elsevier Espana,˜ S.L.U. Todos los derechos reservados.
Resonancia Magnética
Introduction performing one cervical computed tomography (CT) scan
including the carina and even the whole thoracic cav-
ity. The anatomic continuity of retropharyngeal spaces
Nontraumatic head and neck emergencies take over a small
(retropharyngeal space and danger space) up to the lower
portion of the routine radiological day; however, they are
1 mediastinum allow the spread of cervical processes towards
very important. As Brucker et al. claim, this anatomic
the thorax. The use of one single X-ray might be applica-
region contains few structures that can be dispensable. After
ble in cases of young individuals with sudden onsets of this
analyzing the images and taking the clinical data into con-
clinical combination and associated cervical crepitus to be
sideration, the role of the radiologist should be defining the
able to rule out a clinical manifestation as uncommon as
location and spread of the processes, identifying all those
spontaneous emphysema.
radiological signs indicative that the patient might be vitally
In sensory deficits only the visual deficit is included. Taste
compromised, or that might condition his/her treatment,
and smelling deficits will not be studied here because they
and establishing differential diagnosis.
are not as invalidating as the visual deficit, and for the
As we said in Part 1, in most papers, emergencies are
patient they are not as alarming as to go to the emergency
classified according to the region affected by the patholog-
room. Sudden hearing loss usually occurs within a 12 hour-
ical process, but since the patient presents to the hospital
3
span and implies the loss of ≥30 dB as confirmed in at least
with clinical symptoms or signs, an approach from this point
three frequency tests conducted during the first 72 h. It has
of view is interesting. In this review, we will be dealing with
a powerful impact in the patient’s life, above all in associa-
how radiological management is accomplished, and with the
tion with tinnitus and vertigo, occurring in 90 and 20---60% of
clinical characteristics of those entities that present with
4,5
cases, respectively. Its study in the acute phase requires
combined clinical manifestations of cervical tumefaction,
performing one otoscopy and one audiometry in order to
dysphagia, and diarrhoea, and we will also be dealing with
rule out any underlying causes and confirm its diagnosis,
those patients who present to the hospital with acute sen-
and all this is the responsibility of the ENT unit. Although
sory deficits.
included in the diagnostic armamentarium of this entity,
However, this paper will not deal with all the possible
the magnetic resonance imaging (MRI) is never performed
emergency entities that have such clinical manifestations.
in emergent situations.
This is why we chose the most common ones, tried to estab-
lish differential diagnoses, set the record straight on some
concepts and, same as we did in Part 1, emphasized the
Cervical tumefaction and dysphagia-dyspnoea
clinical manifestations that are less common but with char-
acteristic radiological images that will help the radiologist
Abscesses of the oral cavity and the mouth floor
achieve a correct diagnosis yet despite the rarity of such
clinical manifestations.
6
Most head and neck infections have an odontogenic origin.
The dental inflammatory disease may have an endodontal or
Nosological division and imaging modalities periodontal origin. The origin of endodontal infections may
be found in one dental cavity that progressively destroys
There are four clinical situations in nontraumatic head and the dentine, then the dental pulp, and ultimately the den-
neck emergencies: cervical tumefaction cervical, dyspha- tal nerve canal. This is how the infection reaches the dental
gia, dyspnoea, and sensory deficit. The causes responsible apex while making up one granuloma or apical abscess. In
for these clinical presentations may be of inflammatory- the periodontal disease, the infection starts as gingivitis that
2
infectious, tumour or vascular origin. In this Part 2 we will progresses along the periodontal ligament while making up
be looking into those clinical manifestations that combine one periodontal abscess. From the radiological standpoint,
facial tumefaction, dysphagia, and dyspnoea, as well as sen- apical or periodontal abscesses look like radiolucent cavities
sory deficits. surrounding the tooth. The abscess may rupture the max-
The combination of cervical tumefaction, dysphagia, illary or mandibular cortical bones and depending on the
and dyspnoea is not rare. It has been reported in oral dental piece affected, progress following variable location
cavity-mouth floor infections, Ludwig’s angina, necrotiz- and spread.
7
ing fasciitis, in collections of retropharyngeal abscesses, Infections that originate in the maxillary bone may
and spontaneous emphysemas. These situations require spread towards the mouth, the masticator space or the
184 B. Brea Álvarez et al.
Figure 1 Abscesses of the oral cavity. Abscess in the oral vestibule space. (A) Computed tomography (CT) scan, axial cut recon-
structed in bone window. (B) CT scan, sagittal reconstruction in bone window. (C) CT scan, axial cut reconstructed in soft tissues.
Female with clinical manifestations of neuralgia and anterior facial tumefaction. The CT scan shows periodontal affectation in the
premaxillary region (arrows in A and B), dental pieces #21 and #22---showing metallic material due to prior endodoncy---in the form
of periapical abscess with phlegmonous affectation of the oral space and the vestibule (short arrows in C). Submandibular abscess.
(D) CT scan, coronal cut with intravenous (IV) contrast. (E) CT, oblique axial reconstruction in bone window. (F) CT scan, axial
with IV contrast. Sixty-two year old-male with left submandibular pain. In the CT scan there was one collection with peripheral
enhancement (abscess) in the left mouth floor (asterisk in D and F). The infectious focus was located in dental piece #38 (arrow in
E) showing one periapical abscess with dehiscence of the lingual cortex.
parapharyngeal space, depending on whether the patho- Dental Federation (WDF) that numbers teeth as 11---18,
logical pieces are located in the pre-maxillary region, or 21---28, 31---38 and 41---48, the corresponding pieces to the
the second or third molars, respectively. In infections of right and left maxillary dental arches, and the left and right
mandibular origin, the inflammatory processes of the ante- mandibular dental arches, respectively, starting from the
rior dental pieces are found in the sublingual space, and first incisive until the last molar in each of the quadrants.
when infections affect the second and third molars, the Nomenclature from the World Dental Federation (WDF)
inflammatory processes will be found in the submandibular numbers dental pieces from 1 to 32, starting from the right
space, since the roots of these molars are located under- upper arch third molar and continuing successively with the
8,9
neath the mylohyoid line. remaining quadrants following the WDF system.
Other than for dental abscess identification, CT scans
also confirm the presence of fluid collections with periph-
eral enhancement. The location and spread of these fluid Ludwig’s angina
collections should appear in the radiological report since
this is essential to guide surgical drainage. Also, the It is a specific and serious type of cellulitis occurring in the
affected dental piece should be identified (Fig. 1). The mouth floor and spreading bilaterally towards the soft tis-
nomenclature used to define the affected tooth speaks sues of the oral cavity and deep spaces of the neck, and at
of its name (incisive, canine, premolar, and molar) and the same time it implicates the muscles located between the
10
location at the quadrant of the mouth (upper: right or mouth floor and the larynx (Fig. 2). Clinically, it presents
left, lower: right or left). Following one numerical pattern, as pain and tumefaction at the mouth floor and can asso-
the most widely used method in Spain is that of the World ciate chest pain. Before the era of antibiotics, the spread
Nontraumatic head and neck injuries: A clinical approach. Part 2 185
Figure 2 Ludwig’s angina. (A) Computed tomography (CT) scan, coronal cut with intravenous contrast. (B) CT scan, axial cut with
IV contrast. Eighteen-year old patient who presented with odynophagy and (dis) thermal sensation of three day duration. During
the medical examination, he had difficulties opening his oral cavity and showed over-elevation of his tongue. The image confirmed
an increase in the fat density of submandibular and parapharyngeal spaces (arrows in A and B). (D---H) CT scan with IV contrast in
a different patient (C) who presented to the hospital with cervical tumefaction. (D) Sagittal cut. (E and G) Axial cuts. (F) Coronal
cut. (H) Oblique sagittal reconstruction. At the beginning (C---E), the CT scan showed an increase of fat density and trabeculation in
the submandibular space (arrow) associated with small collections in the mouth floor (arrowheads). The patient is admitted to the
hospital with a diagnosis of Ludwig’s angina and IV antibiotic therapy. The patient worsens and another CT scan is performed (F-H)
showing fluid collections (long arrows) in the mouth floor with clear oversize with respect to the initial study. Affectation spread
along the digastric muscle posterior stomach (curved arrow in G and dotted line in H), which was oversized (compare with the left
side one, black curved arrow). Drainage showed seropurulent content.
of this process towards the mediastinum was far more com- In the CT scan, the radiological signs that help us estab-
mon and, therefore, responsible for the denomination given lish its diagnosis are the evidence of cellulitis, fasciitis,
to this entity. It may affect the airways and require tra- myositis, multiple collections, reactive adenopathies, and,
11
cheostomy more commonly than other cervical abscesses. on some occasions, septic thrombosis (Fig. 3). The presence
The CT scan is used to assess the spread of inflammatory of gas (in the absence of recent surgery or radiotherapy) is a
process, the presence of blood collections, or the formation highly suggestive finding of this entity, though this does not
12,13 17
of abscesses that can occur in some cases. occur in all cases.
Necrotizing fasciitis Spontaneous emphysema
Necrotizing fasciitis is one aggressive polymicrobial infec- The spontaneous cervical emphysema is defined as the
tion of the superficial and deep soft tissues of the neck presence of gas in cervical and mediastinal spaces that
usually occurring in patients with comorbid situations like is produced spontaneously in young adults and that is of
18
diabetes or immunosuppression. Infection can occur in the self-limiting an benign character. Clinically, it appears as
skin, the mucosa or the teeth, progress rapidly and reach the an intense sudden retrosternal pain associated with dysp-
14
mediastinum and compromise the life of the patient. Clin- noea of sudden onset. There is no relation whatsoever with
ically, patients show symptoms of cervical tumefaction and iatrogenia, trauma or infection. The underlying physiopa-
dysphagia-dyspnoea associated with high fever. There are thological mechanism is pressure increase in alveoli (caused
certain lab indicators of risk for developing necrotizing fasci- by multiple etiologies: cough, Valsalva, etc.) that causes its
15
itis based on routine lab tests. Such indicators are used to rupture. The air progresses in a centripetal motion towards
distinguish this entity from other less aggressive infections the mediastinum since there is less pressure there. From
of soft tissues in order to be able to early implement the the radiological standpoint, there are air bubbles of ran-
16
treatment of choice: emergent surgical debridement. dom distribution both in the different cervical spaces and
186 B. Brea Álvarez et al.
Figure 3 Necrotizing fasciitis. (A) Sagittal computed tomography (CT) with IV contrast. (B---D) Axial CT scan with IV contrast at
different cervical levels. Seventy-four year old-patient who presents to the ER with clinical manifestations of dyspnoea, odynophagy,
and fever. The patient is then referred to the ENT who confirms saturation levels at 87% and triage and retractions. The image
shows thickening of the skin and the subcutaneous cellular tissue---celulitis (arrow in D), thickening and enhancement of superficial
and deep fascias---fascitis (arrowhead in D), thickening and enhancement with fluid collections of prelaryngeal muscles---miositis
(discontinuous arrow in D), swelling of the pharyngeal mucosal space (black arrows in B), and swelling of the whole retropharyngeal
space (dashed line in A and B) spreading towards the mediastinum (asterisk in C). Also, there was presence of gas (curved arrow in
D) and right pleural effusion (arrow in C).
the mediastinum (Fig. 4A and B). We should distinguish here the upper mediastinum. There is another virtual space,
between Boerhave’s syndrome and esophageal rupture sec- posterior to the retropharyngeal one, called danger space
ondary to vomit --- one clinical manifestation associated with that connects to the posterior mediastinum and descends
greater morbimortality that requires surgical management. towards the lower part of the thoracic cavity. The distinc-
The spontaneous emphysema should not be confused with tion between these spaces at cervical level is not possible
the presence of small quantities of air in the cervical spaces and it is its caudal spread that defines if the inflamma-
that can be incidentally observed in CT scan (Fig. 4C). It has tory process occurs in one or the other (spread beyond
been reported in 0.034% of CT scans of the brain performed T3 would be indicative of danger space affectation). The
in the emergency room to patients with one peripheral implication of any of these spaces is usually secondary to
19
route considered the air access point. The location of an infection originated in the upper aerodigestive tract,
the air bubbles happens at random; it is more common in whose pattern of lymphatic drainage is in the nodes of
the orbital veins, the masticator space, or the cavernous the retropharyngeal space. The infectious process promotes
sinuses. Patients with this finding do not have a history of adenitis and inflammatory changes in the adjacent tissue.
trauma or other relevant data. Adenitis manifests itself as an oversized lymphatic node.
The inflammatory affectation of the adjacent soft parts or
cellulitis appears radiologically as a symmetrical increase
Retropharyngeal and pre-vertebral infection of the retropharyngeal space that is occupied by a layer
The retropharynx or posterior space to the pharynx is a vir- of fluid that is usually no thicker than a few millime-
tual space that spreads from the base of the skull towards tres (Fig. 5A---C). Poorly treated adenitis usually suppurates,
Nontraumatic head and neck injuries: A clinical approach. Part 2 187
Figure 4 Spontaneous cervical emphysema. (A) Simple lateral X-ray. (B) Computed tomography (CT) scan with coronal recon-
struction. (C) Axial CT scan. (A and B) Spontaneous neumomediastinum in one young patient who presents to the ER with clinical
manifestations of retrosternal pain, sensation of dyspnoea, and odynophagy after choking. There is presence of cervical emphysema
(arrows) spreading towards the mediastinum---a very recognizable finding in the simple X-ray. The CT scan was performed in order
to distinguish it from Boerhave’s syndrome. (C) CT scan of the brain of one patient with suspicion of stroke who is a carrier of
one peripheral route. In the image there was presence of air in the masticator space (white arrows), in the anterior fascial vein
(arrowhead), in the epidural space, in anterior portion of the foramen magnum (discontinuous arrows).
ruptures and originates abscesses. In this situation, there is X-ray, the pathognomonic signs, and after observing in one
a greater fluid collection that happens to be asymmetric and CT scan, the presence of dense image calcifications (not
17
with variable parietal enhancement (Fig. 5D and E). Suppu- bony) in the pre-vertebral-retropharyngeal space at C1---C2
rated adenitis represents a relatively common complication level, associated with soft tissue swelling, that spreads from
21,22
of secondary formation of retropharyngeal abscesses in cervical level of C1 to C4.
children.
The pre-vertebral space is that space defined by the
deep cervical fascia where pre-vertebral musculature can Sensory deficit
be found. The infectious process of the spine, spondylodisci-
tis, may reach this space and are usually responsible for The acute loss of eyesight is studied by taking two factors
13,20
its affectation. Spondylodiscitis occurs due to direct into consideration: for how long has the loss been hap-
inoculation (traumatic or surgical), spread of an adjacent pening, and what is the segment responsible for the visual
infection or due to the hematogenous dissemination of system.
pathogen germs. The most common causal agent is Staphy- The duration of the visual loss may be transient or persis-
lococcus aureus and it is usually located in the thoracic tent. The transient duration is defined as a visual loss lasting
or lumbar regions. The MRI is the most sensitive imaging less than 25 h and usually due to one vascular occlusion
modality for its study since it accurately defines spinal disc affecting the eyeball or the visual cortex, or being secondary
affectation and all possible pre-vertebral or epidural collec- to epileptic seizure or migraine. Persistent visual losses last
tions (Fig. 6). more than 24 h and are usually due to transient ischaemias.
There exists a rare entity, probably because it is misdi- Whichever the duration of the visual loss is, it should be
agnosed, called calcific tendonitis of the longus colli muscle assessed by one ophthalmologist, who, if necessary, will
(Fig. 7) that can also implicate the pre-vertebral space too. be conducting imaging modalities for diagnostic purposes.
It is caused by the deposit of calcium hydroxyapatite in the The transient visual loss or unilateral amaurosis fugax is
tendon of the long muscle of the neck (longus colli mus- suspicious of a carotid origin as the cause for the arterial
cle). This anomalous deposit originates one inflammatory occlusion. In this case, we should conduct one Doppler ultra-
response to foreign bodies. The diagnosis of this clinical sound, one angio-CT scan, or one angio-MRI. The loss of
manifestation is achieved after observing, in one simple bilateral vision, above all in the elderly, is associated with
188 B. Brea Álvarez et al.
Figure 5 Infection of the retropharyngeal space. (A) Magnetic resonance imaging (MRI), sagittal cut T2-weighted imaging with fat
saturation. (B) MRI, axial T2-weighted imaging. C) Computed tomography (CT) scan, axial cut. (D) CT scan, sagittal reconstruction
after the administration of IV contrast. (E) CT scan, axial cut after the administration of IV contrast. (A---C) Female with cervical
pain, fever, and odynophagia. In the MRI we saw hypertrophy of the mucosal space of pharyngeal tonsils---amigdalitis (white arrows
in A and B), one left retropharyngeal adenitis (black arrow in B), and retropharyngeal swelling (celulitis) (dashed line in A and
C). Swelling grows bilaterally in the retropharyngeal space and barely distends to space of a few millimetres. (D and E) Fifteen
year old-female diagnosed with mononucleosis who presents with high fever, significant odynophagia, and trismus. The CT scan
confirmed the presence of one asymmetric fluid collection with peripheral enhancement in the retropharyngeal space, suggestive
of an abscess (dashed line arrow), that was confirmed after aspiration and drainage.
vertebrobasilar symptoms and requires performing one CT common neural visual patterns in our daily radiological rou-
scan and/or one MRI for the assessment of the encephalic tine which, though rare, can be interpreted to then maybe
parenchyma and the vascular structures of posterior circu- establish the correct diagnosis (Table 1).
lation.
If we study the visual segment responsible for the visual
loss, we should remember that the luminous stimulus should Inflammatory optic neuritis and acute ischaemic optic
run across the different components of the eyeball, continue neuritis
along the optic nerve, then the intracranial visual pathways, The clinical manifestations of inflammatory optic neuritis
to eventually reach the occipital cortex. Therefore, this (ION) and acute ischaemic optic neuritis (AION) are well
condition may be divided into three different segments: the established. The ION is the most common cause of optic
eyeball (except for the retina), the retina and neural visual nerve disease in young adults, while the AION is the most
patterns. rare aetiology in the elderly.
The alterations in the eyeball and the retina are assessed ION is characterized by a progressive loss of visual acuity,
by ophthalmologists, and such alterations do not usually and can occur in a matter of hours or days, and the follow-
require any additional images. It is the issues in the neural ing are very characteristic presentations: dyscromatopsia,
23
patterns that may require additional radiological studies. reduced sensitivity to contrast, and pain with eye move-
Setting the amaurosis fugax aside (except for the image ments during the first 5 days. Visual acuity improves in most
of ischaemic optic neuritis to be able to distinguish it from cases during the first month. Patients are usually young
inflammatory optic neuritis), we wanted to use this review women in their twenties or forties, and in many times it
24---26
to talk about all those clinical manifestations of the most is associated with multiple sclerosis.
Nontraumatic head and neck injuries: A clinical approach. Part 2 189
Figure 6 Spondylodiscitis. (A and B) Lateral X-ray of the spine. (C) Magnetic resonance imaging (MRI), T2-weighted sagittal cut.
(D) MRI, T1-weighted sagittal cut enhanced with gadolinium. (E and F) MRI, T1-weighted axial cuts enhanced with gadolinium at
C2 level (E) and C6 level (F). Patient presents with neck pain and undergoes ones lateral X-ray (A). The X-ray shows reduction of
intervertebral spaces and mild erosion of C5---C6 and C6---C7 discs that is interpreted as degenerative changes. Twelve (12) days
later the patient presents to the hospital with more intense pain. Another X-ray is performed (B) that confirms clear progression
with loss of height in vertebral bodies C5 and C6 and greater enhancement of pre-vertebral space (double arrow in B). Since
spondylodiscitis was suspected, one MRI is performed that confirms such condition as well as the existence of one pre-vertebral
collection (long arrows in C) with intense enhancement after the administration of gadolinium (arrowheads in D and F). There was
also one collection in the epidural space (dashed line in D). In the location of greater affectation, that is segment C5---C6, there was
an oversized pre-vertebral musculature with increased uptake (black curved arrows in F) that was not present in upper levels like
C2 (white curved arrows in E).
AION is characterized by a sudden loss of visual acuity or In the arteritic variants of AION, we should rule out
by a campimetric defect, usually painless with eye move- giant cell arteritis (GCA). This disease is the most com-
ments. Forty two per cent of patients notice some visual mon systemic vasculitis. It may cause anterior or posterior
27
defect when they wake up. The loss of visual acuity is affectation of the optic nerve. The visual loss usually hap-
maintained though time, though it may improve during the pens in one eye and is transient, yet in 15---20% of the
first 6 months. These patients are usually above 50 years old cases it can be permanent or bilateral; the latter clini-
and associate cardiovascular risk factors. AIONs are divided cal manifestations are more common if diagnosis is not
into anterior, those affecting the optic nerve papilla, poste- achieved or early treatment with corticoids is adminis-
rior or retrobulbar. They may be of arteritic or nonarteritic tered. This entity is suspected in elderly patients, with
origin. visual loss in one eye that characteristically associate clau-
However, even though there are different clinical mani- dication of the jaw, rheumatic polymyalgia, and elevated
festations between both entities, there are times that these values of C-protein and speed of sedimentation. From the
characteristics overlap, and then additional imaging modali- pathogenic standpoint, this condition affects the aorta, the
28
ties are necessary to help us achieve the correct diagnosis. supra-aortic vessels, and the epicranial superficial arteries
In the ION an enlarged optic nerve may be seen in the emer- like the superficial temporal artery and the occipital artery.
29
gent/urgent CT scan of the brain, although there is no The biopsy with histopathological analysis confirming the
doubt that the MRI is the most sensitive imaging modality presence of one granulomatose and lymphocytic inflamma-
to help us distinguish between these two entities. Added tory affectation of the arterial wall is the best diagnostic
to the possible enlargement of the optic nerve, this modal- test. However, there are studies that show that the high-
ity may also show contrast uptake in the T1-weighted image resolution MRI with contrast can be a promising noninvasive
30 32
with gadolinium, and hypersignal and poor definition in the diagnostic technique. With this modality we can see thick-
T2-weighted image of the optic nerve in the ION (Fig. 8A and ening and enhancement after the administration of contrast
B). In the AION, the optic nerve shows normal thickness, yet at parietal-periadventitial level in the superficial and occip-
33
it may show hypersignal diffusion at optic nerve papilla level ital temporal arteries. Affectation of intracranial arteries
(in the anterior variants) more commonly than in the cases has also been reported, such as affectation of the inter-
31
of ION (Fig. 8C---E). nal carotid artery and vertebral arteries, but compared to
190 B. Brea Álvarez et al.
Figure 7 Calcific tendonitis of the longus colli. (A) Magnetic resonance imaging (MRI), sagittal cut T1-weighted imaging. (B) MRI,
sagittal cut T2-weighted imaging. (C) MRI, axial cut T2-weighted imaging with fat saturation. (D) Computed tomography (CT) scan,
sagittal reconstruction in bone window. Patient presents with neck pain. One MRI was performed that confirmed pre-vertebral space
swelling (arrow in B and dashed silhouette in C). Also, there was significant hyposignal anterior to the odontoid apophysis (dashed
arrow in A and B) that in the CT scan was confirmed as a deposit of calcium (dashed arrow in D).
Table 1 Differential diagnosis of the entities responsible for visual deficit.
Entities Epidemiology Clinical Findings Progression
manifestations
ION ♀ 20---40 years old Loss of visual acuity Oversizing and Improvement
in hours or days. alteration of optic during the first
Dyscromatopsia. Pain nerve month. 25% MS
AION >50 years old 42---73% show visual Optic nerve of normal Persistent visual
Cardiovascular risk defects when waking size loss (>6 months)
factors up. Absence of pain Reduced ADC
OID >50 years old Early signs of pain Inflammatory Improves with
and diplopia affectation of the cortocoids. Assess
covers/layers of the possible IgG4
eye, orbital fat, disease
lacrimal gland
Scleritis, uveitis At any age Pain and visual loss ULT: Identifies an It may progress
increased into
echogenecity of the endophtalmitis
covers/layers of the
eye
Infectious orbital At any age Swelling, headache Sinus occupation Antibiotics or
disease surgery: this is
how most cases
resolve
ADC: apparent diffusion coefficient; ULT: ultrasound; OID: orbital idiopathic inflammatory disease; MS: multiple sclerosis; ION: inflam-
matory optic neuritis; AION: acute ischaemic optic neuritis.
Nontraumatic head and neck injuries: A clinical approach. Part 2 191
Figure 8 Optic neuritis. (A) Computed tomography (CT) scan of the brain, axial cut. (B) Magnetic resonance imaging (MRI), coronal
cut, T2-weighted imaging with fat saturation. Twenty-three year old-female who presents to the hospital with visual loss and pain
in her right eye. The CT scan confirms an increased calibre of the optic nerve (arrow in A). The MRI better defines oversized optic
nerves showing hypersignal and poor definition of bulbar covers (arrow in B). Acute ischaemic optic neuritis. (C) CT scan of the
brain, axial cut. (D) MRI, axial cut T2-weighted imaging with fat saturation. (E) MRI, axial cut diffusion-weighted imaging. Sixty-two
year old patient presents to the ER with visual loss in left eye. The CT scan of the brain did not show any significant alterations at
encephalic parenchyma or orbital levels. In the MRI, the optic nerve showed normal thickness and definition. The diffusion-weighted
imaging, however, showed hypersignal in the left optic nerve papilla (arrow in E).
the high sensitivity and specificity of extracranial vessels, this entity: serum IgG4 levels >135 mg/dL, over 40% IgG4
34
sensitivity to intracranial affectation is low. positive plasma cells, and presence of over 10 cells per
high-magnification field in the biopsy sample. In the field of
Orbital idiopathic inflammatory disease neuroradiology, at orbital level it is expressed as an over-
Like we mentioned in Part 1, under this epigraph we find sized lacrimal gland or inflammatory pseudotumor, or as
conditions causing acute orbital inflammation usually asso- hyperthrophic pachymeningitis. As an inflammatory pseudo-
ciated with pain with no infectious aetiology. Hence, in this tumor it can give rise to coronal or extracoronal masses,
nosological group we find entities such as Wegener’s granulo- but we should not forget that most inflammatory pseudo-
matosis, GCA, inflammatory pseudotumor, and IgG4-related tumors are not part of the clinical spectrum of IgG4. The
disease. They appear as inflammatory or oversized soft tis- oversized calibre of trigeminal nerve branches, especially
sues masses and poor definition of the eye structures, which the infraorbital nerve, is one piece of information that is
36,37
poses differential diagnosis with other conditions such as typical of this entity. There are studies that claim that
orbital cellulitis or dysthyroid orbitopathy (Table 2). inflammatory pseudotumors as somehow associated with the
IgG4-related disease is one relatively recent entity IgG4-related disease of the trigeminal nerve in the form of
denomination. It is characterized by elevated concentra- soft tissue masses that are homogeneously enhanced and
tions of serum IgG4 and tissue tumefaction or infiltration affect the base of the skull along the trigeminal V2 and V3
due to IgG4 positive plasma cells. In the histological study divisions.
we can see several IgG4 positive plasma cells, fibrosis, and The diagnostic criteria of the different entities respon-
obliterative flebitis. It is an autoimmune disease that usu- sible for orbital idiopathic inflammatory disease (OID) are
ally progresses during long periods of time, affecting one established based on clinical, analytical and anatomopatho-
or several organs, and usually responding to corticoids. In logical data. In images, inflammatory injuries with more
35
2010, Umehara et al. established the diagnostic criteria of or less characteristic locations depending on the entities,
192 B. Brea Álvarez et al.
Figure 9 Orbital idiopathic inflammatory disease due to giant cell arteritis. (A) Computed tomography (CT) scan of the brain,
axial cut. (B, E and F) Magnetic resonance imaging (MRI), axial cut T1-weighted imaging with fat saturation after the administration
of gadolinium. (C) MRI, coronal cut T1-weighted imaging with fat saturation after the administration of gadolinium. (D) MRI, axial
cut T2-weighted imaging. Sixty eight year old patient (A) who presents to the hospital with visual loss in left eye and diagnosed
with acute ischaemic optic neuritis. In the CT scan there was presence of thickening in both optic nerves (short arrow in A) and
bulbar covers (long arrow in A). Yet despite the fact that nor the clinical data or the biopsies were not conclusive, giant cell arteritis
was diagnosed and with this suspicion in mind it was treated with corticoids. Four (4) months later the patient presents to the
hospital again (B---F) with new clinical manifestations in the right eye. One PET (positron emission tomography) scan is performed
(not shown) that confirms Meckel’s cave and right orbital vertex uptake. The MRI confirms orbital vertex affectation (thick arrow in
B) and shows thickening and hyper-uptake of Meckel’s cave dura mater (arrowhead in E) and right petroclinoid ligament (arrowhead
in B), the latter being hypointense in the T2-weighted imaging (black arrow in D). Also, there was thickening and hyper-uptake of
the basilar and vertebral arterial wall (arrows in C and F).
but without any clear signs as to be able to establish the and damages the optic nerve, or when the inflammatory
exact etiological diagnosis. That is, as radiologists we cannot component compromises the orbital vertex.
define this entity based on images only, but we will need to Fungal sinusitis is one relatively rare sinus infec-
know the clinical parameters as well. Also, some times the tious disease. It may be categorized into invasive and
38,39
diagnostic clinical criteria for these entities are not fully noninvasive. The invasive variant is defined by the pres-
met. In these cases, in view of the radiological findings, for ence of fungi outside the sinus air cavity and occurs in
its management we could use a more general term such as immunosuppressed individuals, while clinically it presents
orbital idiopathic inflammatory disease (Fig. 9). itself acute or chronically. In acute cases, the individ-
ual presents to the hospital with a fever, rhinorrhea, and
Infectious orbital disease mucosal ulceration. In the chronic cases, symptom onset
The infectious orbital disease usually manifests itself as sep- is insidious and is characterized by the progressive inva-
tal and retroseptal cellulitis whose origin is usually pyogenic sion of paranasal sinus structures, like the orbital vertex,
sinusal affectation or, more rarely, fungal affectation. It can which clinically translates into reduced visual acuity and eye
associate loss of visual acuity when the infection spreads motility.
Nontraumatic head and neck injuries: A clinical approach. Part 2 193
Figure 10 Orbital apex syndrome due to fungal sinusitis. (A) Computed tomography (CT) scan of the brain, axial cut. (B) CT
scan of paranasal sinus structures, axial cut. (C and D) Magnetic resonance imaging (MRI), axial cut T1-weighted imaging with fat
saturation after the administration of gadolinium. Patient presents to the ER with visual loss in left eye. One CT scan of the brain
is performed (A) that confirms presence of an oversized optic nerve (arrow in A), complete opacification of the sphenoid sinus that
showed thickened walls, very thick intrasinus calcifications (black arrow in B), and soft tissue increase in the apex (asterisk in B).
Due to suspicion of invasive fungal sinusitis, one MRI is performed (C and D), that confirms soft tissue increase in the orbital apex
(asterisk in C) and that the swelling has spread towards adjacent soft tissues (white arrows in D) in both pterygopalatine fossae.
Table 2 Clinical-radiological differential diagnosis of the most common orbital inflammatory entities.
Data Pseudotumor Cellulitis Dysthyroid
orbitopathy
Pain Intense and with Intense Mild
movements
Vision Usually normal Late onset Late onset
Motility Limited: in the Limited: in the Restricted: targeted
opposite direction to opposite direction to at the affected
the affected muscle the affected muscle muscle
Onset Acute Acute Gradual
Eyelids Ptosis, swelling Swelling Retraction
Clinical data Good response to Fever, sinus High levels of
corticoids affectation antibodies, hormonal
alterations
Imaging Unilateral: Unilateral: Gradual Bilateral asymmetric:
Inflammatory masses inflammatory Oversized extrinsic
No respect for muscle affectation: preseptal ocular extrinsic
insertion to postseptal. muscles
Sometimes presence Respect for muscle
of abscesses insertion
194 B. Brea Álvarez et al.
In the CT scan we can see sinus occupation, pres- Conflicts of interests
40
ence of dense tortuous calcifications, and poor definition
of orbital vertex structures secondary to the presence of
The authors declare no conflict of interests associated with
inflammatory-fungal tissue. The MRI is a better imaging
this article whatsoever.
modality to define orbital affectation and the scope of the
spread process (Fig. 10).
In patients with radiological data of chronic rhinosinusitis
and obliteration of the perisinus fat planes, this diagnosis References
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