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.