eng slo element REVIEW ARTICLE en article-lang 10.6016/ZdravVestn.2900 doi 26.11.2018 date-received 8.7.2019 date-accepted Radiological approach to deep neck space Oncology Onkologija discipline infections Review article Pregledni znanstveni članek article-type Slovenian Radiological approach to deep neck space Radiološka obravnava okužb globokih vratnih article-title Radiološka obravnava okužb globokih vratnih prostorov infections prostorov Medical Radiological approach to deep neck space Radiološka obravnava okužb globokih vratnih alt-title Journal Katarina Šurlan Popović, Cene Jerele infections prostorov infection, cellulitis, abscess, computed tomog- okužba, celulitis, absces, računalniška tomografi- kwd-group raphy, magnetic resonance ja, magnetnoresonančno slikanje The authors declare that there are no conflicts Avtorji so izjavili, da ne obstajajo nobeni conflict of interest present. konkurenčni interesi. Abstract year volume first month last month first page last page Clinical Institute of Despite widespread use of antibiotics, deep neck space infections can still present potentially Radiology, University 2019 88 11 12 529 538 life-threatening conditions. In children, they mostly arise due to perforations of inflamed lymph Medical Centre Ljubljana, nodes, while in adults the common causes are dental infections and various infections in the Ljubljana, Slovenia neck area. Deep neck infections can progress along horizontal and vertical deep neck spaces. name surname aff email The infections may spread to the upper respiratory and digestive tracts, where they can cause Correspondence/ Katarina Šurlan Popović 1 [email protected] Korespondenca: serious complications. Katarina Šurlan Popović, e: Early detection and correct diagnosis are therefore essential in establishing a proper course of [email protected] name surname aff treatment. Cene Jerele 1 Key words: The signs of infection are frequently unclear; radiological imaging techniques are therefore key infection; cellulitis; abscess; computed tomography; in determining the origin of infection, as well as well as in the assessment of the spread of the in- magnetic resonance fection and the assessment of transformation from cellulitis infection to an abscess. The imaging techniques of choice are CT and MRI with contrast agents and in some cases, also the US. Ključne besede: okužba; celulitis; absces; The aim of this article is to present the radiological approach to deep neck space infections. In- računalniška tomografija; fections of individual deep neck spaces are described in more detail, as well as the appropriate magnetnoresonančno diagnostic procedures. This article will help radiologists differentiate among individual infection slikanje types and aid in early identification of deep neck space infections. eng slo aff-id Clinical Institute of Radiology, Klinični inštitut za radiologijo, 1 Received: 26. 11. 2018 Izvleček Accepted: 8. 7. 2019 University Medical Centre Univerzitetni klinični center Okužbe globokih vratnih prostorov kljub široki uporabi antibiotikov pogosto lahko pomenijo Ljubljana, Ljubljana, Slovenia Ljubljana, Ljubljana, Slovenija življenje ogrožajoča stanja. Pri otrocih najpogosteje nastanejo kot posledica predrtja vnetno spremenjene bezgavke, pri odraslih pa zaradi zobnih okužb in različnih vnetij v področju vratu. Globoke okužbe vratu se lahko širijo vzdolž prečnih in navpičnih vratnih prostorov, pri čemer lahko zajamejo zgornja dihala in prebavila, kjer povzročijo hude zaplete. Zgodnje prepoznavanje in ustrezna diagnoza sta tako ključna za ustrezno obravnavo in pravilen izbor zdravljenja. Zaradi pogosto zabrisanih znakov okužbe so radiološke preiskovalne metode ključne pri odkrivanju izvora okužbe, oceni razširjenosti okužbe in oceni prehoda vnetnega celulitisa v ab- sces. Slikovno preiskovalni metodi izbire sta CT in MRI s kontrastnim sredstvom, v določenih oko- liščinah tudi UZ. Namen tega preglednega članka je predstaviti radiološko obravnavo okužb globokih vratnih prostorov. Opisane so okužbe posameznih vratnih prostorov z ustreznimi diagnostičnimi postop- ki. Članek bo pomagal radiologom pri razlikovanju med posameznimi vrstami in pri zgodnejšem prepoznavanju okužb globokih vratnih prostorov. Radiological approach to deep neck space infections 529 ONCOLOGY Cite as/Citirajte kot: Šurlan Popović K, Jerele C. Radiological approach to deep neck space infections. Zdrav Vestn. 2019;88(11–12):529–38. DOI: https://doi.org/10.6016/ZdravVestn.2900 Copyright (c) 2019 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. 1 Introduction Despite widespread use of antibiot- tality rate is approximately 4.2% in adults ics, deep neck space infections are still and 6.2% in children (3). common and can present potentially Radiological imaging techniques are life-threatening conditions. The devel- therefore key in determining the origin of opment of deep neck infections depends infection, as well as in the assessment of on several factors, making their incidence the spread of the infection and the assess- difficult to assess (1). Infections are twice ment of transformation from cellulitis in- as common in men as in women and oc- fection to an abscess, which is the deciding cur at all ages, with most occurring in the factor in the choice of treatment (2). third decade of life. Life-threatening com- Clinical treatment of deep neck space plications develop in 10–20% of deep neck infections is multidisciplinary and in- infections, with mortality rate of approx. cludes an otolaryngologist, thoracic sur- 4% in adults and 6% in children (2,3). geon, infectious disease physician, and They develop within neck spaces, en- radiologist (4). veloped by the deep cervical fascia (4). It represents a natural barrier that limits the 2 Radiological imaging spread of infections into the adjacent neck methods spaces. Infections can spread beyond bor- ders of the deep cervical fascia, into the The radiological imaging method of so-called vertical spaces of the neck, which choice in the clinical diagnosis of deep extend to the mediastinum. This can lead neck space infections is computed tomog- to life-threatening complications (2). raphy (CT) with a contrast agent (CA). The cause of deep neck infections in The scan is completed faster and with few- children is most commonly a perforation er artifacts from swallowing and blood of a suppurated, inflammatory altered ret- flow when compared to scans from mag- ropharyngeal lymph node, which func- netic resonance imaging (MRI). It is per- tions as a drainage pathway for tonsil in- formed from the cranial base to the aortic fections. In contrast, dental infections are arch; this encompasses all neck spaces and the predominant cause in adults, followed the superior mediastinum (6,7). The sensi- by salivary gland inflammations, injuries, tivity of a CT with CA in identification of foreign bodies, paranasal sinus inflamma- deep neck space infections is 80–90%; for tions, inflammations of the lymph nodes differentiation between cellulitis, or rath- in the neck and middle ear inflammations er phlegmon, and abscess in deep neck (5). spaces, the specificity of the scan is lower Early diagnosis of deep neck space (2). Radiological differentiation between infections can be difficult due to initial abscess and phlegmon is a deciding factor treatments that involve antibiotics and for the course of treatment; in contrast to steroids, which cover up clinical signs and phlegmon, abscess requires surgical drain- symptoms. The deep neck infection mor- age (1). With CT scans, we talk about an 530 Zdrav Vestn | November – December 2019 | Volume 88 | https://doi.org/10.6016/ZdravVestn.2900 REVIEW ARTICLE abscess only when we see a change with Ultrasound imaging (US) can be used central suppurative necrosis, possibly with for images of superficial inflammations air present, which accumulates CA at the and percutaneous drainage of superficial edges. A change that also minimally accu- abscesses. It is commonly the first used mulates CA in necrotic area is not an ab- radiological imaging method when a neck scess, but phlegmon. If it is not possible to infection is suspected in children. How- differentiate between the two changes af- ever, ultrasound has a very low sensitivity ter the first, contrast-enhanced scan, scan and specificity for displaying deep neck must be repeated in a few minutes and the space infections and has poor anatomi- possible accumulation of CA in necrotic cal resolution for neck spaces; therefore, a area reassessed (2). negative ultrasound scan does not rule out Research has shown that CT findings a deep neck infection. With children with and surgical findings on differentiation reasonable clinical suspicion of a deep between phlegmon and abscess are a 75% neck infection, it is necessary to perform match in both adult and paediatric popu- a contrast-enhanced MRI (10). lations. The specificity of a CT scan is al- Native X-ray scans are only rarely used most 82% when the size of the abscess is with clinical suspicions of deep neck space larger than 3.5 cm (8). The Boscolo-Rizzo infections. With children, we use the later- et al study found only 11.9% of false pos- al X-ray scan to assess the width of retro- itives at the CT scan (9) of patients with pharyngeal space. This allows us to indi- surgical drainage. The reason for such rectly infer the state of deep neck spaces, good results is probably a careful selection which is the key to planning further