Radiological Approach to Deep Neck Space Infections

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 absces. 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

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 borders 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

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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 diag- of patients for surgery. It was based on re- nostic procedures (11). liable CT-detected signs for abscess, such as a diameter of more than 3.5 cm, a com- 3 Spread patterns of deep neck plete central suppuration or hypodensity infections with an accumulation of CA at the edges. When differentiation between abscess and The most important data contributed phlegmon on a CT scan is not possible, by CT or contrast-enhanced MRI and the we perform a contrast-enhanced MRI; the radiologist’s report are the identification of imaging is focused only on the differenti- the abscess, the assessment of all infected ation between abscess and phlegmon. Un- neck spaces and the identification of com- der the T2-weighted, fat-suppressed MRI plications of the infection (2,4). sequence, the signal for abscess is signifi- Initially, cellulitis or abscess covers only cantly higher than that of phlegmon. At one neck space, bounded by the deep cer- the same time, at the central part of the vical fascia. When the infection spreads abscess under diffusion-weighted imag- past the layers of the deep cervical fascia, it ing, a restricted water molecule movement also affects the adjacent neck spaces. Neck is also present (6). spaces are oriented and interconnected With a bone window CT scan, it is pos- vertically and transversely (5). sible to locate the source of an infection, When the infection reaches vertically such as osteomyelitis, dental and peri- oriented spaces, such as parapharyngeal, odontal inflammatory processes, spondy- retropharyngeal, and paravertebral space, lodiscitis, foreign bodies and sialoliths (4). it spreads downwards, to the upper respi- MRI is the first imaging method of ratory and gastrointestinal tracts, where it choice only in cases where there is a sus- poses a high risk for development of me- pected infection spread into the intracra- diastinitis (2,9). nial structures and the spinal canal, and The treatment method of a deep cer- for children, as we try to avoid exposing vical infection depends on the patient’s them to radiation (6). clinical condition and associated dis-

Radiological approach to deep neck space infections 531 ONCOLOGY

Injuries in the mouth Pharyngitis Submaxillary/sublingual Removal of Tooth infections sialadenitis suspension wires Sinusitis Sialadenitis Dental infections Dental infections Mastoiditis (mandibular molars) (mandibular molars) Tonsilitis Parotitis

Submandibular space Masticatory Peritonsillar Parotid (Ludwig’s angina) space space space

Esophageal perforation Perforation of the Retroesophageal Parapharyngeal Carotid posterior wall of space space space the oesophagus

Obstruction of the Thrombosis of the airway at the level internal jugular vein of the pharynx Thrombosis of the carotid artery Endocarditis Septic pulmonary embolism Vertebral Prevertebral Danger space Cerebrovascular osteomyelitis space insuiciency Horner’s syndrome

Mediastinitis Mediastinum

Perforation of the Pretracheal anterior wall of the space esophagus Pleural Empyema space

Figure 1: Graphic display of deep neck infection progression pattern.

eases, as well as the number and type of ant; abscesses larger than 3 cm are treated neck spaces affected by the infection (6). surgically (9,12). The Boscollo-Rizzo et al study suggests a non-surgical, antibiotic treatment for in- 4 Infections of parapharyngeal fections, delimited to a single, transversely and carotid space oriented space. Infections that take up two transverse spaces should also be treated Anatomically, the parapharyngeal with an antibiotic. If there is clinical im- space is divided into anterior and poste- provement, a repeat contrast-enhanced rior space; the latter essentially represents CT is performed. If the CT does not show the carotid space. Infections spread to radiological improvement, the patient is parapharyngeal space from palatine ton- referred for surgical treatment. If the in- sils, teeth, parotid glands and middle ear fection takes up more than two transverse- (2,5). Patients have fever, sore throat and ly oriented spaces or one of the vertically swelling in the neck area. Trismus can be oriented spaces, the patients require surgi- present as well when the anterior part of cal treatment (Figure 1). the parapharyngeal space is affected (2,22). The size of the abscess is also import- The radiologist must differentiate be-

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cause thrombophlebitis. On CT scans, it is identifiable by pronounced inflammatory changes in the carotid space, by the accumulation of CA in the vein wall and the presence of a thrombus in the lumen of the vein (13). Particular attention should be paid to the possible presence of Lemierre’s syndrome, which is a complication arising from abscesses in the lateral part of the neck and occurs in younger patients who have a normal immune system. Lemierre’s syndrome is an infectious thrombophlebi- Figure 2: On contrast-enhanced CT scan, an abscess is seen in the right tis of the internal jugular vein, with sep- tonsillar fossa, which is bounded towards the parapharyngeal space tic emboli as complications. Infectious and pushes away the parapharyngeal adipose tissue (long arrow) thrombophlebitis can also spread retro- (A). In contrast, Figure B shows an abscess in the region of the right gradely and cause occlusion of the intra- parapharyngeal space; due to that, the parapharyngeal adipose tissue cranial venous sinuses (2,5). is not differentiated. Inflammatory suppurated lymph nodes in area 2a (short arrow) are also present. 5 Retropharyngeal space

tween peritonsillar and parapharyngeal The retropharyngeal space lies posteri- abscess on CT or MRI, as that is the deter- or to pharynx and oesophagus and spans mining factor when choosing the method from the cranial base to the upper medias- of surgical treatment and the type of ap- tinum, where it terminates approximately proach. A peritonsillar abscess occurs in at the level of the third thoracic vertebra the area of the pharyngeal mucosal space (6). It contains only adipose tissue and when a tonsillar infection penetrates the lymph nodes. Radiologically, it is difficult capsule but is still bounded by the middle to distinguish it from the so-called danger layer of the deep cervical fascia. In this space, an anatomical region immediately case, the parapharyngeal space is merely behind it; therefore, radiologists treat both pushed away (Figure 2A). Inflammatory as a single space (4). In children, the ret- enlarged lymph nodes in the retropharyn- ropharyngeal space is most often affected geal and posterior parapharyngeal space as a result of acute pharyngitis or sinusitis, may also be present (4,6,13). which manifests as an infection of retro- A parapharyngeal abscess occurs when pharyngeal lymph nodes. (Figure 3A). In the infection spreads across the middle adults, the retropharyngeal space is less layer of the deep cervical fascia, into the commonly affected; most often it is affect- parapharyngeal space. With parapharyn- ed because of pharyngeal injuries due to geal abscess, the fat signal that is charac- a foreign body or an intubation (11). Pa- teristic of the parapharyngeal space is no tients experience pain when swallowing longer visible (Figure 2B). The pharyn- or neck-stretching, fever, and trismus. geal wall and palatine tonsil are medially Because the retropharyngeal space com- moved. Anterior parapharyngeal abscess- municates directly with the mediastinum, es progress rapidly and are less responsive infection of this space can quickly lead to to antibiotics than infections of posterior mediastinitis and with it, to life-threaten- parapharyngeal space, which are usually ing complications (14,22). caused by lymphadenitis (6). Infections of CT and MRI scans must therefore reach the posterior parapharyngeal space can al- from the cranial base to arcus aorta. Cel- so erode into the internal jugular vein and lulitis of the retropharyngeal space is ra-

Radiological approach to deep neck space infections 533 ONCOLOGY

Figure 4: On the CT scan of the coronal plane, air accumulation is visible because of infection in the submandibular (asterisk), sublingual (short arrow) and parapharyngeal space (long arrow), proving that all three spaces are interconnected. Figure 3: On the T2-weighted MRI sequence, a centrally suppurated, inflammatory enlarged lymph node (A) is visible in the retropharyngeal space. Retropharyngeal space, widened by a few millimetres, with a high signal intensity on the T2-weighted sequence in the sagittal plane, is characteristic of retropharyngeal cellulitis (B). Abscess of the retropharyngeal space on the T1-weighed sequence, Gd-enhanced, accumulates CA and significantly narrows the airway (C).

diologically visualized as a few millimetres spaces are in direct contact with the para- of symmetrically expanded space. On CT pharyngeal space at the posterior edge scans, cellulitis is hypodense, and on MRI of the mylohyoid muscle (Figure 4). This scans it is hyperintense, but less so than means that without proper treatment, in- fluid, making it difficult to differentiate fections from these two spaces can quickly cellulitis from oedema due to other causes spread to the mediastinum (2,6). (Figure 3B) (2). Cellulitis can progress to Infections in the sublingual space are development of an abscess, but even more caused by calcified stones in the salivary often, an abscess of the retropharyngeal glands or a narrowing of their ducts, as space develops from an inflamed, central- well as inflammation of the front teeth of ly necrotic lymph node (Figure 3C). Ab- the lower jaw. In the submandibular space, scesses in the retropharyngeal space can they result from inflammation of the sec- accumulate contrast agent at the edges, ond and third molars of the lower jaw, be- but that does not necessary happen; it is cause periapical inflammation penetrates peculiar to such abscesses (4). The Malloy the thin cortical layer of the mandible and et al study demonstrated that the rate of spreads to the adjacent space (17). Patients contrast agent accumulation does not rep- have painful swelling in the mouth and resent a radiological criterion by which to lower jaw, pain when chewing and swal- assess the need for surgical treatment of an lowing, and trismus (6). abscess. The decisive radiological criterion Using CT scan and MRI, we can accu- in the study was the size, or rather the vol- rately evaluate soft tissue oedema of both ume of the abscess (15). Oedema or fluid the floor of the oral cavity and the platys- in the retropharyngeal space may also be a ma and masseter muscles. CT scan has result of radiation therapy, internal jugular the advantage in finding the cause of in- vein occlusion or retropharyngeal calcify- flammation, i.e. periapical processes, and ing tendinitis (16). calcified stones in the salivary gland ducts. After contrast agent is delivered, there is 6 Submandibular and a delayed accumulation of CA in abscess sublingual spaces cavities. MRI is more sensitive to show soft tissue oedema and early inflammatory The sublingual and submandibular changes in the bone that have a character-

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7 Paravertebral and prevertebral space The prevertebral space lies behind the retropharyngeal space, or rather danger space, from which it is separated by a deep layer of deep cervical fascia. Inflamma- tion of this area can result in or manifest as spondylodiscitis, with the infection spreading hematogenously. The spread Figure 4: On the CT scan of the coronal plane, air accumulation is visible because of infection in the submandibular (asterisk), sublingual of infection directly from adjacent spac- (short arrow) and parapharyngeal space (long arrow), proving that all es across the fascia is rare. It can occur three spaces are interconnected. when the deep cervical fascia is damaged by surgery or by a penetrating injury of a different type. Clinically, it manifests pri- marily as severe neck pains and fever. The istic hypointense T1 signal (18). radiological method of choice for suspect- An entity that must not be overlooked ed inflammation of the paravertebral and by radiologists is Ludwig’s angina or ex- vertebral spaces and for spondylodiscitis spaces are in direct contact with the para- tensive cellulitis of the sublingual, sub- is Gd-enhanced MRI (2,4,5). pharyngeal space at the posterior edge mandibular, and submental space. On a In spondylodiscitis, the inflammation of the mylohyoid muscle (Figure 4). This CT scan, it is seen as a thickening of the involves two adjacent vertebral bodies means that without proper treatment, in- mucosa and submucosal tissues with dif- and an intervertebral disc. At STIR (short fections from these two spaces can quickly fuse accumulation of CA, with possible tau inversion recovery), or a T2-weighted spread to the mediastinum (2,6). presence of air. Radiologists should warn sequence with suppressed adipose tissue, Infections in the sublingual space are of the spread of oedema to the root of the they have a characteristically high MRI caused by calcified stones in the salivary tongue and upper respiratory tract as such signal, and at T1-weighted sequence they glands or a narrowing of their ducts, as spread can be life-threatening (2). have a low signal. When Gd-enhancement well as inflammation of the front teeth of is added, the aforementioned spaces ac- the lower jaw. In the submandibular space, cumulate CA (Figure 5A). An abscess can they result from inflammation of the sec- form in the epidural space of the spinal ond and third molars of the lower jaw, be- canal and in paravertebral muscles, which cause periapical inflammation penetrates accumulates Gd-CA at the edges and has a the thin cortical layer of the mandible and characteristic diffusion restriction on the spreads to the adjacent space (17). Patients diffusion-weighted sequence (DWI) (6). A have painful swelling in the mouth and diffuse staining of the dura and paraverte- lower jaw, pain when chewing and swal- bral space muscles is often visible (Figure lowing, and trismus (6). 5B). Using CT scan and MRI, we can accu- A CT scan usually does not show early rately evaluate soft tissue oedema of both signs of spondylodiscitis, or they may be the floor of the oral cavity and the platys- so subtle that they are difficult to differen- ma and masseter muscles. CT scan has tiate from degenerative changes (14). the advantage in finding the cause of inflammation, i.e. periapical processes, and Figure 5: On the T1-weighted sequence, Gd-enhanced in the 8 Masticator space calcified stones in the salivary gland ducts. sagittal plane (A), a deformation of the upper cervical vertebrae and After contrast agent is delivered, there is accumulation of Gd-CA in the region of intervertebral discs (indicated Infections in the masticatory space are a delayed accumulation of CA in abscess by an arrow) are visible. In the transverse plane, a diffuse staining of most often odontogenic in origin. They cavities. MRI is more sensitive to show the dura in the spinal canal (short arrow) and paravertebral muscles often occur after tooth extraction or as a soft tissue oedema and early inflammatory (asterisk) (B) is visible. result of odontogenic cyst infection. Clin- changes in the bone that have a character-

Radiological approach to deep neck space infections 535 ONCOLOGY

forces, towards the cranial base and into the disintegration of the fascia, the fluid, medial portion of the masticator space. which does not have the capsule charac- Spread of an infection outside the masti- teristic of an abscess, is no longer confined cator space is rare, but it can spread to the to individual neck spaces, but crosses the parapharyngeal and submandibular spac- space borders. The adjacent muscles are es, where it presents a danger for develop- also inflamed and show enhancement af- ment of mediastinitis (2,17). ter CA administration (21). Necrotizing Accurate radiological identification fasciitis spreads rapidly into the area of the and definition of the anatomical position mediastinum, which significantly increas- of the abscess by MRI or CT scans is also es mortality; therefore, in addition to the key in deciding on surgical approach. Ab- neck, the mediastinum must also be in- scesses located medially from the ramus cluded in the CT scan (Figure 7B). are treated with a surgical approach via Figure 6: MRI shows an abscess in the right masticator space, which has a T1-weighted sequence, Gd-enhanced, characterized by CA mouth, while abscesses laterally from the accumulation at the edges (A) and diffusion restriction on the ADC map ramus are operated via an external surgi- of the diffusion-weighted sequence (B). cal approach (19). Abscesses in the masticator space have the same radiological characteristics as ically, patients suffer from painful facial those in other spaces in the neck. Accu- swelling, trismus and pain when swallow- mulation of CA at the edges and diffusion ing. Masticator space is surrounded by a restriction on MRI are characteristic for it superficial layer of deep cervical fascia. It (Figure 6A, Figure 6B). If there is a clinical is divided into suprazygomatic portion, suspicion of the spread of infection to the which is represented by a temporal muscle, cranial base, the radiological method of and infrazygomatic part, which is divided choice is Gd-enhanced MRI (2). by mandibular ramus into medial and lateral parts. The lateral part includes the in- 9 Necrotizing fasciitis sertion of the masseter muscle to mandibular ramus; it is also called submasseteric Necrotizing fasciitis is a rapidly pro- space (17). The latter represents a predi- gressive, life-threatening infection that lection site for a formation of an abscess, most commonly originates in the teeth which is pushed upwards by masticatory (20). Compared to other deep neck space infections that the deep cervical fascia attempts to confine, necrotizing fasciitis causes disintegration and suppuration of both the superficial and deep cervical fascia. Clinically, patients experience severe neck pains and moderate redness of the skin (2). If there is a clinical suspicion of necrotizing fasciitis, the radiological method of choice is a contrast-enhanced CT scan. The most characteristic CT scan sign is involvement of both superficial and deep neck spaces. In the initial stage of infection, we see a thickened fascia, which is not visible on a CT scan of a healthy neck. Figure 7: Accumulation of fluid in multiple neck spaces as a part of When the infection has advanced, there necrotizing fasciitis, visible on CT scan (A). Necrotizing fasciitis can is a simultaneous accumulation of fluid spread rapidly to mediastinum (B). with air present (Figure 7A) (2,20). Due to

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the disintegration of the fascia, the fluid, 10 Conclusion which does not have the capsule characteristic of an abscess, is no longer confined Radiological imaging methods CT and to individual neck spaces, but crosses the MRI allow for the assessment of the origin, space borders. The adjacent muscles are spread and complications of infections in also inflamed and show enhancement af- the deep neck spaces. In modern guide- ter CA administration (21). Necrotizing lines for the treatment of deep neck space fasciitis spreads rapidly into the area of the infections, we also monitor the course mediastinum, which significantly increas- of treatment with radiological imaging, es mortality; therefore, in addition to the thereby significantly influencing the selec- neck, the mediastinum must also be in- tion, course, and success of treatment. cluded in the CT scan (Figure 7B).

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538 Zdrav Vestn | November – December 2019 | Volume 88 | https://doi.org/10.6016/ZdravVestn.2900