Head &Neck 911 Imaging of Neck & Airway Emergencies Disclosure of Commercial Interest Michelle A. Michel, M. D. • Neither I nor my immediate family (that Professor of Radiology and Otolaryngology would be my Bichon Frise “GoGo”) have Medical College of Wisconsin, Milwaukee, WI a financial relationship with a commercial organization that may have a direct or indirect interest in the content of this presentation. Illustrations courtesy Elsevier & Amirsys, Inc. A big thanks to Drs. Philip Chapman, Rebecca Cornelius, Bernadette Koch, C. Douglas Phillips, & Deborah Shatzkes for case material!!! Neck & Airway Emergencies Neck & Airway Emergencies Objectives Overview • Review emergent, non- • What constitutes a H&N traumatic adult conditions of Emergency? the neck • Condition is life threatening • Emphasize imaging findings to • Condition could cause loss of function make the correct diagnosis, • Condition causes severe pain or distress identify secondary findings, • Condition that if not identified early may result and recognize potential in a situation that is life-threatening, causes loss of function or severe pain/distress complications • Vital anatomy in the H&N • Topics • Airway, vasculature, neural elements • Neck space • In close proximity infection/inflammation • Big problems if findings missed or • Conditions affecting the airway misinterpreted! Jean-Baptiste Marc Bougery • Non-traumatic vascular lesions (1831-1854) Neck & Airway Emergencies Neck & Airway Emergencies Imaging Approach Neck Space Infection & Inflammation • Conventional radiographs & MRI have little role in acute setting • Role of imaging • CT is primary imaging modality • Identify location & in emergent H&N conditions source • Fast image acquisition • Relatively insensitive to patient • Assess anatomic motion extension – pattern of • Large FOV & high spatial resolution spread • Reformatted images from single acquisition • Orbit, intracranial, airway, • Widely available vessles, thoracic cavity • Benefits in emergent setting outweigh • Detect complications risks of radiation exposure • Dose-limiting technologies • Guide drainage Neck & Airway Emergencies Neck & Airway Emergencies Neck Space Infection & Inflammation Glandular “Emergency” 57 year old male with left neck swelling & pain • Glandular “emergencies” • Tonsillitis & peritonsillar abscess • Acute calcific prevertebral tendonitis • Odontogenic infection • Floor of mouth infection (Ludwig angina) • Deep neck space infection • Necrotizing fasciitis Acute Submandibular Sialolithiasis-adenitis Neck & Airway Emergencies Neck & Airway Emergencies Acute Sialoadenitis Sialoadenitis • Facial swelling & tenderness 63 year old male with tongue pain and neck swelling ↑ by oral intake • Parotitis – CN7 paresis • Obstructing sialolith • 80-90% of acute cases • SMG (70-80%) • Large, ascending duct & small papillary orifice, ↑ secretion viscosity & slow flow rate Acute on Chronic • No stone?...look for anterior Sialolithiasis/Sialoadenitis FOM mass! Sialoadenitis 2° Tongue/FOM SCCa Neck & Airway Emergencies Neck & Airway Emergencies Glandular Emergency 18 & 19 year old females with sore throat Courtesy C. Douglas Phillips, MD Acute Sialolithiasis and SMG Abscess Tonsillitis without Intratonsillar Abscess Neck & Airway Emergencies Neck & Airway Emergencies Tonsillitis & Tonsillar Abscess Intratonsillar vs. Peritonsillar Abscess • Young patients with sore • Intratonsillar Confusing! throat, trismus, tonsillar • Liquefaction contained by enlargement & erythema capsule, enhancing rim • EBV > Staph, Strep • No extension posterior to ICA/IJV • Imaging in severe cases • Peritonsillar • Evaluate for abscess & extent • Extends beyond capsule • Tonsillitis into connective tissue • Enlarged, “kissing” in midline, between tonsil & superior striated enhancement pattern constrictor ring • Airway compromise • Intratonsillar vs. peritonsillar • Cellulitis in PPS, MS, abscess Courtesy C. Douglas Phillips, MD Intratonsillar Abscesses RPS, PVS Neck & Airway Emergencies Neck & Airway Emergencies ? Tonsillitis Acute Calcific Prevertebral Tendinitis • Relatively rare & 41 year old female with sore throat & dysphagia underdiagnosed • Tonsillitis mimic • Adult (30-60 yrs) • Stiff neck, sore throat, no infection or dental disease • No or low-grade fever, minimal ↑ WBC, ↑ ESR • Crystal deposition in longus Acute Calcific Prevertebral Tendonitis colli tendons & inflammatory with RPS Effusion tendonitis & RPS effusion Courtesy C. Douglas Phillips, MD Neck & Airway Emergencies Neck & Airway Emergencies Masticator Space Infection 33 year old female with facial swelling & trismus • Odontogenic abscess • From molar tooth infection or following dental procedure • 2nd or 3rd molar teeth • Roots below mylohyoid – SMS • Adjacent to posterior body and ramus • +/- Osteomyelitis • Changes therapy Odontogenic Masticator Space Abscess Neck & Airway Emergencies Masticator Space Infection Neck & Airway Emergencies 84 year old female with cheek swelling & erythema 46 year old male with progressive anterior neck swelling and erythema Courtesy Mauricio Castillo MD Maxilllary Odontogenic Abscess with SZMS Extension “Ludwig Angina” Neck & Airway Emergencies Neck & Airway Emergencies Floor of Mouth Infection – Ludwig Angina Floor of Mouth Infection • “Angina Ludovici”, “angina maligna”, “morbus strangularis” • Potentially life-threatening floor of mouth (SLS) cellulitis • ± Abscess • Adults with dental infection > complicated SMG infection • Canine, premolar, 1st molar • Roots above mylohyoid (SLS) • Airway compromise • OP or pretracheal ST Wilhelm Friedrich von Ludwig Courtesy C. Douglas Phillips MD 1790-1865 Neck & Airway Emergencies Neck & Airway Emergencies Deep Neck Space Infection 69 year old male with fever & dysphagia Retropharyngeal & Danger Space Anatomy • RPS between buccopharyngeal fascia & BPF AF alar fascia • Clivus to T3 level • Danger space between alar fascia & prevertebral fascia • Clivus to above diaphragm • Conduit to mediastinum • Potential spaces & PVF Retropharyngeal & PVS Abscess 2° indistinguishable on imaging Cervical Osteodiscitis Neck & Airway Emergencies Neck & Airway Emergencies Retropharyngeal & Danger Space Retropharyngeal Abscess Lateralized > Lymph Node • Most common in children < 6 years • Ruptured suppurative LN or penetrating FB • Less common in adults • Immunocompromised or diabetic Midline > • Cervical osteodiscitis or Effusion/Abscess post-spine surgery • Imaging features • Tense fluid collection • Wall enhancement / gas • Image inferior extent! Courtesy Bernadette Koch, MD Neck & Airway Emergencies Neck & Airway Emergencies Retropharyngeal/Danger Space Deep Neck Space Infection 71 year old male post cervical fusion with fever & dysphagia 54 year old male with fever, neck pain, dysphagia, and difficulty breathing Multispatial, Retropharyngeal & PVS Abscess Screw Extrusion with RPS/PVS Abscess Surgical drainage performed… Neck & Airway Emergencies Neck & Airway Emergencies Deep Neck Space Infection Deep Neck Space Infection 1 week post RPS-PVS abscess drainage presented 56 year old male with tonsillar abscess with ↑ neck pain & paresthesias Cervical Osteodiscitis with PVS → Epidural Abscess RPS & DS Extension with Descending Mediastinitis Neck & Airway Emergencies Neck & Airway Emergencies Descending Mediastinitis • Mediastinitis 2° H&N 50 year old patient post XRT for HP SCCa. Presents with sore infection > 1 ° throat, difficulty swallowing, neck swelling, and sepsis • RPS infection permeates the alar fascia • Infection spreads to danger space & with gravity extends into mediastinum • Potentially life- threatening Courtesy Philip Chapman, MD • Severe sepsis Radionecrosis of the Hyoid Bone and Thyroid Cartilage • Cardiovascular collapse Lee MK, et al. BMC Infectious Diseases 2013 13:475 …but there’s more… Neck & Airway Emergencies Neck & Airway Emergencies Cervicofacial Necrotizing Fasciitis • Rare, but ↑ incidence • Patients immune-compromised, DM, EtOH-ic • Inciting condition • Pharyngitis, odontogenic most often • Symptoms and signs deceptively benign • Polymicrobial • Anaerobes & other • Bacterial enzymes & exotoxins destroy tissue • Mortality: ~ 25% • Sepsis, mediastinitis, carotid http://www.arquivosdeorl.org.br Courtesy Philip Chapman, MD erosion, venous thrombophlebitis, aspiration pneumonia, airway compromise nycems.blogspot.com Necrotizing Fasciitis • Multiple debridements often required Neck & Airway Emergencies Neck & Airway Emergencies Cervicofacial Necrotizing Fasciitis Cervicofacial Necrotizing Fasciitis • Imaging features 65 year old diabetic male with worsening posterior neck pain • Cellulitis: skin thickening, & bloody drainage reticulation of fat • Fasciitis: thickening & enhancement of fascia • Myositis: swelling & enhancement of muscles • Multispatial fluid collections • Necrotic tissue > abscesses • Gas collections (65-75%) • Imaging role for surgery • Vascular complication • Descending mediastinitis • Collection > 3 cm, involving > 2 spaces, or involving CS, PVS, VS Courtesy Deborah Shatzkes, MD Courtesy C. Douglas Phillips, MD Neck & Airway Emergencies Neck & Airway Emergencies Airway Emergencies Epiglottitis & Supraglottitis 46 year old female with sore throat & dysphagia • Potentially life threatening infection/ inflammation of supraglottic larynx in adult with sore throat & dysphagia • Pharyngeal > laryngeal symptoms • Thickened epiglottis, AEF, obliterated preepiglottic fat, mucosal enhancement • Often involves tonsils and base of tongue • Abscess formation more Courtesy Phil Chapman, MD common