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Head and neck infections dr.rekha
- 1. Dr Rekha Swamy MRCPCH FRCR Teleradiology solutions, Bangalore
- 2. Approach to assessment Localize the abnormality Spread / extension Vital structures Summary
- 3. Localise and aid in detection of drainable collections and assess for complications Pediatric Cervical lymphadenitis Tonsillitis Adults DSNI Odontogenic disease Sialadenitis Sinusitis Mastoiditis
- 7. Sublingual space: highlighted by the yellow arrows on the left Submandibular space on the right
- 8. P M ParCPr R
- 10. Axial and coronal contrast enhanced CT demonstrating a left submandibular duct calculus ( black star) with left submandibular space abscess( yellow arrows)
- 11. Axial and coronal contrast enhanced CT demonstrating acute inflammatory changes within the parotid gland
- 14. Orbital infections represent more than half of primary orbital disease processes The location of an orbital infection is described with respect to the orbital septum, as either preseptal (periorbital) or postseptal (orbital)
- 19. Axial and sagittal contrast enhanced CT demonstrating well defined low density non enhancing fluid collection in the retropharyngeal space with ossification of the Longus colli tendon
- 20. Acute otitis media and mastoiditis Complications Epidural abscess, Subdural empyema Petrous apicitis Sigmoid sinus thrombosis Bezold’s abscess Otitis externa
- 23. Rarer conditions Infected branchial cleft cysts Ludwigs angina Necrotising fasciitis Epiglottitis Pyolaryngcoele
- 24. Axial and coronal contrast enhanced CT demonstrating well defined low density lesion in the left level II with mild enhancement situated between the submandibular gland and sternocleidomastoid muscle.
- 27. Airway Circulation Cord
- 30. Cervical lymphadenitis is common in children and is the usual origin of superficial neck abscesses. Adults are more likely than children to have a DNSI, with odontogenic infection being the most common source Role of imaging is to localise and aid in detection of drainable collections and assess for complications.
- 31. Questions?
- 32. Nontraumatic Orbital Conditions: Diagnosis with CT and MR Imaging in the Emergent Setting . Christina A. LeBedis, MD, and Osamu Sakai, MD, PhD Radiographics, Oct 2008 Imaging of Acute Head and Neck Infections Aldo Gonzalez-Beicos, MD, Diego Nunez, MD, MPH, Radiology Clinics , Volume 50 Head and Neck Infection and Inflammation. Rich S. Rana, MD, Gul Moonis, MD , Radiology clinics Emergency Imaging Assessment of Acute, Nontraumatic Conditions of the Head and Neck. Erin Frankie Capps, MD, James J. Kinsella, MD, Manu Gupta, MD, Amol Madhav Bhatki, MD, and Michael Jeffrey Opatowsky, MD Radiographics, Sept 2010 Imaging Features of Invasive and Noninvasive Fungal Sinusitis: A Review Manohar Aribandi, MD, Victor A. McCoy, MD2, and Carlos Bazan, III, MD
Editor's Notes
- Good evening eyryone! Shall start off by a brief aproc to assesment, localise, deen neck spaces , vital structurs with few examples of each
- cervical lymphadenitis is defined as the enlarged, inflamed, and tender lymph nodes of the neck. Cervical lymphadenitis is common in children, and the most common cause is an upper respiratory illness. Because cervical lymphadenitis is typically self-limited, the exact incidence is difficult to ascertain and imaging is usually not performed. Common sites of cervical lymphadenitis are the submandibular and deep cervical nodes because these nodes filter much of the lymphatic fluid from the head and neck..
- 9 year old female presented with neck swelling TB adenopathy: Tuberculous cervical lymphadenitis is the most common manifestation of extra-pulmonary tuberculosis and is a very frequent cause of a peripheral lymphadenitis in the developing world. Additionally in industrialised nations there is a resurgence among intravenous drug users and the immunocompromised population, especially those due ti HIVCervical nodes are the most commonly affected nodes in tuberculous lymphadenitis, accounting for approximately 63% of cases, followed by mediastinal (27%) and axillary nodes (8% maging alone is often unable to categorically distinguish tuberculous lymphadenitis form other causes of cervical lymphadenopathy and necrotic/cystic lymphadenopathy. T appearances of tuberculous lymphadenitis is variable, depending on the degree of caseation present in the node. Nodes may initially appear merely enlarged, often with attenuation similar to muscle. Eventually, central caseation develops and the nodes become centrally low density and eventually frankly cystic. They are,usually, matted together with only minor surrounding inflammatory changes 5.
- Peritonsillar abscess is often polymicrobial.The most common aerobic bacteria aregroup A Streptococcus, S aureus, and Haemophilusinfluenzae, whereas the most commonanaerobic bacteria are Fusobacterium, Peptostreptococcus, and pigmented Prevotella.. Inflammationof the tonsils is referred to as tonsillitis, whichcauses a typically striated appearance with the enhancement of the mucosa and submucosaledema (Fig. 15). Anatomically, peritonsillarabscess represents an infection betweenthe tonsillar capsule and superior constrictormuscle (Fig. 16) and is usually a complication ofacute tonsillitis. Recently, inflammation of theWeber glands, 29which are approximately 2 dozenmucous salivary glands in the soft palate justsuperior to the tonsil, has also been implicated inthe pathogenesis of peritonsillar abscess. Thus, peritonsillar abscess is also possible in patientswho have had tonsillectomy. If infection spreadsoutside the constrictor ring, it represents a parapharyngealabscess
- the suprahyoid and infrahyoid segments. The specific infectious entities are reviewed, based on three distinct areas: the anterior suprahyoid neck, including the nasal and oral cavities; the lateral and deep suprahyoid spaces; and the infrahyoid neck. The retropharyngeal space extends from the skull base to approximately T3-T4 and is bounded anteriorly by the slip of the middle layer of the deep cervical fascia known as the visceral layer. Posteriorly, the retropharyngeal space is bound by a slip of the deep layer of the deep cervical fascia known as the alar fascia. Immediately posterior to the alar fascia is the danger space (see Fig. 1), which extends inferiorly into the posterior mediastinum. An infectious process in these compartments can be seen in a spectrum ranging from phlegmon to suppurative adenitis/frank abscess (Fig. 18). It is not possible to differentiate the retropharyngeal space from the danger space on imaging (Fig. 19), and danger space infection can be inferred only if the infection spreads below the T4 level. Retropharyngeal abscess may extend posteriorly to involve the danger and prevertebral spaces as well as cause osteomyelitis of the spine. Unlike peritonsillar abscess, which is medial to the constrictor ring, parapharyngeal and retropharyngeal abscesses are lateral. The most common sources for retropharyngeal abscess in children is suppurative adenitis. 30 Cervical spine surgery is another potential cause of infection oheprevertebral/retropharyngeal spaces. It is difficult to differentiate suppurative adenitis of the retropharyngeal nodes from frank abscess
- Includes the sinuses, orbits, nasal and oral cavity, sublingual and smg spaces
- Localize it: What space is the abnormality in? Familiarity with the fascial layers and spaces of the neck and the contents of each space is helpful for this discussion.1 The fascial layers of the neck are important barriers to infection, and once infection is established, the fascial layers play a part in directing its spread The superficial fascia completely surrounds the head and neck separating the deep layers of the neck from the skin. It contains fat, superficial lymph nodes, nerves and hair follicles as well as the platysma muscle and the external jugular vein. The deep cervical fascia forms the boundaries of the cervical spaces and creates the normal symmetry of the neck. It is composed of three layers: superficial, middle, and deep. The reflections of these layers form the masticator, parotid, vascular, and parapharyngeal spaces laterally as well as the mucosal, retropharyngeal, and perivertebral spaces deeper around the midline. These fibrous boundaries also determine the communicative pathways for infection spread in the neck. In addition, based on the centered midline position of the hyoid bone, the neck is topographically subdivided into two broad compartments with different anatomic and physiologic features: the suprahyoid and infrahyoid segments. The specific infectious entities are reviewed, based on three distinct areas: the anterior suprahyoid neck, including the nasal and oral cavities; the lateral and deep suprahyoid spaces; and the infrahyoid neck. The retropharyngeal space extends from the skull base to approximately T3-T4 and is bounded anteriorly by the slip of the middle layer of the deep cervical fascia known as the visceral layer. Posteriorly, the retropharyngeal space is bound by a slip of the deep layer of the deep cervical fascia known as the alar fascia. Immediately posterior to the alar fascia is the danger space (see Fig. 1), which extends inferiorly into the posterior mediastinum. An infectious process in these compartments can be seen in a spectrum ranging from phlegmon to suppurative adenitis/frank abscess (Fig. 18). It is not possible to differentiate the retropharyngeal space from the danger space on imaging (Fig. 19), and danger space infection can be inferred only if the infection spreads below the T4 level. Retropharyngeal abscess may extend posteriorly to involve the danger and prevertebral spaces as well as cause osteomyelitis of the spine. Unlike peritonsillar abscess, which is medial to the constrictor ring, parapharyngeal and retropharyngeal abscesses are lateral. The most common sources for retropharyngeal abscess in children is suppurative adenitis. 30 Cervical spine surgery is another potential cause of infection oheprevertebral/retropharyngeal spaces. It is difficult to differentiate suppurative adenitis of the retropharyngeal nodes from frank abscess
- Endodontal/periodontal diease: most common paths of spread of maxillary odontogenic infection are to the buccal, masticator, and parapharyngeal spaces.7 Specifically, infection originating in the maxillary incisors, canines, premolars, and first molars tends to spread to the buccal space, whereas infection originating in the second maxillary molar tends to spread to the masticator space (Fig. 5). Infection of the third maxillary molar tends to spread to the parapharyngeal space.1 mandibular teeth, odontogenic infection originating in the incisors, canines, or first premolars is most likely to spread into the sublingual space. Because the second and third mandibular molar tooth roots extend below the mylohyoid muscle insertion, odontogenic infection originating from these teeth is most likely to spread into the submandibular space
- The submandibular gland is by far most commonly affected because its secretions are more mucous, alkaline, and viscous than that of the other glands.20 Most stones are radiopaque, but CT is more sensitive than radiography to demonstrate sialothiasis and its complications, including sialadenitis and abscesses. Sialadenitis, or glandular inflammation of the salivary glands, is most commonly caused by sialolithiasis. Other inflammatory conditions that cause sialadenitis include mumps, AIDS, influenza, and infection with Coxsackie viruses. Bacterial infections, granulomatous disease, and idiopathic parotitis are less common. On CT, the gland demonstrates enlargement, hypodensity on precontrast scan, and avid postcontrast enhancement, with adjacent inflammatory stranding and fascial thickening. The salivary duct may be dilated and thick-walled, and an obstructing sialolith is usually seen (Fig. 10). On MR imaging, gland enlargement and hyperintensity on T2-weighted images are because of inflammation and edema. Although the sialolith is not as well appreciated, its presence may be inferred if a punctate signal void is seen on all sequences.
- acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis
- acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis Sinusitis may be suspected to be of fungal origin based on atypical clinical presentations, including nonresponse to antibiotics, or on imaging features. Fungal sinonasal disease is typically divided into 4 broad classes based on pathophysiology: acute invasive (fulminant) sinusitis, chronic invasive sinusitis, noninvasive fungal colonization (or mycetoma), and allergic mycotic sinusitis. Fungal hyphal forms are the most common causes of acute invasive sinusitis, with the most frequent being that of Aspergillus species. Mucormycosis is the next most common, with especially high prevalence in persons with diabetes, and is caused by the genus Mucor, belonging to the class of Zygomycetes. Members of this class thrive in high-sugar environments and are thus also found in decaying fruit. Although less common than hyphal forms, yeast forms occur in immunocompromised hosts and include Candida, Histoplasmosa, Cryptococcus, and Coccidioides. Common CT features of invasive fungal sinusitis include soft tissue changes in the sinus with highdensity opacification. In chronic infection, there is often thickened reactive bone, whereas acute invasive sinusitis often demonstrates focal bony erosion.19 Mycetoma has a characteristic hypointensity on T2-weighted magnetic resonance (MR) images. Mucormycosis has a predisposition for the orbits, cavernous sinuses, and skull base (Figs. 8 and 9) and also perineural invasion. Mucormycosis and aspergillosis can be aggressive infections that start usually in the nose and rapidly extend to the orbit and then intracranially by means of perivascular spread and bone destruction. The imaging diagnosis of mycotic sinus infections can be made using either CT or MR imaging, when the combination of bone destruction, nodular sinonasal mucosal thickening, and orbital or intracranial involvement is identified, typically in immunocompromised patients
- Computed tomography (CT) is the first-line imaging modality for orbital evaluation in the acute setting, with magnetic resonance (MR) imaging playing an important secondary role in the diagnostic work-up. he orbital septum provides a barrier against the spread of periorbital infections into the orbit proper (2). The distinction between periorbital and orbital processes is clinically important because postseptal infections are treated more aggressively to prevent devastating complications such as cavernous sinus thrombosis and meningitis. Periorbital cellulitis, which is defined as a preseptal process limited to the soft tissues anterior to the orbital septum, most commonly arises from the contiguous spread of infection from adjacent structures such as the face, teeth, and ocular adnexa. It also may arise from local trauma (3,4). Symptoms include swelling and erythema of the eyelids, chemosis, and, in severe cases, limitation of eye movement without proptosis. Orbital cellulitis is a postseptal infectious process most commonly caused by paranasal sinusitis (Fig 2), which spreads to the orbit via a perivascular pathway (2). Thus, bone destruction is not usually seen. The symptoms at presentation are similar to those of periorbital cellulitis; however, patients with orbital cellulitis also may present with proptosis Development of an orbital subperiosteal abscess is most commonly associated with ethmoid sinusitis Additional complications of orbital cellulitis include thrombosis of the superior ophthalmic vein, the cavernous sinuses, or both; bacterial meningitis; epidural and subdural abscess; and parenchymal brain abscess (4).
- Orbital subperiosteal abscess is a form of postseptal orbital cellulitis in which there is inflammatory tissue and edema formation beneath the orbital periosteum. This form of orbital cellulitis should be suspected in patients presenting to the emergency department with rhinosinusitis and ocular symptoms. Sinusitis of the ethmoid sinus is a common predisposing condition, with the lateral aspect of the ethmoid sinus being a commonly involved site. There may be a thin strip of preserved extraconal fat separating the abscess from the medial rectus muscleophthalmic vein thrombosis and cavernous sinus thrombosis are associated complications. Sinus infection may spread by direct extension or through the valveless communicating veins of the face, particularly to the orbit. The inflammatory process in the orbit produces edema and cellulitis, progressing to subperiosteal and intraorbital abscess (
- There is right periorbital and malar soft tissue swelling. The right lacrimal gland is enlarged with surrounding fat stranding. There is also fat stranding in the superolateral aspect of the right orbit with mild thickening of the lateral and superior rectus muscles. The globes are unremarkable. No orbital fracture is seen. Retention cysts or polyps are seen in the maxillary sinuses. No dental abscess is identified. Dacryocystitis is inflammation and dilatation of the lacrimal sac, which is located along the inner canthus (7). Although the diagnosis of dacryocystitis is based on clinical manifestations, imaging may be requested to exclude orbital cellulitis. The typical imaging finding is a well-circumscribed round lesion that is centered at the lacrimal fossa and that demonstrates peripheral enhancement (
- Periodontal swelling on the right, pain with EOM, fever. Diabetic. The right lacrimal gland is enlarged with surrounding fat stranding. There is also fat stranding in the superolateral aspect of the right orbit with mild thickening of the lateral and superior rectus muscles.
- common among children, and abscess formation is usually the end result of a suppurative adenitis of the retropharyngeal lymph nodes (Fig. 11) but can also be secondary to penetrating trauma or iatrogenic injury from endoscopy or intubation. 13,24 Retropharyngeal infections typically localize off the midline, on either side, posterolateral to the pharyngeal mucosal space. Cervical spine infections can also serve as the nidus for eventual retropharyngeal space infection. 2,25,26 Because the retropharyngeal space extends to approximately the level of T3 in themediastinum, a retropharyngeal abscess can result in mediastinitis.
- Calcific tendonitis affecting the longus coli muscle was first described by Hartley31 in 1964. The clinical presentation for this condition is varied, but there is generally no history of head/ neck infection and no cervical lymphadenopathy. There may be a mild leukocytosis and/or an elevated erythrocyte sedimentation rate. 32 The classic radiographic description is an amorphous calcification anterior to the C1-C4 vertebral bodies with prevertebral soft tissue swelling. However, radiography is unreliable for the diagnosis, and CT has long been considered the preferred modality. 33 On CT, an amorphous calcification is seen moreclearly, is localized to the prevertebral space, and is reliably differentiated from an avulsed fracture (Fig. 20). A diffuse edema or discrete effusion can be differentiated with MR imaging, 34 although this distinction is usually not necessary. However, differentiating this entity roma retropharyngeal abscess is necessary to avoid drainage or surgery. After treatment with nonsteroidal antiinflammatory drugs, this condition is self-limited in about 1 to 2 weeks. Longus colli tendinitis produced by deposition of crystals of hydroxyapatite in the prevertebral tendons can present with dysphagia of acute onset and clinically mimic acute infection. CT demonstrates longus colli tendon enlargement with calcifications, usually at the C1-C2 vertebra
- Mastoiditis most commonly occurs as a result of infection of the middle ear, with the route of spread involving the aditus ad antrum, the mastoid antrum, and eventually the mastoid air cells. Mastoiditis can less frequently be the result of the complication of a cholesteatoma. Destruction of the septa of the mastoid air cells signals the transformation of the incipient mastoiditis to the coalescent form, which portends a worse prognosis. In addition, coalescent mastoiditis has several associated complications, including epidural abscess, sigmoid sinus thrombosis, petrous apicitis, subdural empyema, carotid artery spasm or arteritis, and Bezold abscess. 23 On CT, coalescent mastoiditis demonstrates destruction of the mastoid air cell septa. If the mastoid tip suffers osteolysis, phlegmon and eventually abscess may organize with extent into the cervical soft tissues inferiorly; the resultant abscess is termed Bezold abscess (Fig. 12). .
- 55year old male presented with neck swelling and pain
- This entity is thought to arise in a preexisting laryngocele with stasis, resulting in secondary infection. The incidence is low and has been reported as 1 in 2.5 million in the United Kingdom. 41 Although a rare diagnosis, laryngopyocele can present as an acute airway emergency, 42 and thus it is important to recognize this condition early. Clinical presentation may include odynophagia, aspiration, and respiratory compromise. Intubation or tracheostomy, use of broadspectrum antibiotics, and needle or surgical decompression are considered necessary in the treatment of laryngopyocele. CT demonstrates a fluid or missed fluid-air density collection emanating from the laryngeal ventricle, with extension superolaterally into the paraglottic fat. Thick rim enhancement of the walls indicates inflamma
- Acute epiglottitis in adults is a cellulitis of the epiglottis, aryepiglottic folds, and adjacent tissues (Fig. 22). If not treated promptly, this condition can progress to a life-threatening airway obstruction. Epiglottitis results from bacteremia or direct invasion of the epithelial layer by the pathogenic organism, which typically travels from the posterior nasopharynx. Although the incidence of epiglottitis in children has decreased because of the H influenzae type b (Hib) vaccination, this bacterium is still the most common causative organism. 38 The incidence of epiglottitis in adults appears to be increasing. 39,40 Adult epiglottitis may represent a distinct form of epiglottitisbecause the supraglottic tissues are involved in most cases, and culture yields are uniformly lower
- here is a 3.3 x 2.2 x 2.4 cm, consistent with a tonsillar abscess. There. Mucosal edema is seen extending along the left lateral wall of the hypopharynx causing effacement of the left vallecula and pyriform sinus. Left cervical lymphadenopathy is seen along the jugular chain. The nasopharynx, supraglottic and infraglottic larynx, vocal cords and upper trachea are unremarkable. There is a 3 mm hypodense nodule in the left thyroid. The vessels of the neck are well opacified. No filling defect is seen. Straightening of the cervical spine is identified, which may be related to muscle spasm. Impression: Severe tonsillitis with a large left tonsillar abscess and marked pharyngeal mucosal edema extending from the palate to the level of the glottis resulting in severe airway narrowing.
- Septic thrombophlebitis of the internal jugular vein is a frequent pathology and can occur as a primaryevent or, more commonly, as a complication from indwelling catheters. CT findings include reactive inflammatory changes in the perivascular space and the presence of a thrombus within the vessel lumen. Lemierre syndrome represents infectious thrombophlebitis complicated by septic pulmonary emboli (Fig. 8). 13–15 Other potential
- The role of diagnostic imaging is to define the location of the infection and the possible presence a drainable fluid collection and to search forextension of disease beyond the site of origin. A careful assessment of potential severe complications, such as vascular compromise, osteomyelitis, and airway narrowing, should be performed routinely. These goals can be achieved with the appropriate use of contrast-enhanced CT and MR imaging in selected cases.