Head &Neck 911Imaging of Neck & Airway Emergencies

Michelle A. Michel, M. D.Professor of Radiology and Otolaryngology

Medical College of Wisconsin, Milwaukee, WI

Disclosure of Commercial Interest• Neither I nor my immediate family (that

would be my Bichon Frise “GoGo”) have

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 EmergenciesObjectives

• Review emergent, non-

traumatic adult conditions of

the neck

• Emphasize imaging findings to

make the correct diagnosis,

identify secondary findings,

and recognize potential

complications

• Topics

• Neck space

infection/inflammation

• Conditions affecting the airway

• Non-traumatic vascular lesions

Neck & Airway EmergenciesOverview

• What constitutes a H&N

Emergency?• Condition is life threatening

• Condition could cause loss of function

• Condition causes severe pain or distress

• Condition that if not identified early may result

in a situation that is life-threatening, causes

loss of function or severe pain/distress

• Vital anatomy in the H&N• Airway, vasculature, neural elements

• In close proximity

• Big problems if findings missed or

misinterpreted!Jean-Baptiste Marc Bougery

(1831-1854)

Neck & Airway EmergenciesImaging Approach

• Conventional radiographs & MRI

have little role in acute setting

• CT is primary imaging modality

in emergent H&N conditions

• Fast image acquisition

• Relatively insensitive to patient

motion

• Large FOV & high spatial resolution

• Reformatted images from single

acquisition

• Widely available

• Benefits in emergent setting outweigh

risks of radiation exposure

• Dose-limiting technologies

• Role of imaging

• Identify location &

source

• Assess anatomic

extension – pattern of

spread

• Orbit, intracranial, airway,

vessles, thoracic cavity

• Detect complications

• Guide drainage

Neck & Airway EmergenciesNeck Space Infection & Inflammation

Neck & Airway EmergenciesNeck Space Infection & Inflammation

• Glandular “emergencies”

• Tonsillitis & peritonsillar

abscess

• Acute calcific prevertebral

tendonitis

• Odontogenic infection

• Floor of mouth infection

(Ludwig angina)

• Deep neck space infection

• Necrotizing fasciitis

57 year old male with left neck swelling & pain

Neck & Airway EmergenciesGlandular “Emergency”

Acute Submandibular Sialolithiasis-adenitis

Neck & Airway EmergenciesAcute Sialoadenitis

• Facial swelling & tenderness

↑ 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

• No stone?...look for anterior

FOM mass!

Acute on Chronic

Sialolithiasis/Sialoadenitis

Neck & Airway EmergenciesSialoadenitis

63 year old male with tongue pain and neck swelling

Sialoadenitis 2° Tongue/FOM SCCa

Courtesy C. Douglas Phillips, MD

Neck & Airway EmergenciesGlandular Emergency

Acute Sialolithiasis and SMG Abscess

Neck & Airway Emergencies

18 & 19 year old females with sore throat

Tonsillitis without Intratonsillar Abscess

Neck & Airway EmergenciesTonsillitis & Tonsillar Abscess

Intratonsillar Abscesses

• Young patients with sore

throat, trismus, tonsillar

enlargement & erythema

• EBV > Staph, Strep

• Imaging in severe cases

• Evaluate for abscess & extent

• Tonsillitis

• Enlarged, “kissing” in midline,

striated enhancement pattern

• Intratonsillar vs. peritonsillar

abscess

• Intratonsillar• Liquefaction contained by

capsule, enhancing rim

• No extension posterior to ICA/IJV

• Peritonsillar• Extends beyond capsule

into connective tissue between tonsil & superior constrictor ring

• Airway compromise

• Cellulitis in PPS, MS, RPS, PVS

Neck & Airway EmergenciesIntratonsillar vs. Peritonsillar Abscess

Confusing!

Courtesy C. Douglas Phillips, MD

41 year old female with sore throat & dysphagia

Acute Calcific Prevertebral Tendonitis

with RPS Effusion

Neck & Airway Emergencies? Tonsillitis

• Relatively rare &

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

colli tendons & inflammatory

tendonitis & RPS effusionCourtesy C. Douglas Phillips, MD

Neck & Airway EmergenciesAcute Calcific Prevertebral Tendinitis

33 year old female with facial swelling & trismus

Odontogenic Masticator Space Abscess

Neck & Airway Emergencies

• 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

Neck & Airway EmergenciesMasticator Space Infection

84 year old female with cheek swelling & erythema

Neck & Airway EmergenciesMasticator Space Infection

Maxilllary Odontogenic Abscess with SZMS Extension

Neck & Airway Emergencies

46 year old male with progressive anterior

neck swelling and erythema

Courtesy Mauricio Castillo MD

“Ludwig Angina”

Neck & Airway EmergenciesFloor of Mouth Infection – Ludwig Angina

• “Angina Ludovici”, “angina maligna”, “morbusstrangularis”

• 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

1790-1865

Neck & Airway EmergenciesFloor of Mouth Infection

Courtesy C. Douglas Phillips MD

69 year old male with fever & dysphagia

Retropharyngeal & PVS Abscess 2°

Cervical Osteodiscitis

Neck & Airway Emergencies

• RPS between buccopharyngeal fascia & alar fascia

• Clivus to T3 level

• Danger space between alar fascia & prevertebral fascia

• Clivus to above diaphragm

• Conduit to mediastinum

• Potential spaces &

indistinguishable on imaging

BPF AF

PVF

Neck & Airway EmergenciesDeep Neck Space Infection

Retropharyngeal & Danger Space Anatomy

Neck & Airway EmergenciesRetropharyngeal & Danger Space

Lateralized >

Lymph Node

Midline >

Effusion/Abscess

• Most common in children < 6 years• Ruptured suppurative LN

or penetrating FB

• Less common in adults• Immunocompromised or

diabetic

• Cervical osteodiscitis or post-spine surgery

• Imaging features• Tense fluid collection

• Wall enhancement / gas

• Image inferior extent!Courtesy Bernadette Koch, MD

Neck & Airway EmergenciesRetropharyngeal Abscess

Neck & Airway EmergenciesRetropharyngeal/Danger Space

Screw Extrusion with RPS/PVS Abscess

71 year old male post cervical fusion with fever & dysphagia

Neck & Airway EmergenciesDeep Neck Space Infection

Multispatial, Retropharyngeal & PVS Abscess

54 year old male with fever, neck pain, dysphagia,

and difficulty breathing

Surgical drainage performed…

1 week post RPS-PVS abscess drainage presented

with ↑ neck pain & paresthesias

Cervical Osteodiscitis with PVS → Epidural Abscess

Neck & Airway EmergenciesDeep Neck Space Infection

56 year old male with tonsillar abscess

RPS & DS Extension with Descending Mediastinitis

Neck & Airway EmergenciesDeep Neck Space Infection

• Mediastinitis 2° H&N infection > 1 °• RPS infection permeates

the alar fascia

• Infection spreads to danger space & with gravity extends into mediastinum

• Potentially life-threatening• Severe sepsis

• Cardiovascular collapse

Neck & Airway EmergenciesDescending Mediastinitis

Lee MK, et al. BMC Infectious

Diseases 2013 13:475

Neck & Airway Emergencies

Courtesy Philip Chapman, MD

50 year old patient post XRT for HP SCCa. Presents with sore

throat, difficulty swallowing, neck swelling, and sepsis

Radionecrosis of the Hyoid Bone and Thyroid Cartilage

…but there’s more…

Neck & Airway Emergencies

Courtesy Philip Chapman, MD

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 erosion, venous thrombophlebitis, aspiration pneumonia, airway compromise

• Multiple debridements often required

Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis

http://www.arquivosdeorl.org.br

nycems.blogspot.com

Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis

• Imaging features• Cellulitis: skin thickening,

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 C. Douglas Phillips, MD

Neck & Airway EmergenciesCervicofacial Necrotizing Fasciitis

Courtesy Deborah Shatzkes, MD

65 year old diabetic male with worsening posterior neck pain

& bloody drainage

46 year old female with sore throat & dysphagia

Courtesy Phil Chapman, MD

Neck & Airway EmergenciesAirway Emergencies

Supraglottitis

• 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

common in adults

Neck & Airway EmergenciesEpiglottitis & Supraglottitis

Courtesy Deborah Shatzkes, MD

40 year old female with intermittent right neck

swelling; follow up 18 months later

Laryngocele → Laryngopyocele

Neck & Airway EmergenciesAirway Emergencies

• Thin walled air or fluid-

filled cystic lesion

communicating with

laryngeal ventricle

• Types:

• Internal

• Mixed (external)

• Secondary laryngocele

• Laryngopyocele

Neck & Airway EmergenciesLaryngopyocele

Neck & Airway EmergenciesAirway Emergencies

67 year old female with rapid onset of tongue swelling &

difficulty breathing; Tx with ACE inhibitor x 1 year for HTN

Courtesy Philip Chapman, MD

ACE Inhibitor-Induced Angioedema

Neck & Airway EmergenciesLaryngotracheal Angioedema

Thyroiditis & Laryngeal Edema

• Generalized inflammation of

mucosa & submucosa

• Varying airway narrowing &

respiratory compromise

• Minor Δ in luminal size →

significant impact on airflow

• ↓ Diameter by ½ = ↑ airway

resistance 16x

• Etiologies: Drugs (ACE inh),

anaphylaxis, XRT, cellulitis

• Tx aimed at underlying

condition, airway protection

Neck & Airway EmergenciesVascular

• Jugular vein

• Thrombosis

• Thrombophlebitis

• Arterial

• Dissection

• Carotid

pseudoaneurysm

• Carotid “blowout”

Neck & Airway EmergenciesVascular

59 year old with lupus and renal failure developed neck

swelling after subclavian CVL placement

Courtesy Philip Chapman, MD

Jugular Vein Thrombosis

Neck & Airway EmergenciesVascular

Internal Jugular Vein Thrombophlebitis

20 year old female post removal of CVL 17 year old with sore throat, left neck swelling,

& respiratory distress

Neck & Airway EmergenciesVenous Thrombophlebitis

Courtesy C. Douglas Phillips, MD

Neck & Airway EmergenciesVenous Thrombophlebitis

17 year old with sore throat, left neck swelling,

& respiratory distress

Courtesy C. Douglas Phillips, MD

Neck & Airway EmergenciesVenous Thrombophlebitis

17 year old with sore throat, left neck swelling,

& respiratory distress

Courtesy C. Douglas Phillips, MD

Lemierre Syndrome

• Lemierre was a French

bacteriologist

• In 1936, published 20

cases of throat infections

followed by anaerobic

septicemia

• 18 patients died

• Septic thrombosis of facial,

EJ, or IJ veins following

suprahyoid neck infection

Neck & Airway EmergenciesLemierre Syndrome

Andre-Alfred Lemierre

1763-1820

Neck & Airway EmergenciesLemierre Syndrome

• Young patients

• Toxic, febrile (“picket fence”

fevers) 1 week post tonsillitis

• Fusobacterium necrophorum

• Neck tenderness

• May have respiratory distress

due to septic pulmonary

emboli from clot propagation

•Large joints 2nd most site of

emboli > septic arthritis

•Very high mortality

Courtesy Philip Chapman, MD

#1

#2

#3

Neck & Airway EmergenciesVascular

Carotid Artery “Blowout” (Pseudoaneurysm)

69 year old male 1 week post carotid endarterectomy

Neck & Airway EmergenciesVascular – Carotid “Blowout’

Patient post neck

dissection & XRT for SCCa

Courtesy Rebecca Cornelius MD

• Semi-contained

rupture/pseudoaneurysm

• Prior surgery, XRT >

carotid space infection,

vasculitis, trauma, tumor

invasion

• XRT damages vaso vasorum

• Can lead to exanguination,

emboli/ischemia

• Endovascular repair vs.

sacrifice

Neck & Airway EmergenciesSummary & Key Points

• CT is modality of choice for imaging of neck

emergencies

• Our role: Identify source, extent, & complications

• ? Orbital, intracranial, or thoracic spread

• ? Airway compromise, venous or arterial involvement

• Do not mistake RPS effusion for abscess

• Assess inferior extent of collections in the RPS & for

epidural extension if process involves the PVS

• Consider less common entities in the appropriate

setting

• Acute calcific prevertebral tendonitis, necrotizing fasciitis,

Lemierre syndrome

Thank You!