IMAGING MEDICAL EMERGENCIES

of the NECK(and beyond)

MI Zucker, MD

A dr Z Lecture

• On nontrauma conditions of the neck

RADIOGRAPHY

AP and lateral views.

You need BOTH!

POSITION

• NEVER lie a patient supine for radiographs

• ALWAYS do imaging upright

In supine position, you can lose the airway.

andYou may not be able to retrieve it.

ANATOMY

• Hard and soft palate

• Uvula

• Base of tongue

• Epiglottis

• Vallecula

• Aryepiglottic folds

• Larynx

• Trachea

• Prevertebral soft tissues

INFECTIONS

• Epiglottitis

• Croup

• Retropharyngeal cellulitis and abscess

• Ludwig’s angina

EPIGLOTTITIS

• Demographics are changing: fewer kids, more immune-impaired adults.

• Infectious agents are changing: less H. influenza (due to vaccine), more mixed bacterial.

• It is still a very serious and potentially lethal bacterial infection of the epiglottis and adjacent soft tissues.

EPIGLOTTITIS: Findings

• Thick biconvex epiglottis

• Thick, indistinct aryepiglottic folds

• Encroachment upon vallecula

• Distended hypopharynx

CROUP

• Viral tracheobronchitis

• Etiology: Parainfluenza and many other viruses.

• Demographics: Children under age 2 years, but any age including adults.

• Can be a very serious condition.

CROUP: Findings

• Subglottic trachea narrowing.

• This is the “steeple’ sign.

• Don’t confuse a normal closed glottis with subglottic inflammatory edema.

No STEEPLE vs STEEPLE

• No steeple: Steeple:

normal subglottic edema

Normal: No Steeple

Croup: Steeple Sign

RETROPHARYNGEAL or PREVERTEBRAL

INFECTION

• Cellulitis or abscess:

• Distinction is important:

Cellulitis is treated with IV antibiotics.

Abscess needs to be surgically drained in addition to IV antibiotics.

RETROPHARYNGEAL INFECTION: Findings

• Enlargement and abnormally convex contour of the prevertebral soft tissues.

• Swelling may extend to anterior soft tissues.

• If gas bubbles are present: abscess.

• If no gas seen, cellulitis or abscess.

• Plain films can be indeterminate: CT is definitive.

CELLULITIS

• Thick retropharyngeal soft tissues with abnormal contour

(can’t exclude abscess, however)

PREVERTEBRAL ABSCESS

• Enlarged prevertebral soft tissues with abnormal contour

• Gas bubbles within the soft tissues

LUDWIG’S ANGINA

• A severe bacterial infection of the base of the tongue.

• Uncommon.

LUDWIG’S ANGINA: Findings

• The base of the tongue is markedly thickened and enlarged and encroaches upon the vallecula.

• The inflammatory process may involve adjacent soft tissues.

ALLERGIC REACTIONS

• Edema of any of the soft tissues.

• Variety of causes: drugs, food, insect stings.

UVULA EDEMA

• The soft palate and especially the uvula are enlarged.

FOREIGN BODIES

• Accidental

• Iatrogenic

• Deliberate (“selfogenic”)

• Metal, bone, food, plastic, wood.

FOREIGN BODIES: Locations

• Nasopharynx• Vallecula• Pyriform fossae• Hypopharynx• Esophagus• Trachea

FISH BONE

Location: Esophagus

• Fish bones vary in their visibility, depending upon the species of fish.

• In general, they are harder to see than chicken bones.

CHICKEN BONE

Location: vallecula

Chicken bones are easier to see than fish bones.

USDA GRADE A CHICKEN TAB

BASEBALL MISADVENTURES

• Dodger dog.

• Dodger beer

METAL OBJECTS

• Razor blade in mouth

• Dental drill in pyriform fossa

SILVER SOUP LADDLE

COINS

• On PA view

In esophagus: en face.

In trachea: on edge.

• However, always get a lateral view and you won’t have to remember this.

TWENTY CENTS

INGESTED FOREIGN BODIES

• ESOPHAGUS:• Must be removed

quickly, either UP or DOWN.

• DISTAL GI TRACT:• Good chance will pass

on own.• However, sharp

objects may perforate and large objects may obstruct and batteries can erode.

BATTERIES

• Ingestion of batteries, especially mercury or lithium for cameras and small electronic instruments, are a MEDICAL EMERGENCY!

• They can erode through the esophagus wall in a short time.

• Once they pass GE junction, they are less of a danger, but still can erode.

DRUG SMUGGLING

• Body Packers or ‘Mules’ electively ingest drugs, usually cocaine or heroin, wrapped in condoms.

• Body Stuffers ingest the drugs they are carrying emergently when about to be apprehended.

COCAINE SMUGGLING MISADVENTURES

• Cocaine is smuggled into the USA INSIDE human ‘Mules’.

• The drugs are wrapped in condoms and swallowed.

• Each condom contains 10 grams of cocaine.

• Each ‘mule’ carries 100 condoms.

• The total per ‘mule’ is 1000 grams.

• The condoms may leak, and cocaine is readily absorbed from the GI tract.

• The average lethal dose is only 1.2 grams, much less than in ONE condom.

BODY PACKER

GOODBYE

• Copyright 2004

MI Zucker