Oslo4 HN emergenciesFh24-files.s3.amazonaws.com/110213/692971-xuLEM.pdf · Neck infection Imaging...
Transcript of Oslo4 HN emergenciesFh24-files.s3.amazonaws.com/110213/692971-xuLEM.pdf · Neck infection Imaging...
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Kathleen R. Fink, MDUniversity of Washington5th Nordic Emergency Radiology Course
May 21, 2015
+ Disclosure
My spouse receives research salary support from:
Bracco
BayerHealthcare
Guerbet
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Outline
Case-based review of head and neck emergencies:
1. Foreign body
2. Neck infection focusing on complications
3. Sinus infection
4. Acute orbital abnormalities
5. Mastoid infections
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ CT: Dysphagia after eating chicken casserole last night
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Foreign body—in esophagus.
Are we done?
Pearl: esophageal foreign body: looks for signs of perforation
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May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT: Esophageal foreign body
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Esophageal wall edematous and enhancing.
Fat stranding in visceral space surrounding the esophagus
No extraluminal gas and FB appears confined to lumen
Endoscopy is therapeutic (object retrieval) and diagnostic (perforation)
In this case, esophageal wall irritated, but not perforated.
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+ Foreign body: Aspirated insulin cap
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Patient with neurodegenerative disease arrived to ER, worried he had swallowed the cap to an insulin syringe.
But what would that look like? Could you see a plastic cap on CT?
Aha! Savvy resident, Lauren Toney, decided to image the patient with a second syringe cap on the skin surface so she would know what to look for.
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May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyPitfall: Appropriate window and level vital to find subtle foreign body
+ Foreign body: disk/button battery
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Vital to diagnosis FB as battery due to possibility of erosive changes from: Electrolyte leakage
Alkali produced in situ
Mercury toxicity (if Hg battery) - theoretical
Pressure necrosis -theoretical
Batteries can become lodged many places:
Esophagus Nasal cavity
Ear
Lin et al, Int J Pediatr Otorhinolaryngol 68:4, 473-9. 201
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From: Lin, Daniel and PapsinInt J Pediatr Otorhinolaryngol 68:4, 473-9
Differentiating battery from coin can be difficult.
Raise the possibility!
Look for double ring sign.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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Foreign bodyHelpful to know what you are looking for.
Appropriate window/level.
Main concern: airway obstruction
Beware of disk batteries: regardless of location.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Neck Infection
Odontogenic abscess
Tonsillar abscess
Abscess versus phlegmon
Complications
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ CT: facial swelling and pain
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT: cellulitis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Soft tissue thickening (cellulitis)
Submandibular space
Stranding Sublingual space
Thickening of mylohyoid muscle and platysma (myositis)
No ring enhancing collection.
Subcutaneous edema and skin thickening
Treated with antibiotics
Pearl: If there is no enhancing mass or collection, the term cellulitis is appropriate
+ CT: One week later, worsened swelling
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ CT: Phlegmon/Abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Low density collection with surrounding enhancement.
Phlegmon: Enhancing inflammatory mass preceding abscess
Abscess: Ring enhancing fluid.
Here: Aspirated 10 ml pus
+ CT: companion case
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Phlegmon! No pus on I&D
Pitfall: There is an imaging overlap between abscess and phlegmon
+ Differentiating cellulitis/phlegmon from abscess Important distinction because abscess requires
surgical I&D but cellulitis/phlegmon may be successfully treated with antibiotic therapy alone.
CT has limitations: Positive predictive value for abscess versus cellulitis: 71 -94% Negative predictive value 26-53%
Imaging criteria for abscess: Area of decreased attenuation with complete rim of contrast
enhancement. If no well definite rim, diagnosed “cellulitis”
Accuracy increased when correlated with clinical examination
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyVural, et al, Am J Otolaryngol 24:3, 143-8, 2003. Rosenthal et al, J Oral Maxillofac Surg 69:6, 1651-6 2011
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+ CT: “Slam dunk” abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Pearl: Look at teeth on bone windows if you see abscess or cellulitis involving submandibular or sublingual spaces
+ CT: Maxillary teeth can also be involved.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Odontogenic abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Often involves submandibular space
May involve sublingual space if anterior teeth are involved.
Look for cortical dehiscense of alveolar ridge
Look for dental disease: Periapical abscess Severe dental caries
Evaluate bone changes for osteomyelitis: Permeative bone lesion Osseous destruction Periosteal reaction
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+ CT: Sore throat and swelling
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT Tonsillitis:
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Unilateral enlarged tonsil
No low density collections
May be edematous with a striated appearance
May see bilaterally enlarged tonsils
“Kissing tonsils”
Lymphoid hyperplasia is the differential
+ CT: Sore throat
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ CT: Tonsillar abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Findings:
Low density well circumscribed collection in palatine (faucial) tonsil
Fat stranding in parapharyngeal space but no frank abscess extension
Pus aspirated
+ CT: Parapharyngeal space.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT: Tonsillar versus peritonsillar abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Tonsillar abscess versus peritonsillar abscess terminology used loosely!
Definition 1: Peritonsillar abscess extends through fibrous tonsillar capsule but may still be bounded by the superior constrictor muscle (CT cannot distinguish)
Definition 2: Peritonsillar abscess refers to extension into surrounding spaces, usually submandibular or parapharyngeal (CT can distinguish)
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+ Peritonsillar abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyPearl: Always look carefully at fat-containing parapharyngeal space with tonsillar infections
+ Peritonsillar abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Definite extension into parapharyngeal space, masticator space, and carotid space
Note mucosal edema of uvula and narrowing of oropharynx
Consider infectious complications!
+ Peritonsillar abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Definite extension into parapharyngeal space, masticator space, and carotid space
Note mucosal edema of uvula and narrowing of oropharynx
Consider infectious complications!
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+ Neck Infection: Complications
Thrombophlebitis
Lemierre Syndrome
Arteritis
Mediastinitis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT: Neck swelling after IVDA
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Complications: thrombophlebitis
Because of antibiotic therapy, septic thrombophlebitis is increasingly uncommon after typical head and neck infections
Certain risk factors
Intravenous drug use
Central venous catheterization
Malignancy/neck dissection
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyLin et al, Laryngoscope 114:1, 56-60 2004
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+ Complications: Pulmonary abscesses
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Lemierre syndrome (postanginal septicemia or necrobacillosis)
Originally reported after odontogenic, tonsillar or peritonsillar abscess, mastoiditis, other infections
“Metastatic abscesses”
- Lung abscess
- Pulmonary Empyema
- Liver or renal lesions
- Septic arthritis
Lemierre, Lancet 227:5874, 701-703 1936
Increasingly rare due to antibiotic treatment
Several days of progressive left ear pain, neck stiffness and developing area of redness over left neck and ear.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Involves retropharyngeal space
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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Involves carotid space
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ Complication: Carotid artery pseudoaneurysm
Pseudoaneurysm is a rare but potentially life threatening complication of neck infection.
Left untreated, may increase in size and/or rupture.
Arterial narrowing/spasm from arteritis should also be specifically evaluated
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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Progressive dysphagia and sore throat
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Involves multiple spaces:Pharyngeal mucosal space and parapharyngeal space
Submandibular space
Carotid space
Retropharyngeal space
Visceral space
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Where does the collection end?
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+ Complications: Mediastinitis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Uncommon but important complication of retropharyngeal infection due to high mortality (20-40%)
Retropharyngeal space extends from skull base to mediastinum (T3 or so)
Provides a path of infection from neck to chest
Important to recognize to allow early debridement, which requires involvement of thoracic surgeons.
Sandner et al J Oral Maxillofac Surg 65:4, 794-800 2007
Right mandibular pain, treated with antibiotics. Returned to ED with progressive swelling and taken urgently to OR
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ Special case: Ludwig’s angina
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Rapidly progressive infection of the floor of mouth, usually of odontogenic origin
Hallmarks:
Extension across midline, into deeper cervical spaces
Cellulitis/soft tissue edema without liquefaction
Airway compromise is the main clinical concern.
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Neck infectionImaging overlap between phlegmon and abscess
Complete ring enhancement increases likelihood of abscess
Evaluate for complications
Extension into adjacent cervical spaces
Image entire involved area
Vascular involvement
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Sinus infection: bacterial
Presume Acute bacterial sinusitis if: Symptoms last longer than 10 days
Worsened symptoms within 10 days after an initial improvement (viral to bacterial transition).
No need for imaging.
Consider imaging if Suspect alternative diagnosis
Treatment failure
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Rosenfeld et al. Otolaryngol Head Neck Surg 137:3 Suppl, S1-31 2007
+ CT signs of acute bacterial sinusitis.Imaging findings correlating with acute bacterial sinusitis include:
Sinus opacification
Air-fluid level
Moderate to severe mucosal thickening.
CT better than radiographs
Evaluate for complications:
Orbital, intracranial, deep face extension
MRI is only indicated for suspected complications of acute rhinosinusitis.
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyRosenfeld et al. Otolaryngol Head Neck Surg 137:3 Suppl, S1-31 2007
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+ Sinus infection: fungal
Multiple subtypes:
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Invasive Noninvasive
Acute invasive fungal sinusitis
Allergic fungal sinusitis
Chronic invasive fungal sinusitis
Fungal mycetoma
Chronic granulomatous invasive fungal sinusitis (rare in US)
Aribandi et al. Radiographics 27:5, 1283-96 2007
+ Acute invasive fungal sinusitis
Patients at risk: Immunocompromised Poorly controlled diabetes
High mortality
Painless necrotic usually nasal septal ulcer sinusitis rapid orbital and intracranial spread death
Angioinvasion and hematogenous dissemination
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Acute invasive fungal sinusitis
Imaging: Hypoattenuating mucosa or
small area of soft tissue attenuation in lumen of nasal cavity or sinus.
Subtle mucosal thickening with bone erosion
Check fat planes along sinuses carefully!
Early MRI to eval for intracranial and intraorbital extension.
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyMucormycosis
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+ Fungal sinusitis running amok
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology Woman with CLL and facial pain
+ Fungal sinusitis: vascular complications Expanded nonenhancing left
cavernous sinus
Cavernous sinus thrombosis
Loss of left cavernous carotid enhancement
Carotid occlusion
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+Invasive fungal sinusitis: Hallmarks
Early invasion
Vascular invasion
• Venous thrombosis
• Arterial involvement• Aneurysms
• Infarcts
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Basilar artery aneurysm due to sphenoid sinus aspergillus infection
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+ Sinus Infection: complications
Orbital extension
Soft tissue extension (Pott’s puffy tumor)
Subdural empyema, epidural abscess
Venous sinus thrombosis
Intracerebral abscess
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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FLAIR
Complications: Orbital and Epidural extension
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
T2
T1 post
+ Complications: Subdural empyema and Potts’ puffy tumor
May 21,2015Fink: 5th Nordic Course in Emergency Radiology
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SinusitisBacterial sinusitis is a clinical diagnosis.
Imaging is to evaluate for complications: Orbital extension Intracranial extension Venous sinus thrombosis
In immunocompromised patients, always look for invasive fungal sinusitisHallmarks: bone erosion and involvement of adjacent fat planes
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Acute orbital abnormalities
Abscess: Preseptal/postseptal
Hemorrhage Vitreous
Choroid
Retinal
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Orbital inflammatory disease, Chandler classification*Classification Category Description
Stage 1 Pre-septal Eyelid or skin swelling
Stage 2 Orbital cellulitis Orbital fat involvement, proptosis
Stage 3 Subperiosteal abscess Pus beneathperiosteum of bony orbit
Stage 4 Orbital abscess Pus within the orbit
Stage 5 Cavernous sinus thrombosis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology*Chandler et al The Laryngoscope 80:9, 1414-1428. 1970
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+ Preseptal cellulitis:
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyFrom: Matthew et al. Br J Radiol 87:1033, 20130503. 2014
Pearl: Always look carefully retrobulbar fat to determine post septal involvement. Reformats helpful.
Preseptal: Cellulitis limited to eyelid and periorbital soft tissue.
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Preseptal
Postseptal
+ Postseptal cellulitis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Preseptal
Postseptal
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Post septal cellulitis often results from sinus disease, particularly from ethmoids through lamina papyracea
May cause:
Increased intraorbital pressure
Central retinal artery or vein occlusion
Optic nerve stretching or damage
Contrast enhanced study may help evaluate for abscess.
Importance of post septal involvement:
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ Importance of post septal involvement:
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Extraconal and intraconal involvement
+ Retinal hemorrhage
Retinal hemorrhage/detachment
- Hyperdense material in V shape with apex at optic nerve head
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Choroidal hemorrhage
Choroidal hemorrhage/detachment
- Hyperdense material in concave shape, often bilateral
Be aware: some globe surgeries can result in an appearance of choroidal hemorrhage.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ Vitreous hemorrhage/Globe rupture Hyperdense material in the
vitreous chamber.
Here see associated loss of globe shape and volume loss Globe rupture.
Be aware: some retinal re-attachment procedures can result in an appearance of vitreous hemorrhage.
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ Lens dislocation
Hyperdense material in vitreous chamber looks really concave.
Lens dislocation Occurs with disruption of
zonular fibers of ciliary body
Dislocation usually posterior
If bilateral, think connective tissue disorder such as Marfan’s
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+Acute orbital abnormalitiesInfection:
Important to determine whether there is post septal involvement
Evaluate for signs of increased intraocular pressure
Orbits are a radiology blind spot. Don’t forget to look!
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ CT: Red swollen mass behind ear
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
+ CT: Otomastoiditis
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Fluid opacification of middle ear and mastoids
Antibiotics have dramatically decreased the incidence acute mastoiditis and complications.
Coalescent mastoiditis: Erosion of mastoid air cells.
Bezold abscess*: extension to the soft tissues of the neck, usually through erosion through the mastoid tip
*Nelson: Am J Emerg Med 31:11, 1626.e3-4 2013
+ Mastoiditis:
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Same patient: associated gas in epidural space. Contrast clearly demonstrates the associated epidural abscess
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+ Mastoiditis: Complications
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Complications include:
Sigmoid sinus thrombosis
Empyema
Subdural abscess
Epidural abscess
Luntz Laryngoscope 122:12, 2813-7 2012
+ Mastoiditis: Complications
May 21,2015K. Fink: 5th Nordic Course in Emergency RadiologyFrank cerebral abscess
Left transverse and sigmoid sinus thrombosis
Pearl: Always remember to check venous sinuses!
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MastoiditisOften treated before complications occur.
Evaluate for
Intracranial extension
Venous sinus thrombosis
Extracranial soft tissue extension (Bezold abscess)
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
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+ Outline
Case-based review of head and neck emergencies:
1. Foreign body
2. Neck infection focusing on complications
3. Sinus infection
4. Acute orbital abnormalities
5. Mastoid infections
May 21,2015K. Fink: 5th Nordic Course in Emergency Radiology
Thank you!Kathleen [email protected]
Hard rain comes down on the University of Washington, Seattle campus. February 18th, 2014. Photo by Katherine B. Turner