On Call Head and Neck Gladwin Hui Acknowledgement: Special thanks to Elissa Price
CT Head and Neck Emergency Requests from Emerg or ENT Talk to referring physician to make sure airway is secured IV Contrast Neck vs. C-spine
CT Head and Neck Difficult studies Not very often (maybe once a month) Focus on the urgent issues (will take a long time to learn Head and Neck well)
Technique Skull base to below carina, to include top of pericardium
My Approach to CT Neck 1) Airway - Nasopharynx, oropharynx and hypopharynx (whole airway) - Trachea and esophagus 2) Deep neck spaces - Parapharyngeal space - Retropharyngeal space - Masticator space - Carotid space - Perivertebral space - Anterior visceral space - Submandibular/sublingual space
Approach to CT Neck 3) Glands - Parotid - Submandibular - Thyroid 4) Vessels and lymph nodes 5) Bones and Soft tissues 6) Neuro - Brain, orbits, paranasal sinuses, mastoid air cells 7) Cord 8) Chest - Lung apices - Mediastinum, Pericardial region
Approach to CT Neck Check your ABC’S Bottom Line A = AIRWAY B = BONES C = CAROTID SHEATH/VESSELS S = SPINAL CORD/CANAL
Anatomy: Fat Planes & Spaces Deep neck spaces - Parapharyngeal space - Retropharyngeal space - Masticator space - Carotid space - Perivertebral space - Anterior visceral space - Submandibular/sublingual space
Lateral pterygoid muscle Masticator space
Pharyngeal mucosal space Nasopharynx
Medial Pterygoid Muscle Parotid
Parapharyngeal space Styloid process ECA Internal jugular vein ICA Carotid space
Uvula Nasopharynx Oropharynx
Retropharyngeal space
Posterior belly digastric muscle
Perivertebral space
Back edge submandibular gland Lt JDG node Jugulodigastric lymph node </= 1.5-cm
Back edge sternocleidomastoid muscle
mylohyoid
ad ad= ant belly digastric muscle
Epiglottis Vallecula Oropharynx Hypopharynx
Submandibular space Submandibular Gland
Hyoid bone
Hyoid bone
Hyoid bone
Aryepiglottic Folds
Piriform sinus
Cricoid cartilage
Cricoid cartilage
Cricoid cartilage
Cricoid cartilage
Thyroid Cricoid cartilage
Anterior Visceral Space Extends from hyoid bone to anterior mediastinum Sling around the trachea, esophagus Contiguous with the retropharyngeal space
Retropharyngeal Space Extends from skull base to superior mediastinum Limited anteriorly by middle layer of deep cervical fascia, and posteriorly by deep layer of deep cervical fascia Extends to mid T-spine, then connects to Danger space and closed off by connective tissue at carina Content: Fat, LN
Danger Space Extends from skull base to diaphragm in the posterior mediastinum Posterior to retropharyngeal space Lies between the alar and prevertebral layers of the deep cervical fascia Spread of infection from neck to mediastinum
Carotid space – Neurovascular Bundle Extends from skull base to mediastinum CCA, IJV, Vagus Dissection, narrowing, aneurysm, rupture Thrombus Mass
Parapharyngeal Space Key landmark – primarily fat-containing How is it being effected by a process going on in the region?
Retropharyngeal space Parapharyngeal space Carotid artery Internal jugular vein
Tonsil Submedial pterygoid space Parapharyngeal space Parotid gland Neurovascular bundle Retropharyngeal space
Anterior visceral space Retropharyngeal space Neurovascular bundle
Visceral space Esophagus Retropharyngeal space
Tonsil Parapharyngeal space Submandibular gland
Parapharyngeal space Medial pterygoid muscle Submandibular gland Submandibular space
Submandibular and Sublingual Spaces Important regions to evaluate for floor of mouth infections
Pathophysiology Cellulitis Phlegmon Fluid collections Abscess
Cellulitis Focal or diffuse Streaky infiltration of fat planes Diffuse enlargement of adjacent muscles No focal loculation of fluid
Cellulitis
Phlegmon Slightly heterogeneous solid swelling May be minimal low density suggestive of fluid loculation developing Usually seen in tonsillar/peritonsillar or retropharyngeal locations
Phlegmon
Fluid Collections homogeneous or minimally heterogeneous no good peripheral margin, no enhancement turns the fat planes grey
Fluid Collection
Abscess Well-defined capsule Little or no cellulitic change in adjacent tissues Often adjacent to bone (secondary to osteomyelitis)
Complications ALWAYS CHECK FOR: Airway obstruction Carotid pseudoaneurysm or rupture Internal jugular vein thrombosis Mediastinitis/fluid collection/abscess Pericarditis
Dental Infections Usually mandibular, usually molar Submedial pterygoid space Floor of mouth Anterior visceral space Parapharyngeal space Neurovascular bundle Retropharyngeal space
Ludwig’s Angina Cellulitis that involves inflammation of the tissues of the floor of the mouth, under the tongue Extremely dangerous Early airway compromise Extensive edema of tongue and floor of mouth +/- Floor of mouth fluid/air No abscess Dental origin
Tonsil Unilateral swollen tonsil Parapharyngeal space Floor of mouth Neurovascular bundle Retropharyngeal space
Iatrogenic Post-intubation Post-endoscopy
Pharyngeal/Esophageal Perforations Air in the fat planes Retropharyngeal space Neurovascular bundle Mediastinum
Salivary Gland Obstruction Parotid Submandibular
Courtesy: Learning Radiology
Courtesy: Learning Radiology Epiglottitis on Lateral Xray
My Approach to CT Neck 1) Airway - Nasopharynx, oropharynx and hypopharynx (whole airway) - Trachea and esophagus 2) Deep neck spaces - Parapharyngeal space - Retropharyngeal space - Masticator space - Carotid space - Perivertebral space - Anterior visceral space - Submandibular/sublingual space
Approach to CT Neck 3) Glands - Parotid - Submandibular - Thyroid 4) Vessels and lymph nodes 5) Bones and Soft tissues 6) Neuro - Brain, orbits, paranasal sinuses, mastoid air cells 7) Cord 8) Chest - Lung apices - Mediastinum
Approach to CT Neck Check your ABC’S Bottom Line A = AIRWAY B = BONES C = CAROTID SHEATH/VESSELS S = SPINAL CORD/CANAL
Good resources Statdx http://www.med.wayne.edu/diagRadiology/Anatomy_Modules/axialpages/Overview.html
Thank you