1. IMAGING MEDICAL EMERGENCIES of the NECK (and beyond)
MI Zucker, MD

2. A dr Z Lecture
On nontrauma conditions of the neck

3. AP and lateral views. You need BOTH!
RADIOGRAPHY
AP and lateral views.
You need BOTH!

4. POSITION NEVER lie a patient supine for radiographs
ALWAYS do imaging upright

5. In supine position, you can lose the airway. and
You may not be able to retrieve it.

6. ANATOMY Hard and soft palate Uvula Base of tongue Epiglottis Vallecula
Aryepiglottic folds
Larynx
Trachea
Prevertebral soft tissues

8. INFECTIONS Epiglottitis Croup Retropharyngeal cellulitis and abscess
Ludwig’s angina

9. 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.

10. EPIGLOTTITIS: Findings
Thick biconvex epiglottis
Thick, indistinct aryepiglottic folds
Encroachment upon vallecula
Distended hypopharynx

12. 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.

13. CROUP: Findings Subglottic trachea narrowing.
This is the “steeple’ sign.
Don’t confuse a normal closed glottis with subglottic inflammatory edema.

14. No STEEPLE vs STEEPLE
No steeple: Steeple:
normal subglottic edema

15. Normal: No Steeple

16. Croup: Steeple Sign

17. 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.

18. 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.

19. CELLULITIS Thick retropharyngeal soft tissues with abnormal contour
(can’t exclude abscess, however)

20. PREVERTEBRAL ABSCESS
Enlarged prevertebral soft tissues with abnormal contour
Gas bubbles within the soft tissues

21. LUDWIG’S ANGINA
A severe bacterial infection of the base of the tongue.
Uncommon.

22. 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.

23. ALLERGIC REACTIONS Edema of any of the soft tissues.
Variety of causes: drugs, food, insect stings.

24. UVULA EDEMA
The soft palate and especially the uvula are enlarged.

25. FOREIGN BODIES Accidental Iatrogenic Deliberate (“selfogenic”)
Metal, bone, food, plastic, wood.

26. FOREIGN BODIES: Locations
Nasopharynx
Vallecula
Pyriform fossae
Hypopharynx
Esophagus
Trachea

27. 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.

28. CHICKEN BONE Location: vallecula
Chicken bones are easier to see than fish bones.

29. USDA GRADE A CHICKEN TAB

30. BASEBALL MISADVENTURES
Dodger dog.
Dodger beer

31. METAL OBJECTS
Razor blade in mouth
Dental drill in pyriform fossa

32. SILVER SOUP LADDLE

33. 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.

34. TWENTY CENTS

35. 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.

36. 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.

37. 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.

38. 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.

39. BODY PACKER

40. GOODBYE
Copyright 2004
MI Zucker