Figure 2b. Intracranial masses, large aneurysms of the circle of Willis, acute infarcts, and intracranial hemorrhages are additional examples of intracranial anomalies that can be seen on neck CT images. After completing this journal-based SA-CME activity, participants will be able to: ■ Describe how to systematically interpret the findings of neck CT performed in the emergency department. (c) Coronal contrast-enhanced CT image at the level of the parotid glands in a 22-year-old woman with acute left parotiditis shows edema, enlargement, and hyperenhancement of the left parotid gland (white arrowhead). The trachea (black arrow) and esophagus (black arrowhead) also are seen. Neck CT Scan with Contrast Unless contraindicated, intravenous contrast media is used when scanning the neck. The classic location of second branchial cleft anomalies is anterior to the sternocleidomastoid muscle, at the angle of the mandible; however, different types may manifest along a line between the oropharynx and the supraclavicular region (11). Following a 10-second delay, imaging is commenced. Between 20 and 49 in number, they drain lymph vessels from the lateral quadrants of the breast, the superficial lymph vessels from thin walls of the chest and the abdomen above the level of the navel, and the vessels from the upper limb. Apply a warm compress. A periodontal abscess is a focal pocket of pus that forms adjacent to a tooth owing to the direct spread of infection, such as pericoronitis, or following a bony breakthrough of periapical disease into adjacent soft tissues. The thrombus may extend superiorly to the sigmoid sinuses or inferiorly to the mediastinal veins. Figure 25b. Sialadenitis in two patients. Neck CT images show focal or diffuse low-attenuation swelling of all or some of the soft tissues of the upper airway. Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, Som P, Wolf GT. The two superior parathyroid glands are most commonly located dorsal to the superior poles of the thyroid gland, and the two inferior parathyroid glands are most commonly located inferior, dorsal, or lateral to the inferior thyroid pole (42). Wooden foreign bodies have air attenuation in the acute phase and therefore are best detected by using lung windows, and they may mineralize and increase in attenuation with time (30). Infection involving the orbits, paranasal sinuses, or temporal bones can spread to the intracranial compartment by means of bone dehiscence or through valveless diploic veins. (a) Axial nonenhanced CT image shows asymmetric soft-tissue thickening (white *) medial to the left mandibular ramus, as well as thickening of the left masseter muscle (black *). Visible Human Project . The drainage of lymph begins in lymph channels, which start as blind ended capillaries and gradually develop into vessels. If "level VII" is used for superior mediastinal lymph nodes, it should refer to the extension of the paratracheal chain below the suprasternal notch but above the level of the brachiocephalic artery 4. As a final note regarding this disease, when fungal sinusitis is suspected, this should be mentioned in the report, as the pathologist can use special stains, such as silver and periodic acid–Schiff stains, to highlight organisms that have invaded the vessel walls and lumen (59). The arterial lumens generally are uniform in diameter, except in the carotid bulb, a region of normal luminal widening at the origin of the internal carotid artery. Comparing the side of the clinical symptoms with the contralateral side can be helpful in determining whether there is erosion of the mastoid septa. Infection may spread into the periodontal or more distant tissues as a result of dental procedures such as tooth extraction (33). In children, contrast-enhanced CT of the neck depicts suppurated lymph nodes as round structures posterior to the pharynx, with decreased internal attenuation and a rim of enhancement . Swollen nodes that are close to your collarbone or the lower part of your neck when you're over 40 are more likely to be cancer. Left retropharyngeal suppurated lymph node and retropharyngeal abscess in a 5-year-old boy. The major salivary glands include the parotid, submandibular, and sublingual glands. The node is enclosed in a capsule and has an indentation on one surface (along one of its long axes) known as the hilum.The hilum is the point at which arteries carrying nutrients and lymphocytes enter the lymph node and veins leave it. Som PM, Curtin HD, Mancuso AA. If the dental disease is directly related to the reason that the examination was performed, a complete discussion is warranted. A person can actually be completely free of the signs but get diagnosed during a general medical checkup. MRI is superior to CT for the diagnosis of discitis and osteomyelitis, particularly early in the course of disease, and should be performed if discitis or osteomyelitis is suspected. Normal epiglottis versus epiglottitis in two patients. 125 (4): 388-96. elevators, retractors and evertors of the upper lip, depressors, retractors and evertors of the lower lip, embryological development of the head and neck. Imaging-based nodal classification for evaluation of neck metastatic adenopathy. It is seen most commonly in children and manifests as pain, discharge, and edema of the ear canal. If there is diffuse disease, a general statement should be made and may be followed by a description of the worst one or two lesions. They are the ones that deal with the drainage coming from the lymph nodes… Descending mediastinitis in a 50-year-old woman who recently underwent a dental procedure. Infection may be localized to the tooth and its surrounding structures, or it may spread to distant locations. Sagittal contrast-enhanced CT image shows prevertebral edema (*). Ludwig angina in a 26-year-old man. The vocal cords should be evaluated for signs of asymmetry, as paralysis may occur owing to compression of the recurrent laryngeal nerve (40). Such nodes usually result from a spread of cancer on the scalp or back of the neck. (a) Axial nonenhanced CT image shows an opacified right EAC (white arrow). Fistulization and drainage to the skin also may occur (Fig 15). (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). Malignant otitis externa of the right ear in a 55-year-old man. Consensus statement on the classification and terminology of neck dissection. Still, having a systematic approach to evaluating the common locations of disease is beneficial for efficient and consistent detection of all salient imaging findings. Axial contrast-enhanced CT image shows enlarged palatine tonsils (arrows) that are in contact with each other (“kissing” tonsils) at the midline. These complications are discussed in greater detail in the following sections. In this setting, extensive arterial wall thickening may be seen and usually also involves the visualized mediastinal arteries (Fig E10). Figure 6b. Unable to process the form. At CT, acute bacterial sinusitis is characterized by the presence of fluid and mucosal thickening in one or more sinuses (55). Retropharyngeal edema due to calcific tendinitis of the longus colli in a 71-year-old woman. Second branchial cleft anomalies account for 95% of these anomalies, and cysts are the most common anomaly at this location (11). Axial (a) and coronal (b) contrast-enhanced CT images show bilateral low-attenuation collections (arrows) superolateral to the palatine tonsils (* in b). Uncomplicated otomastoiditis manifests at CT as opacification of the middle ear cavity and mastoid air cells, without osseous destruction. On CT images, goiter appears as an enlarged nodular heterogeneous gland with regions of hemorrhage, cysts, necrosis, and calcification (Fig 13). The lymphadenopathy responds to antibiotic therapy, and response to treatment may be evaluated with serial CT. Figure 14c. We recommend a systematic approach to evaluating and reporting cervical lymph nodes for head and neck squamous cell carcinoma (HNSCC) and thyroid carcinoma that involves four steps: systematically search for abnormal nodes, particularly in expected drainage sites; describe location and review check locations (Figs. Although the presence of mastoid air cell fluid is common, it does not necessarily indicate mastoiditis. When a branchial cleft anomaly is not infected, it appears at CT as a fluid-attenuation cyst with a thin wall (12). Bone tumors can arise from the vertebra or intervertebral discs or can spread to the spine from other organs … These glands are usually very small. The diagnosis of Lemierre syndrome (discussed earlier) is used to illustrate this synthesis process (Figure E15). The rising incidence of adult acute epiglottitis and epiglottic abscess, Infections of the Neck and Pharynx in Children, Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis, Predictors of intratonsillar versus peritonsillar abscess: A case-control series, Aberrant internal carotid artery in the mouth mimicking peritonsillar abscess. 2014 1. There is gas (white arrows in b) within the adjacent left lateral soft tissues, consistent with perforation. - see reference below. They may represent an infection around that area, such as a tooth infection or abscess, throat infection, viral health problem, or upper respiratory infection. If there is an obstructing ductal stone (Fig 14), ductal dilatation also is present. Figure 6c. There is also bone dehiscence (black arrow) along the dorsal aspect of the petrous apex. Left petrous apicitis in an 11-year-old girl who presented with ear drainage and diplopia. (a, b) Acute right submandibular sialadenitis in a 57-year-old woman. When possible, a PTA should be differentiated from an intratonsillar abscess, which may not require drainage and is associated with a lower recurrence rate (22). The higher rate of stone formation in the submandibular gland is due to the small papillary orifice, ascending course of the (Wharton) duct, higher viscosity of saliva, and slow salivary flow rate (25). (2008) Archives of otolaryngology--head & neck surgery. The thyroid gland synthesizes the hormones triiodothyronine and thyroxine. The Delphian lymph node in thyroid cancer. Also known as lymph glands, lymph nodes remove cell waste and fluids from lymph (lymphatic fluid), and store lymphocytes (white blood cells). (b) Axial contrast-enhanced CT image obtained 3 days later, by which time the patient’s condition had worsened such that intubation was required, shows that the suppurated lymph node (arrow) has ruptured into the retropharyngeal space (black arrowhead). The paranasal sinuses consist of the maxillary, sphenoid, and frontal sinuses, as well as the ethmoid air cells. Part of the lymphatic system, lymph nodes are scattered throughout the body, including the neck, armpits, abdomen and groin. Figure 4b. Subcutaneous edema of the involved side should be included in the “Cutaneous and Subcutaneous Soft Tissues” section. Calcific tendinitis of the longus colli, technically a prevertebral process, results from an inflammatory reaction to hydroxyapatite deposits within the longus colli muscle or tendon (27). Cavernous sinus thrombosis is seen occasionally. 4. They function as filters, trapping viruses, bacteria and other causes of illnesses before they can infect other parts of your body. Lymph nodes that lie near the surface of the skin, such as in the neck, armpit, groin, and sometimes those in the arm (elbow) and back of the knee may be felt when enlarged, but others may only be seen on imaging studies such as a CT scan. Epidural abscess and subgaleal phlegmon in a 13-year-old boy. Sixty milliliters of iodinated contrast material is injected at 2 mL/sec for 30 seconds. Internal cysts and a calcification also are noted. In the United States, the most common cause of goiter is Hashimoto thyroiditis, whereby the gland is unable to produce an adequate amount of thyroid hormone and is continuously stimulated by thyroid-stimulating hormone to enlarge. Although a discussion of this topic, including characterization and workup, is beyond the scope of this review, this subject has been reviewed previously in this and other journals (36–38). (a) Axial contrast-enhanced CT image (bone window) shows tympanomastoid opacification (*). Normal lymph nodes demonstrate an ovoid morphology, a fatty hilum, smooth margins, and homogeneous isoattenuation to muscle at CT. Cervical lymph nodes can be classified into levels (I–VII) and anatomic groups (supraclavicular, parotid, retropharyngeal, and occipital stations) according to established criteria (45). Note the tapered superior and inferior margins in b. Incidentally detected nodules or masses may also represent previously unknown lung malignancy. Besides a regular physical exam and medical history, your doctor will evaluate your swollen lymph nodes for: Size. For instance, ear pain, fever, and enlarged lymph nodes near your ear are clues that you may have an ear infection or cold. To diagnose this condition, it is essential to administer intravenous contrast material to delineate the extent of disease and determine whether there is a drainable collection (Fig 10). Noninfectious etiologies are usually the main cause of lymphadenopathy; however, there can be overlap. Axial 0.625-mm images constructed by using bone and soft-tissue kernels also are sent to the picture archiving and communication system. These are a part of the lymphatic system. Figure 24a. The reporting of thyroid enlargement should include a description of the extent of the enlargement and of any mass effect on the trachea, esophagus, and neck vessels (39). Periodontal disease—that is, inflammation of the gingiva (gums)—can progress to periodontitis, in which the periodontal ligament that connects the tooth to the alveolar process, as well as the bone of the alveolar process, is lost (Fig E8). Retrospective correlation of CT scans and surgical findings in 51 patients with laryngeal cancer undergoing radical neck dissection suggested that the node-bearing areas in the neck can be usefully evaluated with CT scans. Swollen lymph nodes aren’t a disease, they’re a symptom. They are basically one subgroup of the two cervical lymph nodes which are the major lymph nodes of the head. 2. Interpreting findings seen at CT of the neck is challenging owing to the complex and nuanced anatomy of the neck, which contains multiple organ systems in a relatively small area. There is coalescence of the right mastoid air cells (black arrow) with breakthrough of the overlying cortex (white arrow). When it is infected, the wall thickens and demonstrates contrast enhancement, and surrounding inflammatory fat stranding develops (12). (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). Since the advent of the Haemophilus influenzae type B vaccine, there has been a dramatic reduction in epiglottitis cases among children. The infected material may be released at the apex of the tooth into the periapical region, causing periapical periodontitis, which may then develop into a periapical abscess, granuloma, or cyst. The last category of dental infection is pericoronitis, in which food material becomes trapped under a gum flap, commonly in the setting of a partially erupted third molar, and causes acute inflammation and infection (Fig E9). {"url":"/signup-modal-props.json?lang=us\u0026email="}. A masslike hyperattenuating focus is typically seen in a sinus or multiple sinuses, and there is gradual sinus wall destruction. The presence of degenerative changes should be noted, at least in general terms, and if severe spinal canal stenosis or an alignment abnormality is present, a more detailed description is warranted. These findings are merged in the “Impression” section, with the final diagnosis being Lemierre syndrome (Figure E15). In adults who present with symptoms such as severe sore throat, dysphagia, and fever, with a more gradual onset, CT can be performed as the initial imaging investigation. Acute invasive fungal sinusitis is characterized by unilateral destruction of the osseous margins of the sinus, with extension into adjacent structures such as the orbits, intracranial compartment, and subcutaneous tissues. Additional similar lesions were seen on other images (not shown). In a large series (29), 76% of pharyngeal and esophageal foreign bodies were impacted just below the cricopharyngeus muscle, at approximately the C6 level. Note the thickening of the left platysma muscle (arrow). (b) Image in a obtained in soft-tissue windows shows an overlying or developing abscess (arrow). The degree of mediastinal extension, which is important when surgery is being planned, is measured from the sternal notch (39). (b) Axial nonenhanced CT image obtained superior to a shows foci of gas (arrow) in the right middle cranial fossa. The use of a systematic approach to interpreting neck CT findings is essential for identifying all salient findings, recognizing and synthesizing the implications of these findings to formulate the correct diagnosis, and reporting the findings and impressions in a complete, clear, and logical manner. Retropharyngeal edema involves the retropharyngeal space from side to side, with tapered superior and inferior ends; however, there is no rim enhancement (Fig 6) (24). (b) Image in a obtained in soft-tissue windows shows epidural phlegmon (white arrow) and nonenhanced foci (black arrows), consistent with abscess. Nodular goiter usually begins as diffuse gland enlargement and progresses to the nodular form. Most cases of mediastinal extension are substernal, although a fraction of cases are posterior mediastinal. Epidural abscess and subgaleal phlegmon in a 13-year-old boy. In this situation, repeat CT with intravenous contrast material may be necessary to delineate an abscess. These systems employ the American Joint Committee on Cancer staging system and traditionally established node levels. An epiglottic abscess increases the risk of airway obstruction at the stylomastoid.. Infecting organism ( 43 ) context of vertebral infection folds should be reported SB. 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