Images courtesy of Lennard A. Nadalo, MD
Images courtesy of Lennard A. Nadalo, MD
Author
Lennard A. Nadalo, MD
Clinical Professor, Department of Radiology
University of Texas Southwestern Medical School
Consulting Staff
Envision Imaging of Allen and Radiological Consultants Association
Dallas, Texas
Disclosure: Lennard A. Nadalo, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, has disclosed no relevant financial relationships.
Reviewer
Jose Varghese, MD
Associate Professor of Radiology
Boston University School of Medicine
Boston, Massachusetts
Disclosure: Jose Varghese, MD, has disclosed no relevant financial relationships.
Infections of the head and neck are commonly encountered in clinics and emergency departments. Therefore, clinicians must be able to readily differentiate between infections that can be managed conservatively and those that require urgent intervention with intravenous (IV) antibiotics or even surgery. The close proximity of these infections to the airways, orbits, and brain means that complications of head and neck infections can be catastrophic.
The contrast-enhanced coronal neck CT shown demonstrates a left peritonsillar abscess (yellow arrow) with extension into the pyriform sinus (red arrow) and an adjacent enlarged lymph node (white arrow).Note the associated soft-tissue swelling resulting in mass effect and effacement of the left side of the oropharynx and hypopharynx.
Answer: A. Sinusitis
An MRI is performed. The T1-weighted images reveal a soft-tissue mass with intermediate signal in the left frontal sinus (arrows, left image) and lateral rectus muscle (arrows, right image) that correspond to the findings seen on the x-rays. The tissue was biopsied and found to be mucormycosis, a fungal infection classically found in diabetic or immunocompromised patients. Such infections may develop rapidly and become life-threatening within a matter of weeks. Treatment involves aggressive therapy with glycemic control, antifungal therapy, and surgical debridement. This patient underwent surgical debulking and antifungal therapy.
The x-ray reveals a soft-tissue mass near the base of the tongue (arrows) consistent with the clinical diagnosis of tonsillitis. In most cases, the diagnosis is purely clinical but imaging may be important if there is concern for airway compromise or to rule out other potentially life-threatening etiologies, such as epiglottitis or retropharyngeal abscess. Treatment is largely supportive with pain control and adequate fluid intake. Antibiotics may be given for secondary bacterial pharyngitis and corticosteroids may shorten the duration in cases of infectious mononucleosis. This child recovered with supportive care without any complications.
The CT reveals peritonsillar edema (white arrows) with compression of the oropharynx (yellow arrow) consistent with tonsillitis and an early abscess. The classic presentation of a peritonsillar abscess is odynophagia, fever, drooling, halitosis, trismus, and altered voice quality, termed "hot potato" voice. Patients who develop a peritonsillar abscess require aspiration with incision and drainage in addition to antibiotics and supportive care. The major concern is airway compromise, which dictates the speed with which procedural intervention is performed.
A coronal reformat of the CT reveals multiple abnormalities: there is complete opacification of the left maxillary sinus (red arrow) consistent with sinusitis and periapical bony destruction with fluid collection (black arrow) indicative of a dental abscess. Both dental disease and sinusitis can erode through bone and migrate into the surrounding soft tissues to produce soft-tissue infections. Incidentally, there is also a large defect in the medial left orbital lamina papyracea with herniation of fat (white arrow) that is most likely posttraumatic. This places the patient at risk for intraconal extension of infection that could potentially lead to vision loss.
The CT scan reveals opacification of the mastoid air cells (red arrow) on the right consistent with chronic mastoiditis. Acute mastoiditis is a rare complication of otitis media while chronic mastoiditis is associated with chronic suppurative otitis media or cholesteatoma formation. The pneumatized mastoid air cells become filled with mucopurulent debris, which leads to demineralization of the surrounding bone and potential abscess formation.
An axial CT image from a patient with acute mastoiditis demonstrates fluid in the mastoid air cells (yellow arrow) and soft-tissue swelling of the external auditory canal (white arrows). In early mastoiditis, osseous resorption has not yet occurred. Patients with acute and chronic mastoiditis are at risk of developing serious complications including epidural abscess, dural venous thrombophlebitis, or subdural empyema. Aggressive therapy is needed, usually with a combination of antimicrobial therapy and surgical drainage, to avert these serious complications.
The x-ray reveals prevertebral soft-tissue swelling (arrow) consistent with a retropharyngeal abscess. The prevertebral soft tissues should never be wider than the vertebral bodies. Infections to this area can be seeded through trauma or a respiratory infection that drains into the cervical lymph nodes. Patients are at risk for airway compromise and treatment focuses on airway management, broad spectrum antibiotics, and possible surgical drainage.
The x-ray reveals prominent facial swelling (yellow arrows) and opacification of the right maxillary sinus (black arrow) consistent with sinusitis. CT or MRI is generally reserved for cases of chronic or recurrent sinusitis or those at risk for complications, such as immunocompromised patients. Acute uncomplicated sinusitis can be treated with supportive care, including humidification, compresses, and analgesia. The mainstay of therapy for most patients, though, is oral antibiotics. Surgical therapy is reserved for patients who fail medical management, especially in chronic sinusitis, or for those with potentially serious complications such as erosion through adjacent osseous structures. In this patient, the facial swelling rapidly cleared following antimicrobial therapy.
Images courtesy of Lennard A. Nadalo, MD
Author
Lennard A. Nadalo, MD
Clinical Professor, Department of Radiology
University of Texas Southwestern Medical School
Consulting Staff
Envision Imaging of Allen and Radiological Consultants Association
Dallas, Texas
Disclosure: Lennard A. Nadalo, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, has disclosed no relevant financial relationships.
Reviewer
Jose Varghese, MD
Associate Professor of Radiology
Boston University School of Medicine
Boston, Massachusetts
Disclosure: Jose Varghese, MD, has disclosed no relevant financial relationships.
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