Emergency Imaging. Alexander B. Baxter

      88Emergency Imaging

      Infection/Inammation

      • CT Face or Neck with Intravenous Contrast

       –Tonsillitis/pharyngitis

       –Parapharyngeal or retropharyngeal abscess

       –Dental or periodontal disease with abscess

       –Sialadenitis

       –Orbital cellulitis

       –Infectious or reactive adenopathy

      (suppurative adenitis, mycobacterial disease, mononucleosis)

      Mass

      • CT Face or Neck with Intravenous Contrast

      • MRI with Gadolinium

       –Lymphoma

       –Metastatic head and neck carcinoma –Parotid or submandibular neoplasm

       –Developmental cysts (thyroglossal duct cyst, branchial cleft cyst)

       ◆ Clinical Presentations and Dierential Diagnosis

      Clinical Presentations and Appropriate Initial Studies

      Trauma

      • CT Face or Neck without Intravenous Contrast

       –Frontal sinus/orbital roof fracture

       –Nasal or nasal septal fracture

       –Naso-orbito-ethmoid fracture –Zygomaticomaxillary complex fracture

       –Le Fort fracture

       –Orbital wall (blowout) fracture

       –Globe rupture

       –Orbital hematoma

       –Temporal bone fracture

       –Skull base fracture

       –Carotid or vertebral vascular injury

       –Larynx fracture

      Fig. 3.2Cervical lymph node levels. Level 1A nodes are submental and lo-cated between the digastric muscles. Level 1B nodes are submandibular and located lateral to the digastric and ante-rior to the posterior aspect of the hyoid bone. Level 2A, 2B, 3, and 4 are nodes of the jugular chain. Level 2 nodes are above the hyoid, Level 3 nodes are between the hyoid and cricoid carti-lages, and level 4 nodes are below the cricoid. Level 2B nodes are posterior to the jugular vein but anterior to the margin of the sternocleidomastoid. Level 5 nodes are all posterior to the sternocleidomastoid margin and make up the spinal accessory chain, with level 5A nodes above the cricoid and level 5B nodes below it. Level 6 and 7 nodes are paratracheal and paraesophageal.

      89

      3 Head and Neck

      Carotid Space Mass

      • Paraganglioma

      • Schwannoma

      • Carotid pseudoaneurysm/dissection

      Jugular Foramen Mass

      • Schwannoma

      • Meningioma

      • Paraganglioma

      Masticator Space Mass

      • Odontogenic abscess

      • Primary bone or muscle neoplasm (sarcoma)

      • Osteomyelitis

      Submandibular Space Mass

      • Odontogenic abscess

      • Submandibular sialadenitis/abscess

      • Salivary gland neoplasm

      • Obstructed minor salivary gland

      (ranula)

      • Lymphadenopathy

      Mandibular Cystic Lesion

      • Periradicular cyst (in carious teeth)• Dentigerous cyst (around crown of unerupted tooth)

      • Aneurysmal bone cyst

      • Ameloblastoma

      • Giant cell tumor

      Sinus Disease with Bone Destruction

      • Invasive fungal sinusitis

      (mucormycosis, actinomycosis)

      • Carcinoma

      • Lymphoma

      • Wegener granulomatosis

      Thyroid Mass

      • Benign nodule

      • Carcinoma

      • Parathyroid adenoma

      • Distal thyroglossal duct cyst

      Dierential Diagnosis

      Clival/Skull Base Mass

      • Metastasis• Chordoma

      • Chondrosarcoma

      Nasopharyngeal Mass

      • Prominent lymphatic tissue (normal in patients < 30, consider HIV in patients > 40)

      • Prevertebral space infection (osteomyelitis/diskitis)

      • Nasopharyngeal carcinoma

      • Juvenile nasopharyngeal angiofibroma

      (adolescent males)

      • Lymphoma

      • Tornwaldt cyst

      Pharyngeal Mucosal Space Mass

      • Tonsillitis/abscess

      • Squamous cell carcinoma

      • Lymphoma

      Retropharyngeal Mass

      • Abscess/phlegmon

      • Adenopathy/nodal metastasis

      • Lymphoma

      Prevertebral Space Mass

      • Osteomyelitis/diskitis

      • Abscess

      • Chordoma/skull base chondrosarcoma/

      vertebral metastasis

      Parotid Space Mass

      • Parotitis (diuse enlargement)

      • Benign salivary gland neoplasm, 80%

      (pleomorphic adenoma, Warthin tumor)

      • Malignant neoplasm, 20%

      (mucoepidermoid, adenoid cystic carcinoma)

      • Intraparotid lymph node

      • Lymphoepithelial cyst (HIV)

      90Emergency Imaging

      Extraconal Orbital Mass

      • Orbital abscess

      • Lacrimal gland tumor or inflammation

      • Dermoid

      • Lymphoma

      • Metastasis

      • Hematoma

      Orbital Muscle Enlargement

      • Thyroid orbitopathy

      • Idiopathic orbital inflammation

      (pseudotumor)

      Multiple Enlarged Cervical Lymph Nodes

      • Lymphoma

      • Mycobacterial disease

      • Metastatic head and neck carcinoma

      • Lymph node hyperplasia

      Low