Transcript Submandibular gland calculus, neck infection

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
• Bottom Line
– Check your ABC’S
– A = AIRWAY
– B = BONES
– C = CAROTID SHEATH/VESSELS
– S = SPINAL CORD/CANAL
Anatomy: Fat Planes & Spaces
• Deep neck spaces
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- Parapharyngeal space
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- Retropharyngeal space
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- Masticator space
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- Carotid space
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- Perivertebral space
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- Anterior visceral space
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- Submandibular/sublingual space
Lateral pterygoid muscle
Masticator space
Pharyngeal
mucosal
space
Nasopharynx
Medial
Pterygoid
Muscle
Parotid
Parapharyngeal space
Styloid process
ECA
ICA
Carotid space
Internal jugular vein
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
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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:
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Airway obstruction
Carotid pseudoaneurysm or rupture
Internal jugular vein thrombosis
Mediastinitis/fluid collection/abscess
Pericarditis
Dental Infections
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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
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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
• Bottom Line
– Check your ABC’S
– A = AIRWAY
– B = BONES
– C = CAROTID SHEATH/VESSELS
– S = SPINAL CORD/CANAL
Good resources
• Statdx
• http://www.med.wayne.edu/diagRadiology/Anato
my_Modules/axialpages/Overview.html
Thank you