Prof. Hossam Thabet, M.D.

OtolaryngologyOtolaryngology-Head & Neck Surgery Department Alexandria University

Plain Imaging Of The Neck

Plain Imaging of H&N Neck

  

Lateral Soft Tissue AP Soft Tissue Cervical Spine

1. 2. 3. 4. 5.

Lateral (Flexion & Extension) AP Right Lateral Oblique Left Lateral Oblique Odontoid View, Open Mouth

Nasopharynx Prevertebral Space C2 Vallecula Base Of Tongue Epiglottis Aryepiglottic Fold Cricoid Cartilage Prevertebral Space C6

Hyoid Bone Ventricle Tracheal Airway

Neck Soft Tissue Lateral View

Prevertebral space


Anatomically; it is defined by the anterior part of the cervical spine and the deep layer of the deep cervical fascia running between the transverse processes of the spine. Extends along entire vertebral column

Radiologically; it is defined posteriorly by the anterior surface of the cervical spine and anteriorly by the pharyngeal & tracheal walls


Cervical Fascia Space Visceral

Vascular Space Retropharyngeal Space Alar Space Prevertebral Space Perivertebral Space

Prevertebral space
The prevertebral space contains
1. The prevertebral muscles (longus colli and longus capitis) 2. Vertebral vessels 3. Scalene muscles 4. Phrenic nerve 5. proximal part of the brachial plexus.

Prevertebral space
Causes of widening of the prevertebral space:
1. Retropharyngeal infection (Cellulitis/Abscess) 2. Postcricoid carcinoma 3. Posterior pharyngeal wall carcinoma 4. Trauma of cervical spine 5. Potts disease of cervical spine 6. Vertebral osteomyelitis 7. Spondylodiscitis 8. Vertebral metastasis. 9. Posterior spread of H & N tumor 10.Primary tumors arising within this space.
  

Hodgkin lymphoma Chordoma Lipoma

Lateral Neck Soft Tissue



Screening examination  Mainly for Prevertebral Space & Airway  Normal Prevertebral Space:  7mm at C-2, 14mm at C-6 ( kids)  22mm at C-6 (adults)  Technique dependent (Extension& Inspiration)  Sensitivity 83%, compared to CT 100%

Step

off sign

Normal Prevertebral Space:



C3 = <3 mm (< 1/3 AP diameter) At C6 = < AP width of C6 vertebral body C2 = 7mm At C6 = 14 mm (kids) = 22mm (Adults)
At

At

True widening of prevertebral space

False +ve widening of prevertebral space

Adenoid Hypertrophy

Pediatric Sleep Apnea

Pediatric Sleep Apnea

Lingual tonsillitis causing stridor

Ludwigs angina (Sublingual cellulitis)

Cervical Spine
    

Lateral (Flexion & Extension) AP Right Lateral Oblique Left Lateral Oblique Odontoid View, Open Mouth

Cervical Spine AP

Cervical Spine AP

Cervical Spine AP

Cervical Spine Lateral

Cervical Spine Lateral

F - facet joint SP - spinous process L - lamina Od - odontoid

Left Lat. Oblique

Right Lat. Oblique

Left Lat. Oblique

Right Lat. Oblique

Odontoid View, Open Mouth

Odontoid View, Open Mouth

Odontoid View, Open Mouth

Fish Bone vallecula

F.B Upper Esophagus

Coin In the Upper Esophagus

Bottle Cap

Facts about Button Battery Ingestions



Ingested lithium cells pose a higher risk due to their larger diameter which makes them more likely to lodge in the esophagus and their greater voltage which generates more local hydroxide when lodgement occurs

Facts about Button Battery Ingestions

 

  

Emergency NaOH, KOH, mercury  1 hour mucosal damage  2 - 4 hours muscular layers  8 - 12 hours perforation Esophagoscopy Observation for gastric location for 4-7 days Laparotomy for bowel perforation

Facts about Button Battery Ingestions



Disc batteries lodged in the esophagus can potentially cause serious problems in 3 ways:

1) Direct pressure necrosis (similar to coins or other inert F.B.). 2) Caustic injury due to the leakage of sodium or potassium hydroxide from a leaking battery. 3) Injury from low voltage burns from a disc battery that still has a charge.

For these reasons, all disc batteries lodged in the esophagus should be removed expeditiously to avoid these injuries.

Impacted Esophageal F.B.



Commonly impacted just below cricopharyngeous (70%)

  

Another 20% impact at the level of the aortic arch Another 10% at EG junction Once past the esophagus, most F.Bs will pass through the GI tract

Plain films usually do not demonstrate all FB but are still obtained first


If negative, then either contrast esophagram or CT if high index of suspicion

Impacted Esophageal F.B.



Food or true F.B.

 

Chicken bones (opaque), fish bones (non-opaque) Coins, toy trucks

 

Chicken bones are usually opaque Fish bones contain less calcium and usually are not

The black arrow is pointing to stylo-hyoid ligament calcification . The grey arrow is the hyoid bone The white arrow is the thyroid cornu

Ossified stylohyoid ligament

Impacted Esophageal F.B.

Lateral X-ray of the neck demonstrates a linear density in the proximal esophagus (arrow) consistent with an impacted F.B. (a chicken bone)

Impacted Esophageal F.B.

chicken bone (arrowed) stuck in the pharynx

Impacted Esophageal F.B.



A faint irregular mottled density in the oesophagus with an A/F level superior to this density (arrowed). The mottled density is assumed to be the meat Air in oesophagus can be a normal finding associated with air swallowing. An air-fluid level is suggestive of obstruction in the oesophagus.

Impacted Esophageal F.B.

Sea food shell in the pharynx at the origin of the oesophagus (arrowed)

The arrowed structure is food in a Zenker diverticulum.

Impacted Esophageal F.B.



F.B. stuck in the patient's esophagus ( arrow), a tablet which is still in its foil packaging. There is some soft tissue swelling associated with the foreign body

Impacted esophageal Fish bone.

Chicken bones are usually opaque Fish bones contain less calcium and usually are not

Stone

Fish bone

Edema & obliteration of the Rt. Pyriform sinus and PGS with a F.B. in the prevertebral space

Radio-opaque shadow in the prevertebral space opposite to C5

Esophageal Fish bone

migrating to the neck

Posttonsillectomy ECA embolization for recurrent severe 2ry bleeding, F29y

Aspirated F.B.
Common aspirated objects(Choke Hazard)  Latex Balloons (29% of choking deaths)  Marbles, Balls (19% of choking deaths)  Peanuts  Popcorn  Hot dogs  Other foods  Plastic or metal toy objects

Aspirated F.B.

Metallic wire larynx

Aspirated F.B.

F.B. Button in the larynx

Aspirated F.B.

Infected TGDC

Infected TGDC with subcut. Edem (white arrow), edema of the preepiglottic space (black arrows) & arytenoid edema ( blue arrow)

Upper Airway Infections



The Big Two

 

Croup Epiglottitis

Upper Airway Infections

Croup
    

Croup - Scottish for barking cough Laryngotracheobronchitis 6 months to 3 years old (rare<1y) Younger than epiglottitis Usually viral (Parainfluenza types 1 & 2)

Upper Airway Infections

Croup
 

URI symptoms Difficult to distinguish from early retropharyngeal abscess  Barking cough & hoarseness  Inspiratory or biphasic stridor  Low-grade fever

Upper Airway Infections

Croup


Four major findings



Distension of the hypopharynx Distension of the laryngeal ventricle Haziness or narrowing of subglottic space
Pencil tip)

(AP neck - Steeple sign



Normal Epiglottis

(AP neck - Steeple sign Pencil tip)

Upper Airway Infections

Epiglottitis


Haemophilus influenzae type B most common Peak incidence : 6-7 years



Croup occurs from 6 months to 2 years Supine position may close off airway

Lateral radiograph -- Erect position only



Upper Airway Infections

Epiglottitis Key Findings
 

Toxic Child X-ray findings

 

Thumbprint Dilated hypopharynx(Children)

Cherry Red Epigottis

Upper Airway Infections

Epiglottitis
Radiological Key Points 1. Swollen Epiglottis (Thumb print appearance) 2. Thickened edematous AEF 3. Swollen edematous arytenoids 4. Dilated hypopharynx 5. Obliterated vallecula 6. Normal subglottis 7. Loss of cervical lordosis 8. Associated pneumonia in 25 %

Upper Airway Infections

Epiglottitis


Ballooning of the hypopharynx is a finding in children with croup, and sometimes those with epiglottitis, A rare radiographic finding in adults. Ballooning is caused by sucking air through an open mouth against an obstruction

Congenital Cervical Lung Herniation

  

The least common location of lung herniation. Patients <3 years of age Unilateral or bilateral

Bilateral Laryngoceles

Bilateral laryngoceled

Dysphagia


Cricophgaryngeus Spasm
63 year-old with dysphagia

The cricopharyngeus muscle (the upper esophageal sphincter) lies at about the level of C5-C6 A prominent cricopharyngeus, however, can be seen on barium swallows in about 510% of asymptomatic individuals

Dysphagia
Prominent Cricopharyngeus  The cricopharyngeus muscle is normally contracted at rest  Upon the initiation of swallowing, the normal cricopharyngeus muscle relaxes in anticipation of the bolus and helps to form part of the pharyngeal peristaltic wave  Therefore, the cricopharyngeus muscle is usually not seen on a barium swallow

Posterior hypopharyngeal wall carcinoma

Postcricoid Ca

Post.Ph. W. Ca

Vallecular Spindle Cell carcinoma

Extensive papillary caecinoma with retrophartngeal extension & calcifications (black arrows)

Extensive papillary caecinoma with retrophartngeal extension,dysphagia , V.C paralysis and aspiration (red arrow)

Left: Lateral neck radiograph showing a large mass in theretropharyngeal space, extending from the nasopharyngeal roof to the level of the 4th cervical vertebra, narrowing the upper airway.Right: axial CT at the level of the palate showing a homogeneous and hypodense mass with multiple intrinsic septa. Weixi Gong MS et al. A Retropharyngeal Lipoma Causing Obstructive Sleep Apnea in a Child Journal of Clinical Sleep Medicine, Vol. 2, No. 3, 2006

Retropharyngeal abscess
Suppuration of the retropharyngeal, danger or prevertebral spaces collectively RPA  The 2nd most common DNSI in children  Almost all occur before age 6  50% between 6-12 months  In adults, usually 2ry to trauma to oropharynx, Iatrogenic or FB


Retropharyngeal abscess
Retropharyngeal Space
Posterior to pharynx & esophagus  Anterior to alar layer of deep fascia  Extends from skull base to T1-T2 T1  Midline raphe connects superior constrictor to the deep layer of deep C.F.  Contains retropharyngeal nodes.


Retropharyngeal abscess
Pathogenesis
Children 3m-3y (<5y) (<5 Causes 1.Suppuration in lymph nodes of Henle 2. Nose, adenoids, nasopharynx, & sinus infections Adults Causes 1.Ttrauma, F.B, instrumentation 2.Extension from adjoining deep neck space

Retropharyngeal abscess
Lateral Cervical Radiographs
 

   

Swelling: Diffuse cellulitis/Focal abscess Widened prevertebral space, slightly thicker than width of vertebral body Reversal of normal lordosis Air/fluid levels Vertebral body destruction Foreign body

Retropharyngeal abscess

A ten-Y/O boy with fever& neck pain due to posttrumatic (F.B.) ten-

Retropharyngeal abscess

18 year male with post traumatic retroph. abcess

Retropharyngeal abscess

Retropharyngeal abscess

Retropharyngeal abscess

Retropharyngeal abscess

Retropharyngeal Abscess

Cervical Spondylolethesis

5 Y/O female child with torticollis to left side, fever , dysphagia, neck pain. X-ray neck shows loss of lordosis, reversed lordosis. XCT shows enlarged adenoid, lt retropharyngeal & parapharyngeal abscess extending downward to the visceral space & left thyroid region

Retropharyngeal abscess
Danger Space
    

Anterior border-alar layer of deep fascia borderPosterior border-prevertebral layer borderExtends from skull base to diaphragm Contains loose areolar tissue Little resistance to spread of infection

Retropharyngeal abscess
Danger Space
A potential space composed of loose aereolar tissue & fat, extends down to mediastinum.  Nearly identical presentation to RPA  Cause: Cause: Extension from retropharyngeal, prevertebral or parapharyngeal space  Cannot be distinguished by imaging from retropharyngeal space. space.


Retropharyngeal abscess
Prevertebral Space
Anterior border - prevertebral fascia  Posterior border-vertebral bodies & deep N.ms border Lateral border transverse processes  Extends along entire vertebral column  Infection tends to be localized due to dense fibrous attachments between fascia & deep muscles


Retropharyngeal abscess
Prevertebral Space
Mostly originates from the cervical spine  Cause: Pott s abscess, trauma, osteomyelitis, extension from retroph. & danger spaces  Back, shoulder, neck pain made worse by deglutition  Dysphagia or dyspnea


Diffuse Idiopathic Skeletal Hyperostosis (DISH)



Often confused radiographically with ankylosing spondylitis, as bridging osteophytes are seen in both conditions. However, the lack of facet joint arthritis and fusion, sacroiliitis, and syndesmophytes in DISH help to confirm the diagnosis.

Diffuse Idiopathic Skeletal Hyperostosis (DISH)




1.

2.

3.

A generalized spinal & extraspinal articular disorder that is characterized by ligamentous calcification and ossification The definitive criteria for the diagnosis : Flowing calcification or ossification along the anterolateral aspect of at least 4 contiguous vertebral bodies. Relative preservation of intervertebral disc height of the involved segments Lack of associated signs of disc degeneration

Lateral view of the cervical spine showing 1. Loss of cervical lordosis. 2. Mild prominence of prevertebral soft tissues 3. Presence of calcification at level of C2.
Rodrguez JR et al, Applied Radiology 2004

(A and B) Axial CTCE images soft tissue and bone windows,respectively. An area of calcification is seen in the retropharyngeal space with prominence of this region. The scans exhibit low attenuation with no abnormal enhancement Rodrguez JR et al, Applied Radiology 2004

37 Y/O man with an 8 day history of low grade fevers, neck stiffness, & odynophagia. unremarkable medical history. O/E Decreased cervical range of motion upon flexion and extension, with marked paraspinous muscle spasm. There is no spinal tenderness or meningismus. Laboratory evaluation reveals a WBC of 8.3 and an ESR of 56.

(A) amorphous calcification anterior to the C1 and C2 vertebrae (yellow arrow) with marked prevertebral soft tissue swelling (red arrow). (B) higher magnification

The appearance of the calcification varies from punctuate to a dense, prominent concretion

Axial CT scan at the level of 3rd &4th cervical vertebra shows fluid collection (arrow) in the retropharyngeal space .

Acute Calci c Tendinitis of The Longus Colli



Idiopathic noninfectious inflammation of tendinous insertion of longus colli muscle with deposition of calcium hydroxyapatite crystals, confused with retropharyngeal abscess .

T2MRI shows the effusion (straight arrows) Sagittal reformat shows tapering of the fluid (arrowheads) superiorly & inferiorly tapering to a point inferiorly (curved arrow) at the level of C5. The level of attachment in the typical pattern of the longus colli is at the anterior arch of the atlas (open arrow).

Acute Calci c Tendinitis of The Longus Colli



The longus collis muscle originates from the C1 to T3 vertebrae and consists of vertical, inferior oblique, and superior oblique fibers. The superior oblique fibers originate from the transverse processes of C3 to C5 and fuse into a tendon that inserts onto the anterior tubercle of the atlas and is most vulnerable to calcific deposits

Acute Calci c Tendinitis of The Longus Colli

Pathology  Inflammation of tendinous insertion of longus colli muscle with deposition of calcium hydroxyapatite crystals  Oblique fibers of muscle are involved  Effusion can extend from prevertebral space into retropharyngeal space  Abnormality begins in prevertebral space rather than in retropharyngeal space, edema or fluid collection may surround part of muscle, particularly superiorly

Acute Calci c Tendinitis of The Longus Colli

 

The exact cause of crystal deposition is unknown. There seems to be a genetic and metabolic predisposition associated with chronic trauma, inflammation, and tendon degeneration. Acute symptoms develop when these contained deposits rupture, provoking an acute inflammatory process that usually lasts 2 to 3 weeks and responds to the administration of nonsteroidal antiinflammatory medication

Acute Calci c Tendinitis of The Longus Colli

Clinical Presentation  Mimics retropharyngeal abscess, but patient is less febrile  May have normal white blood cell count  Illness is self-limited, responds to either steroids or nonsteroidal anti-inflammatory drugs

Acute Calci c Tendinitis of The Longus Colli

Diagnosis  Middle-aged patients with no gender predilection.  No history of trauma or history of minor trauma  Neck pain, limited range of motion, & odynophagia.  Tender neck muscles over the transverse processes of the higher cervical vertebrae  In 50% of cases, there may be a low-grade fever  Normal WBC or Mild leukocytosis  Elevation of CRP & ESR

Acute Calci c Tendinitis of The Longus Colli

Diagnosis  A plain lateral neck film - an amorphous calcific deposit below the arch of C1 and anterior to the body of C2 with associated swelling of the prevertebral soft tissue from C1 to C4.  CT is more sensitive for depiction of intratendinous calcifications, showing also the edema of the retropharyngeal space.  MRI is excellent to identify soft tissue edema or fluid collection

Acute Calci c Tendinitis of The Longus Colli

Differential Diagnosis  retro- or naso-pharyngeal abscess  acute thyroiditis  occult C-spine fracture  malignancy  calcific tendonitis  accessory ossicle (appear osseous with a demarcated
cortex, without soft tissue swelling)


calcified stylohyoid ligament

Acute Calci c Tendinitis of The Longus Colli

Prognosis  The natural history of this condition is spontaneous resolution.  Symptomatic support with analgesia and anti-inflammatories is useful; symptoms improve over a 1 to 2 week period.

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

TB Retropharyngeal Abscess & Multineck abscesses

T.B. Of the Prevertebral Space (Potts Disease)

Prevertebral Space


Complicated retropharyngeal abscess (White retropharyngeal arrow)/(asterisk) extending to the prevertebral space & arrow)/ the neural canal (Black arrow)

CT. Multiple lytic areas seen involving bodies and posterior elements

Epidural Extension Of Actinomycosis in HIV infected immunocompromised 30ymale

Lateral cervical radiograph. Note the presence of permeative lytic areas involving spinous processes of C4-5 vertebrae with widening of prevertebral soft tissue and presence of posterior cervical soft tissue shadow

Prevertebral Abscess with Osteomyelitis of the Cervical Vertebrae and Spinal Compression
Sagittal MRI showing the abscess opposite Lateral cervical spine film shows widening C4-C5. Destruction of C5 and C6, collapse of the prevertebral space and destruction of the intervertebral space and posterior extension of the abscess into the spinal of C5 and C6 vertebrae canal.

Retropharyngeal abscess
High risk patients for cervical osteomyelitis:
1. 2. 3. 4. 5. 6. 7.

Trauma to the pharynx or cervical spine Near by cervical infection IV drug abusers D.M. Immunocompromize, HIV infection Chronic renal failure Elderly

Retropharyngeal Emphysema
Causes
1. Pharyngeal Perforation
 

Trauma to esophagus or trachea Penetrating injuries from weapons Perforation from within
 

Chicken bone Mediastinal emphysema tracking into neck

Surgery

2. Retropharyngeal abscess (gas(gas-forming organism )

Pharyngeal perforation with extensive surgical emphysema

Pharyngeal Perforation
Imaging findings


Streaks of air in soft tissues of neck Anterior displacement of pharynx Associated pneumothorax possible Cervical or mediastinal air in 60% of cases of ruptured esophagus