CT and MR imaging evaluation of neck infections with clinical correlations

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses

OBJECTIVE

To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses.

MATERIALS AND METHODS

We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification.

RESULTS

Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage.

CONCLUSION

Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

Severe neck infections that require wide external drainage: clinical analysis of 17 consecutive cases

Infections in the neck layers and spaces are potentially life-threatening diseases causing further complications, like mediastinitis, airway obstruction, or sepsis. Despite of the need for a conservative approach, they still regularly require surgical intervention. Records of 17 patients with severe neck infections that were treated by wide external incision and open wound management were retrospectively analyzed. The aim of the study was to clinically characterize these most serious neck infections. The most common presenting symptoms were neck pain and tense neck mass (94-94%) regularly with fever (65%), always accompanied by a marked elevation of C reactive protein level (average 192 uG/l). These findings were constant and very similar among both the deep neck infection and necrotizing fasciitis cases. More than half of the patients (53%) had at least one systemic co-morbidity. The parapharyngeal space was most commonly affected (83%), but extended disease involving more than two major neck regions was found in 13 cases (76%). Dental (29%) was the most common primary infection, followed by peritonsillar abscess (23%), Microbiological results showed a wide variety of corresponding bacteria. Mediastinitis was developed in three cases (18%), and airway obstruction requiring tracheostomy in two cases (12%). All the patients survived. Severe neck infections are a heterogenous group of diseases regarding to the primary site of infection, microbiology, localisation and host reaction. However, rapidly developed, painful, tense neck mass with a highly elevated CRP level should always alert for an extended or phlegmonous process in the layers or spaces of the neck.

Head and neck fascia and compartments: no space for spaces

An accurate understanding of the arrangement of cervical fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The purpose of this detailed review is to summarize the anatomic, clinical, and radiological literature to determine what is known about the arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and compartments is replete with confusing synonyms and inconsistencies, creating important interdisciplinary differences in understanding. The term "spaces" is inappropriate. A modified nomenclature underpinned by evidence-based anatomic and radiologic findings is proposed. This should not only enhance our understanding of cervical anatomy but also facilitate clearer interdisciplinary communication.

Conservative treatment in isolated penetrating cervical esophageal injury: case report

Non-iatrogenic traumatic cervical esophageal perforations are usually hard to manage in the clinical setting, and often require a careful and individualized approach. The low incidence of this particular problem leads to a restricted clinical experience among most centers and justify the lack of a standardized surgical approach. Conservative treatment of esophageal perforation remains a controversial topic, although early and sporadic reports have registered the efficacy of non-operative care, especially following perforation in patients that do not sustain any other kind of injuries, and who are hemodynamically stable and non-septic. We report a case of a patient sustaining a single cervical gunshot wound compromising the cervical esophagus and who was treated exclusively with cervical drainage, enteral support and antibiotics.

A pain in the neck--imaging in neck sepsis

Deep neck infection has a high morbidity and mortality and the extent of infection is often difficult to estimate clinically. The complex anatomy and the communication between neck spaces means that infection can spread along fascial planes leading to life-threatening complications such as airway compromise, vascular erosion/thrombosis, neural dysfunction, and ultimately descending necrotizing mediastinitis. Imaging has an important role to play in identifying the extent of infection and the presence of complications.

A case of Kawasaki disease with coexistence of a parapharyngeal abscess requiring incision and drainage

Kawasaki disease (KD) causes multisystemic vasculitis but infrequently manifests with deep neck infections, such as a peritonsillar abscess, peritonsillar or deep neck cellulitis, suppurative parapharyngeal infection, or retropharyngeal abscess. As its etiology is still unknown, the diagnosis is usually made based on typical symptoms. The differential diagnosis between KD and deep neck infections is important, considering the variable head and neck manifestations of KD. There are several reports on KD patients who were initially diagnosed with retropharyngeal abscess on on computed tomography scans (CT). However, the previously reported cases did not have abscess or fluid collection on retropharyngeal aspiration. Therefore, false-positive neck CT scans have been obtained, until recently. In this case, suspected neck abscess in patients with KD unresponsive to intravenous immunoglobulin could signal the possible coexistence of suppurative cervical lymphadenitis.

Imaging appearance of granulomatous lesions of head and neck

We aim to review the imaging appearance of granulomatous lesions of the head and neck. Granulomatous lesions are seen in different regions of the head and neck and a difficult diagnostic challenge for the radiologist. Infective granulomas may be due to bacterial or fungal agents. Non-infective granulomas are Wegener's granulomatosis, sarcoidosis, amyloidosis, chemical granuloma and reparative giant cell granuloma. Familiarity with the clinical presentation and imaging features of these lesions can suggest diagnosis in some cases. CT and MR imaging demonstrate the exact location, extension and effect on surrounding structures. A thorough knowledge of age, gender, common location, clinical features and imaging appearance of granulomatous lesions are important for diagnosis.

Cervical Lymphadenitis, Suppurative Parotitis, Thyroiditis, and Infected Cysts

Neck masses are common and have a variety of infectious agents and noninfectious causes. This article reviews the more common infectious causes of neck masses-cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts. Important clinical pearls, diagnostic evaluation including laboratory studies, and imaging are summarized. Methods for prevention are highlighted.

Is ultrasound useful for evaluating paediatric inflammatory neck masses?

OBJECTIVE

To determine the accuracy of ultrasound in detecting the presence of pus in a neck mass in children.

DESIGN

Retrospective case sheet review.

SETTING

A district general hospital.

PARTICIPANTS

Children admitted from January 2000 to January 2004 with an acute cervical mass who were investigated by ultrasonography.

MAIN OUTCOME MEASURES

The presence of a clinically relevant abscess that did not respond to clinical management was used to determine the accuracy of the ultrasound result.

RESULTS

The sensitivity of ultrasound in the detection of an abscess was 65% and the specificity 88%. The predictive value of a positive ultrasound result was 81% and the predictive value of a negative test 77%.

CONCLUSIONS

Ultrasound is a useful modality in the evaluation of acute cervical masses but is observer dependent and has a relatively low sensitivity in detecting whether or not pus is present. The clinical indicators for the presence of an abscess are discussed and clinicians should combine clinical findings with the ultrasound findings in order to determine treatment.

Retropharyngeal Abscess Presenting as Benign Neck Pain

OBJECTIVE

To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain.

CLINICAL FEATURES

A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. Minimal response to chiropractic treatment leads to coordination of treatment with the patient's primary care physician. Laboratory assessment and magnetic resonance imaging initially were viewed as insignificant but were repeated and showed a retropharyngeal abscess.

INTERVENTION AND OUTCOME

Chiropractic treatment did not reduce the patient's neck pain as expected. Fusion of C1 to C2 was eventually performed.

CONCLUSION

Neck pain is a common reason for patients to seek chiropractic care. This case shows an uncommon differential diagnosis for a patient who does not respond quickly to chiropractic treatment for neck pain.

MR imaging of lymph nodes in the head and neck

This article reviews imaging-based nodal classification, recent advancements in MR imaging techniques for lymph node imaging, and characteristics of MR imaging for necklymphadenopathy. Further technical development of MR imaging is necessary to improve accuracy of diagnosis of lymph node metastases in patients with no head and neck cancer. Development of new tissue-specific MR contrast agents and functional imaging studies to address biologic activity of lymph nodes is essential in the future.

Management of isolated extrapulmonary tuberculosis in a pregnant patient

The worldwide incidence of tuberculosis is increasing, largely as a consequence of both the increasing prevalence of human immunodeficiency virus and the emergence of drug-resistant strains. The pulmonary system is typically the primary site of involvement by this infectious disease; however, extrapulmonary disease does occasionally occur. Although uncommon, neck involvement can occur. The usual presentation is bilateral adenopathy from pulmonary dissemination. Tuberculous cervical adenitis in the absence of pulmonary findings is rare. A concurrent diagnosis of pregnancy complicates the treatment of the infected patient. We present a case of isolated, unilateral tuberculous cervical adenitis in a pregnant patient and discuss the multidisciplinary approach necessary for the appropriate management of this unique situation.

Infection of the facial area, oral cavity, oropharynx, and retropharynx

Radiologists play an important role in the evaluation of upper neck infections. Although most oral cavity infections arise from diseased teeth, several other sources of infection need to be considered. The distinction between abscess and phlegmon is of particular importance. Cross-sectional imaging is frequently used to identify complications of the initial infection.

Deep Fascial Space Infection of the Neck: A Continuing Challenge

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Inflammatory thyroid disorders

Inflammatory thyroid disorders encompass a broad spectrum of diseases that are generally self-limited, and relatively easy to diagnose and manage. Autoimmune subtypes are by far the most commonly encountered diagnoses and create the most confusion because of simultaneous overlap and the potential for interconversion among the subtypes. The otolaryngologist will frequently see these disorders and provide valued consultative care and surgical intervention as needed.

MR imaging of lymph nodes in the head and neck

This article reviews imaging-based nodal classification, recent advancements in MR techniques for lymph node imaging, and characteristics of MR imaging for neck lymphadenopathy. Further technical development of MR imaging is necessary to improve accuracy of lymph node metastases in patients with N0 neck. Development of new tissue-specific MR contrast agents and functional imaging studies to address biologic activity of lymph nodes are essential in the future.