IMAGING MEDICAL EMERGENCIES of the NECK (and beyond) MI Zucker, MD

A dr Z Lecture On nontrauma conditions of the neck

AP and lateral views. You need BOTH! RADIOGRAPHY AP and lateral views. You need BOTH!

POSITION NEVER lie a patient supine for radiographs ALWAYS do imaging upright

In supine position, you can lose the airway. and You may not be able to retrieve it.

ANATOMY Hard and soft palate Uvula Base of tongue Epiglottis Vallecula Aryepiglottic folds Larynx Trachea Prevertebral soft tissues

INFECTIONS Epiglottitis Croup Retropharyngeal cellulitis and abscess Ludwig’s angina

EPIGLOTTITIS Demographics are changing: fewer kids, more immune-impaired adults. Infectious agents are changing: less H. influenza (due to vaccine), more mixed bacterial. It is still a very serious and potentially lethal bacterial infection of the epiglottis and adjacent soft tissues.

EPIGLOTTITIS: Findings Thick biconvex epiglottis Thick, indistinct aryepiglottic folds Encroachment upon vallecula Distended hypopharynx

CROUP Viral tracheobronchitis Etiology: Parainfluenza and many other viruses. Demographics: Children under age 2 years, but any age including adults. Can be a very serious condition.

CROUP: Findings Subglottic trachea narrowing. This is the “steeple’ sign. Don’t confuse a normal closed glottis with subglottic inflammatory edema.

No STEEPLE vs STEEPLE No steeple: Steeple: normal subglottic edema

Normal: No Steeple

Croup: Steeple Sign

RETROPHARYNGEAL or PREVERTEBRAL INFECTION Cellulitis or abscess: Distinction is important: Cellulitis is treated with IV antibiotics. Abscess needs to be surgically drained in addition to IV antibiotics.

RETROPHARYNGEAL INFECTION: Findings Enlargement and abnormally convex contour of the prevertebral soft tissues. Swelling may extend to anterior soft tissues. If gas bubbles are present: abscess. If no gas seen, cellulitis or abscess. Plain films can be indeterminate: CT is definitive.

CELLULITIS Thick retropharyngeal soft tissues with abnormal contour (can’t exclude abscess, however)

PREVERTEBRAL ABSCESS Enlarged prevertebral soft tissues with abnormal contour Gas bubbles within the soft tissues

LUDWIG’S ANGINA A severe bacterial infection of the base of the tongue. Uncommon.

LUDWIG’S ANGINA: Findings The base of the tongue is markedly thickened and enlarged and encroaches upon the vallecula. The inflammatory process may involve adjacent soft tissues.

ALLERGIC REACTIONS Edema of any of the soft tissues. Variety of causes: drugs, food, insect stings.

UVULA EDEMA The soft palate and especially the uvula are enlarged.

FOREIGN BODIES Accidental Iatrogenic Deliberate (“selfogenic”) Metal, bone, food, plastic, wood.

FOREIGN BODIES: Locations Nasopharynx Vallecula Pyriform fossae Hypopharynx Esophagus Trachea

FISH BONE Location: Esophagus Fish bones vary in their visibility, depending upon the species of fish. In general, they are harder to see than chicken bones.

CHICKEN BONE Location: vallecula Chicken bones are easier to see than fish bones.

USDA GRADE A CHICKEN TAB

BASEBALL MISADVENTURES Dodger dog. Dodger beer

METAL OBJECTS Razor blade in mouth Dental drill in pyriform fossa

SILVER SOUP LADDLE

COINS On PA view In esophagus: en face. In trachea: on edge. However, always get a lateral view and you won’t have to remember this.

TWENTY CENTS

INGESTED FOREIGN BODIES ESOPHAGUS: Must be removed quickly, either UP or DOWN. DISTAL GI TRACT: Good chance will pass on own. However, sharp objects may perforate and large objects may obstruct and batteries can erode.

BATTERIES Ingestion of batteries, especially mercury or lithium for cameras and small electronic instruments, are a MEDICAL EMERGENCY! They can erode through the esophagus wall in a short time. Once they pass GE junction, they are less of a danger, but still can erode.

DRUG SMUGGLING Body Packers or ‘Mules’ electively ingest drugs, usually cocaine or heroin, wrapped in condoms. Body Stuffers ingest the drugs they are carrying emergently when about to be apprehended.

COCAINE SMUGGLING MISADVENTURES Cocaine is smuggled into the USA INSIDE human ‘Mules’. The drugs are wrapped in condoms and swallowed. Each condom contains 10 grams of cocaine. Each ‘mule’ carries 100 condoms. The total per ‘mule’ is 1000 grams. The condoms may leak, and cocaine is readily absorbed from the GI tract. The average lethal dose is only 1.2 grams, much less than in ONE condom.

BODY PACKER

GOODBYE Copyright 2004 MI Zucker