1. On Call Head and Neck Gladwin Hui Acknowledgement: Special thanks to Elissa Price

2. 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

3. 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)

4. Technique
Skull base to below carina, to include top of pericardium

5. 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

6. 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

7. Approach to CT Neck Check your ABC’S Bottom Line A = AIRWAY B = BONES
C = CAROTID SHEATH/VESSELS
S = SPINAL CORD/CANAL

8. Anatomy: Fat Planes & Spaces
Deep neck spaces
- Parapharyngeal space
- Retropharyngeal space
- Masticator space
- Carotid space
- Perivertebral space
- Anterior visceral space
- Submandibular/sublingual space

9. Lateral pterygoid muscle
Masticator space

10. Pharyngeal
mucosal
space
Nasopharynx

11. Medial
Pterygoid
Muscle
Parotid

12. Parapharyngeal space
Styloid process
ECA
Internal jugular vein
ICA
Carotid space

13. Uvula
Nasopharynx  Oropharynx

14. Retropharyngeal space

15. Posterior belly
digastric
muscle

21. Perivertebral space

23. Back edge
submandibular
gland
Lt JDG node
Jugulodigastric
lymph node </= 1.5-cm

24. Back edge
sternocleidomastoid
muscle

26. mylohyoid

29. ad
ad= ant belly digastric muscle

31. Epiglottis
Vallecula
Oropharynx  Hypopharynx

32. Submandibular space
Submandibular Gland

33. Hyoid bone

34. Hyoid bone

36. Hyoid bone

37. Aryepiglottic Folds

38. Piriform sinus

44. Cricoid cartilage

46. Cricoid cartilage

49. Cricoid cartilage

50. Cricoid cartilage

51. Thyroid
Cricoid cartilage

52. Anterior Visceral Space
Extends from hyoid bone to anterior mediastinum
Sling around the trachea, esophagus
Contiguous with the retropharyngeal space

53. 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

54. 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

55. Carotid space – Neurovascular Bundle
Extends from skull base to mediastinum
CCA, IJV, Vagus
Dissection, narrowing, aneurysm, rupture
Thrombus
Mass

56. Parapharyngeal Space Key landmark – primarily fat-containing
How is it being effected by a process going on in the region?

57. Retropharyngeal space
Parapharyngeal space
Carotid artery
Internal jugular vein

58. Tonsil
Submedial pterygoid space
Parapharyngeal space
Parotid gland
Neurovascular bundle
Retropharyngeal space

59. Anterior visceral space
Retropharyngeal space
Neurovascular bundle

60. Visceral space
Esophagus
Retropharyngeal space

61. Tonsil
Parapharyngeal space
Submandibular gland

62. Parapharyngeal space
Medial pterygoid muscle
Submandibular gland
Submandibular space

63. Submandibular and Sublingual Spaces
Important regions to evaluate for floor of mouth infections

64. Pathophysiology
Cellulitis
Phlegmon
Fluid collections
Abscess

65. Cellulitis Focal or diffuse Streaky infiltration of fat planes
Diffuse enlargement of adjacent muscles
No focal loculation of fluid

66. Cellulitis

67. Phlegmon Slightly heterogeneous solid swelling
May be minimal low density suggestive of fluid loculation developing
Usually seen in tonsillar/peritonsillar or retropharyngeal locations

68. Phlegmon

69. Fluid Collections homogeneous or minimally heterogeneous
no good peripheral margin, no enhancement
turns the fat planes grey

70. Fluid Collection

71. Abscess Well-defined capsule
Little or no cellulitic change in adjacent tissues
Often adjacent to bone (secondary to osteomyelitis)

73. Complications ALWAYS CHECK FOR:
Airway obstruction
Carotid pseudoaneurysm or rupture
Internal jugular vein thrombosis
Mediastinitis/fluid collection/abscess
Pericarditis

74. Dental Infections Usually mandibular, usually molar
Submedial pterygoid space
Floor of mouth
Anterior visceral space
Parapharyngeal space
Neurovascular bundle
Retropharyngeal space

77. 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

85. Tonsil Unilateral swollen tonsil Parapharyngeal space Floor of mouth
Neurovascular bundle
Retropharyngeal space

89. Iatrogenic
Post-intubation
Post-endoscopy

90. Pharyngeal/Esophageal Perforations
Air in the fat planes
Retropharyngeal space
Neurovascular bundle
Mediastinum

95. Salivary Gland Obstruction
Parotid
Submandibular

98. Courtesy: Learning Radiology

99. Courtesy: Learning
Radiology
Epiglottitis on
Lateral Xray

100. 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

101. 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

102. Approach to CT Neck Check your ABC’S Bottom Line A = AIRWAY B = BONES
C = CAROTID SHEATH/VESSELS
S = SPINAL CORD/CANAL

103. Good resources
Statdx

104. Thank you