Plain Radiology of the Neck

Prof.Prof. Hossam Thabet, M.DHossam Thabet, M.D..

Otolaryngology-Head & Neck Otolaryngology-Head & Neck Surgery DepartmentSurgery Department

Alexandria UniversityAlexandria University

Plain Imaging Of The Neck

Plain Imaging of H&N

Neck Lateral Soft Tissue AP Soft Tissue Cervical Spine

1. Lateral (Flexion & Extension)2. AP3. Right Lateral Oblique4. Left Lateral Oblique5. Odontoid View, Open Mouth

Hyoid Bone

Ventricle

Tracheal Airway

Cricoid Cartilage

Aryepiglottic FoldEpiglottis

Base Of Tongue

Prevertebral Space C2

Prevertebral Space C6

Vallecula

Nasopharynx

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 columnalong entire vertebral column

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

Cervical FasciaVisceral SpaceVisceral Space

Retropharyngeal Retropharyngeal SpaceSpace

Alar SpaceAlar Space

Prevertebral SpacePrevertebral Space

Vascular SpaceVascular Space

Perivertebral SpacePerivertebral Space

The prevertebral space contains1. 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

Prevertebral space Causes of widening of the prevertebral space:1. Retropharyngeal infection (Cellulitis/Abscess)2. Postcricoid carcinoma 3. Posterior pharyngeal wall carcinoma4. Trauma of cervical spine 5. Pott’s disease of cervical spine6. 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:At C3= <3 mm (< 1/3 AP diameter)At C6 = < AP width of C6 vertebral body At C2 = 7mmAt C6 = 14 mm (kids) = 22mm (Adults)

True widening of prevertebral space

False +ve widening of prevertebral space

Adenoid Hypertrophy Pediatric Sleep Apnea

Pediatric Sleep Apnea

Lingual tonsillitis causing stridor

Ludwig’s 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

Right Lat. ObliqueLeft Lat. Oblique

Right Lat. ObliqueLeft Lat. Oblique

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

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


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 (

chicken bone (arrowed)stuck in the pharynx


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.



The arrowed structure is food in a Zenker diverticulum.

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

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

Radio-opaque shadow in the prevertebral space opposite to C5

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

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

Metallic wire larynx

Aspirated F.B.

F.B. Button in the larynx

Aspirated F.B.

Aspirated F.B.

Infected TGDC

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

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)


Croup URI symptoms Difficult to distinguish from early

retropharyngeal abscess Barking cough & hoarseness Inspiratory or biphasic stridor Low-grade fever


Croup Four major findings

Distension of the hypopharynx

Distension of the laryngeal ventricle

Haziness or narrowing of subglottic space –

(AP neck - “Steeple sign” “ Pencil tip”)

Normal Epiglottis


(AP neck - “Steeple sign” “ Pencil tip”)

Epiglottitis Haemophilus influenzae type B most

common Peak incidence : 6-7 years

Croup occurs from 6 months to 2 years Lateral radiograph -- Erect position only

Supine position may close off airway


EpiglottitisKey Findings ‘Toxic’ Child X-ray findings

‘Thumbprint’ Dilated

hypopharynx(Children) ‘Cherry Red’ Epigottis


Epiglottitis Radiological Key Points1.Swollen Epiglottis (Thumb print appearance)2.Thickened edematous AEF3.Swollen edematous

arytenoids4.Dilated hypopharynx5.Obliterated vallecula6.Normal subglottis7.Loss of cervical lordosis8.Associated pneumonia in 25

%


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

DysphagiaCricophgaryngeus Spasm 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 5-10% of asymptomatic individuals

63 year-old with 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

Dysphagia

Posterior hypopharyngeal wall carcinoma

Postcricoid CaPost.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 abscessRetropharyngeal 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 SpaceRetropharyngeal Space Posterior to pharynx & esophagusPosterior to pharynx & esophagus Anterior to alar layer of deep Anterior to alar layer of deep fasciafascia Extends from skull baseExtends from skull base to T1-T2to T1-T2 Midline raphe connects superior Midline raphe connects superior constrictor to the deep layer of deep constrictor to the deep layer of deep C.F.C.F. Contains retropharyngeal nodes.Contains retropharyngeal nodes.


• Children 3m-3y Children 3m-3y (<5y) (<5y) • CausesCauses1.Suppuration in 1.Suppuration in lymph nodes of lymph nodes of HenleHenle2. Nose, adenoids, 2. Nose, adenoids, nasopharynx, & nasopharynx, & sinus infectionssinus infections

• AdultsAdults• CausesCauses1.Ttrauma, F.B, 1.Ttrauma, F.B, instrumentationinstrumentation2.Extension from 2.Extension from adjoining deep adjoining deep neck spaceneck space

PathogenesiPathogenesiss


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


A tenA ten--Y/O boy with fever& neck pain due to posttrumatic Y/O boy with fever& neck pain due to posttrumatic

(F.B.)(F.B.)


18 year male with post traumatic retroph. abcess






Retropharyngeal Retropharyngeal AbscessAbscess

Retropharyngeal Retropharyngeal AbscessAbscess

Cervical Spondylolethesis

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

Danger SpaceDanger Space Anterior border-alar layer of deep Anterior border-alar layer of deep fasciafascia Posterior border-prevertebral layerPosterior border-prevertebral layer Extends from skull base to diaphragmExtends from skull base to diaphragm Contains loose areolar tissueContains loose areolar tissue Little resistance to spread of infectionLittle resistance to spread of infection


Danger SpaceDanger Space AA potential space composed of loose potential space composed of loose aereolar tissue & fat, extends down to aereolar tissue & fat, extends down to mediastinummediastinum. .

Nearly identical presentation to RPANearly identical presentation to RPA Cause: Extension from retropharyngeal, Cause: Extension from retropharyngeal, prevertebral or parapharyngeal spaceprevertebral or parapharyngeal space Cannot be distinguished by imaging Cannot be distinguished by imaging from retropharyngeal space.from retropharyngeal space.


Prevertebral SpacePrevertebral Space Anterior border - prevertebral fasciaAnterior border - prevertebral fascia Posterior border-vertebral bodies & deep Posterior border-vertebral bodies & deep N.msN.ms Lateral border – transverse processesLateral border – transverse processes Extends along entire vertebral columnExtends along entire vertebral column Infection tends to be localized due to Infection tends to be localized due to dense fibrous attachmentsdense fibrous attachments between fascia between fascia & deep muscles& deep muscles



Mostly originates from the cervical spineMostly originates from the cervical spine Cause: Pott’s abscess, trauma, osteomyelitis, Cause: Pott’s abscess, trauma, osteomyelitis, extension from retroph. & danger spacesextension from retroph. & danger spaces Back, shoulder, neck pain made worse by Back, shoulder, neck pain made worse by deglutitiondeglutition Dysphagia or dyspneaDysphagia 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(

A generalized spinal & extraspinal articular disorder that is characterized by ligamentous calcification and ossification

The definitive criteria for the diagnosis :1. Flowing calcification or ossification along the

anterolateral aspect of at least 4 contiguous vertebral bodies.

2. Relative preservation of intervertebral disc height of the involved segments

3. 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.

Rodríguez 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 enhancementRodríguez 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 Calcific 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 .

Sagittal reformat shows tapering of the

fluid (arrowheads) superiorly &

inferiorly in the typical pattern

T2MRI shows the effusion (straight arrows) tapering to a point inferiorly (curved arrow) at the level of C5. The level of attachment of the longus colli is at the anterior arch of the atlas (open arrow).


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


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


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 anti-inflammatory medication


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


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


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


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


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







T.B. Of the Prevertebral Space (Pott’s Disease)


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

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

CT. Multiple lytic areas seen involving bodies and posterior elements

Epidural Extension Of Actinomycosis in HIV infected immunocompromised 30ymale

Lateral cervical spine film shows widening of the prevertebral space and destruction of C5 and C6 vertebrae

Sagittal MRI showing the abscess opposite C4-C5. Destruction of C5 and C6, collapse of the intervertebral space and posterior extension of the abscess into the spinal canal.

Prevertebral Abscess with Osteomyelitis of the Cervical Vertebrae and Spinal Compression

High risk patients for cervical osteomyelitis:

1. Trauma to the pharynx or cervical spine2. Near by cervical infection3. IV drug abusers4. D.M.5. Immunocompromize, HIV infection6. Chronic renal failure7. Elderly


Causes 1.1. Pharyngeal PerforationPharyngeal Perforation Trauma to esophagus or

trachea Penetrating injuries from

weapons Perforation from within

Chicken bone Mediastinal emphysema tracking

into neck Surgery Retropharyngeal abscess Retropharyngeal abscess

(gas(gas--forming organismforming organism ))Pharyngeal perforation with extensive surgical emphysema

Retropharyngeal Retropharyngeal EmphysemaEmphysema

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

Pharyngeal PerforationPharyngeal Perforation

Documents

Plain Radiology of the Neck