CT AND MR IMAGING EVALUATION OF NECK INFECTIONS WITH CLINICAL CORRELATIONS

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Infection of the neck is a common clinical problem in all age groups, especially children and young adults.10, 19, 20, 60, 105 The clinical symptoms and signs are often suggestive of the diagnosis.3 Imaging studies including CT and MR imaging are frequently required to confirm the diagnosis but more importantly to localize the infectious process and search for and delineate an abscess cavity.88, 105 Ultrasound has also been used in the evaluation of superficial neck infections, especially to determine fluid accumulation. Conventional films consisting of an anteroposterior and lateral view were the examination before the introduction of CT in 1972. Conventional films still can be used for a preliminary survey, especially of the retropharyngeal space when there is a question of a retropharyngeal phlegmon or abscess. Moreover, the lateral view depicts the larynx, trachea, and pharynx for obstruction and displacement (Fig. 1).105, 108

As in other parts of the head and neck knowledge of the anatomy is paramount for localization and evaluation of the extent of the inflammatory process.34, 49, 59, 67, 91 Neck infections can be subdivided into deep37, 38, 51 or intrinsic encompassing Ludwig's angina, peritonsillar, and parapharyngeal and retropharyngeal inflammation, and extrinsic comprising cervical adenitis, submandibular, and submental and masticator space infections.30 The causative organisms of neck infection including lymphadenitis are varied and can be subdivided into bacterial, fungal, parasitic, and viral inflammatory disorders as delineated below. Neck infections are classified according to the anatomic location, also delineated below. The symptoms and signs of neck infections are general and localized depending on the anatomic location.2 They consist of fever, pain with limitation of neck motion, trismus, anorexia, dysphagia, odynophagia, adenopathy, and a neck mass secondary to phlegmon or an abscess associated with an elevated leukocyte count (>15,000). Trismus, the inability to open the mouth, is caused by an inflammatory infiltrate involving the muscles of mastication (masseter, temporalis, and medial and lateral pterygoid muscles) or the motor branch of the trigeminal nerve. Early fluctuation in deep neck infection is difficult to appreciate on clinical examination.29 In these cases CT or MR imaging are valuable imaging tools to recognize early abscess formation and to map out the location and extent of the abscess.55, 66, 107 In advanced neck infections with laryngeal edema there may be dysphonia, hoarsness, stridor, and dyspnea. In involvement of the retropharyngeal space (danger space) with delayed or inadequate treatment, mediastinal extension may ensue with symptoms of pain, dyspnea, asphyxia secondary to aspiration, swelling with mediastinal widening, and dysphagia from esophageal compression.9, 21 Further complications of neck infection include arterial rupture, venous thrombosis with or without distant embolism, and base of skull involvement.111 The treatment varies depending on whether an abscess has developed. Intravenous antimicrobial therapy is the treatment of choice for phlegmon; however, if an abscess is present surgical intervention is mandated. The type and approach has to be tailored according to the location and size of the abscess.14, 37, 49 Causes of Neck Infections

  1. Bacterial infection

    • Aerobic

    • Anaerobic

    • Necrotizing fasciitis

  2. Mycobacterial infection

    • Mycobacterium tuberculosis

    • Atypical mycobacterium

  3. Other bacterial infections

    • Cat-scratch disease

    • Actinomycosis

    • Brucellosis

    • Bubonic plague

    • Tularemia

  4. Fungal diseases

    • Coccidioidomycosis

    • Paracoccidioidomycosis

    • Histoplasmosis

  5. Parasitic diseases

    • Toxoplasmosis

    • Filariasis

  6. Viral infections

    • Viral adenitis

    • Infectious mononucleosis

    • Cytomegalovirus lymphadenitis

    • HIV infection with lymphadenopathy

  7. Inflammatory disorders

    • Kawasaki syndrome

    • Sarcoidosis

    • Sinus histiocytosis with massive lymphadenopathy

    • Kimura's disease

    • Kichuchi- Fujimoto disease

    • Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome

    • Solitary myositis

Bacterial Neck Infection According to Anatomic Location

  1. Intrinsic (deep)

    • Peritonsillar abscess

    • Submandibular space infection

    • Ludwig's angina

    • Masticator space infection

    • Parotid space infection

    • Retropharyngeal infection

    • Parapharyngeal infection

  2. Extrinsic

    • Cervical adenitis with phlegmon or abscess

Section snippets

RADIOLOGIC EVALUATION OF NECK INFECTION

Radiologic assessment of neck infection is invaluable in the diagnosis, location, spread of the inflammatory infiltrate, and determination of the presence and location of an abscess cavity.66, 107 It is important to determine the position of the great vessels and their relationship to the infectious process. A conventional lateral neck film provides a survey of the neck including pharynx, larynx, trachea, retropharyngeal space, and prevertebral space including cervical spine (see Fig. 1). The

Etiology and Sources of Bacterial Neck Infections

The source of neck infections is unknown in up to 50% of cases, chiefly in extrinsic neck infections. Some cases of neck infection result from suppurative adenitis with the primary infection commonly originating from the mucosa of the oral cavity, paranasal sinuses, and pharynx. Dental caries and periodontal disease of the teeth are other sources frequently implicated in deep neck infection.22, 35112 Salivary gland infection either arising in the submandibular gland or parotid gland often

LYMPHADENITIS AND LYMPHADENOPATHY: GENERAL COMMENTS

The neck is the seat of many lymph nodes (300 of 800) in the body.95 Palpable lymph nodes less than 0.5 cm in diameter are commonly found in children not associated with infection or systemic illness with the exception of infants, where any palpable mass including lymph nodes is abnormal.68 Likewise, any lymph nodes in the supraclavicular fossa should undergo biopsy. When lymph nodes are enlarged, distinction should be made between lymphadenitis (tender, red, and warm); suppurative

Cervical Mycobacterial Lymphadenitis (Scrofula)

Mycobacterial tuberculosis (MTB) is caused by Mycobacterium tuberculosis, M. bovis, and M. africanum. The pulmonary forms of tuberculosis account for the vast majority of cases of MTB. Cervical tuberculous lymphadenitis is the most common form of head and neck tuberculosis and accounts for about 5% of cases of cervical lymphadenopathy. Cervical lymph node MTB comprises 15% of extrapulmonary tuberculosis, and 1% to 2% of all new cases of MTB.46 The incidence of extrapulmonary disease is greater

Actinomycosis

Actinomycosis is an anaerobic bacterial, subacute, or chronic infection that occurs most commonly in the cervicofacial region (57%); abdominal cavity (22%), and chest (15%). Actinomyces israeli, the predominant pathogen in man, occupies the oral cavity and the gastrointestinal tract as a saprophyte but invades damaged tissue, as may occur after oral trauma including dental manipulation. The Actinomyces bacterium usually causes significant tissue destruction with extension and insinuation into

Histoplasmosis

Rarely, histoplasmosis presents as an isolated neck mass with the exception of Histoplasmosis dubossi, encountered in Africa, where enlarged cervical lymph nodes are present. Histoplasma capsulatum is ubiquitous in the central United States (Ohio Valley), where 50% to 100% of the population have been infected. The infection is contracted from inhaled airborne spores generated from bird droppings. The disease manifestation ranges from asymptomatic to pulmonary infection or systemic infection

Toxoplasmosis

Toxoplasma gondii is a ubiquitous protozoon that causes asymptomatic disease or chronic regional or generalized lymphadenopathy with mononucleosis-like symptoms in immunocompetent older children and adults.52 Rarely, a neck mass may be the presenting finding.30 In immunocompromised patients including those with HIV there is central nervous system involvement. Newborns with toxoplasmosis transmitted from infected mothers have multisystem disease. Transmission of oocysts occurs from cat feces,

Viral Adenitis

This is the most common infection causing cervical adenitis in the pediatric age group. It includes a diverse number of pathogens, such as adenovirus, rhinovirus, and enterovirus, in addition to measles, mumps, rubella, and varicella. The diagnosis is made by clinical examination and selective diagnostic laboratory tests.

Infectious Mononucleosis

Infectious mononucleosis is caused by the Epstein-Barr virus. The disease is associated with an exudative tonsillitis; lingual tonsillitis; cervical lymphadenopathy; adenoid

Kawasaki Syndrome

Kawasaki syndrome is an inflammatory condition that probably has an infectious cause. Unilateral and occasionally bilateral cervical lymphadenopathy, often the anterior nodes, is a feature in 50% to 70% of cases.83 These nodes may be slightly tender and erythematous. Lymphadenopathy occurs in association with fever, rash, nonpurulent conjunctivitis, mucositis, and extremity changes. Most cases afflict children under 4 years of age.

Kikuchi-Fuchimoto Disease

Kikuchi's disease, first described in Japan, is thought to be

Calcific Tendinitis of the Longus Colli Muscle

This condition is characterized by deposition of calcium hydroxyapatite into the longus colli tendon. There is acute onset of odynophagia, dysphagia, neck pain with rigidity, occipital headache, and occasionally slight fever.23 Symptoms usually subside in 1 to 2 weeks and are relieved by anti-inflammatory agents.77, 78 Radiologic investigation by conventional lateral films and CT demonstrates prevertebral soft tissue thickening with calcification located in the prevertebral area at the level C1

References (111)

  • R. Bahadory et al.

    Tuberculosis of the cervical spine

    Otolaryngol Head Neck Surg

    (1994)
  • A.S. Baker et al.

    Oropharyngeal space infections

    Curr Clin Top Infect Dis

    (1987)
  • A.S. Baker et al.

    Infections of head and neck spaces and salivary glands

  • G. Barratt et al.

    Retropharyngeal abscess: A ten year experience

    Laryngoscope

    (1984)
  • J. Bar-Ziv et al.

    Branchial pouch sinus tract from the piriform fossa causing acute suppurative thyroiditis, neck abscess or both: CT appearance and the use of air as a contrast agent

    AJR Am J Roentgenol

    (1996)
  • M.B. Becker et al.

    Necrotizing fasciitis of the head and neck: Role of CT in diagnosis and management

    Radiology

    (1997)
  • E.F. Bello et al.

    Salmonella Dublin neck abscess Arch Otolaryngol Head Neck Surg

    (1985)
  • M.J. Belmont et al.

    Atypical presentations of actinomycosis

    Head Neck

    (1999)
  • I. Bloomquist et al.

    Life-threatening deep fascial space infections of the head and neck

    Infect Dis Clin North Am

    (1988)
  • C.D. Bluestone

    Head and neck space infections in infants and children

    Otolaryngol Head Neck Surg

    (1995)
  • G.A. Borends

    Subphrenic and medlastinal abscess formation: A complication of Ludwig's angina

    Br J Oral Maxillo Surg

    (1985)
  • C. Boucher et al.

    Retropharyngeal abscesses: A clinical and radiologic correlation

    J Otolaryngol

    (1999)
  • L. Braun et al.

    Jugular venous thrombosis: MR imaging

    Radiology

    (1985)
  • L. Brodsky et al.

    Needle aspiration of neck abscesses in children

    Clin Pediatr

    (1992)
  • M. Castillo et al.

    Imaging of Bezold's abscess

    AJR Am J Roentgenol

    (1998)
  • M.M. Chetham et al.

    Infectious mononucleosis in adolescents

    Pediatr Ann

    (1991)
  • V.F.H. Chong et al.

    The suprahyoid neck: Normal and pathological anatomy

    J Laryngol Otol

    (1999)
  • A. Chow

    Infections of the oral cavity, neck, and head

  • A.W. Chow

    Life threatening infections of the head and neck

    Clin Infect Dis

    (1992)
  • A.W. Chow et al.

    Orofacial odontogenic infections

    Ann Intern Med

    (1978)
  • K. Chowdhury et al.

    Spontaneous and nonspontaneous internal jugular vein thrombosis

    Head Neck

    (1990)
  • J.I. Cohen

    Calcific tendinitis of the longus colli muscle

    Head Neck

    (1997)
  • S.A. Deluca et al.

    Vocal cord paralysis: A latent effect of perivascular thorium dioxide

    Arch Otolaryngol

    (1984)
  • K. Eckbom et al.

    Magnetic resonance imaging in retropharyngeal tendinitis

    Cephalalgia

    (1994)
  • B. Edison

    Bezold's abscess with extension to the suprascapular space

    Otolaryngol Head Neck Surg

    (1990)
  • A.A. El Khouly et al.

    Primary cholesteatoma of the mastoid presenting as cervical abscess

    J Laryngol Otol

    (1989)
  • Y. El-Sayed et al.

    Deep neck space abscesses

    J Otolaryngol

    (1996)
  • J.E. Engel et al.

    Toxoplasmosis appearing as an anterior neck mass

    Ear Nose Throat J

    (1993)
  • J.W. Fairley et al.

    View from beneath: Pathology in focus Kikuchi's necrotising lymphadenitis

    J Laryngol Otol

    (1991)
  • M. Grodinsky et al.

    The fasciae and fascial spaces of the head, and neck and adjacent regions

    Am J Anat

    (1938)
  • R.C. Harbour et al.

    Septic cavernous sinus thrombosis associated with gingivitis and parapharyngeal abscess

    Arch Ophthalmol

    (1984)
  • H.R. Harnsberger et al.

    Differential diagnosis of head and neck lesions based on their space of origin. 1. The suprahyoid part of the neck

    AJR Am J Roentgenol

    (1991)
  • H.J. Hyung Kim et al.

    Odontogenic versus nondontogenic deep neck space infections

    J Comput Assist Tomogr

    (1997)
  • G. Isaacson et al.

    Focal myositis: A new cause for the pediatric neck mass

    Arch Otolaryngol Head Neck Surg

    (1991)
  • J.T. Johnson

    Changing concepts in the management of deep neck infection

    AAO-HNS Bulletin

    (1992)
  • A. Karkanevatos et al.

    Acute non-tuberculous retropharyngeal abscess in an adult. A case report and review of the literature

    J Laryngol Otol

    (1997)
  • Y.J. Kim et al.

    CT manifestations of cervical tuberculous lymphadenitis

    J Otolaryngol

    (1993)
  • A.D. King et al.

    MRI of tuberculous lymphadenopathy

    J Comput Assist Tomogr

    (1999)
  • D. Langenbrunner et al.

    Pharyngomaxillary space abscess with carotid artery erosion

    Arch Otolaryngol

    (1971)
  • J.B. Lazor et al.

    Comparison of computed tomography and surgical findings in deep neck infections

    Head Neck Surg

    (1994)

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