Imaging of Pediatric Head and
Neck Emergencies
Adam Schneider1, Wilson Altmeyer1, Bundhit Tantiwongkosi1,
Yutaka Sato2, Achint K Singh1
1.
2.
University of Texas Health Science
Center at San Antonio
University of Iowa Hospitals and Clinics
Disclosure Statement
• We have no financial relationships to disclose that may have a direct
or indirect interest in the content.
Purpose
•Detail the spectrum of non-traumatic
pediatric head and neck pathologies
seen in an emergency room setting and
review critical findings that radiologists
must convey to clinicians which can
directly influence patient treatment and
outcomes.
Introduction
•Head and neck emergencies are less
common in the pediatric age group with
often non-specific signs and symptoms
•Imaging plays an important role in the
timely diagnosis of these conditions and
is necessary for effective management
Table of contents
Airway Emergencies
Deep Neck Infections
Orbital Emergencies
Temporal Bone/Ear Emergencies
Sinonasal Disease
Complications of Neoplasms
Home
Airway Emergencies
Croup
Epiglottitis
Foreign Body
Home
Croup (Laryngotracheobronchitis)
Frontal radiograph shows
straightening of the normally
convex subglottic airway with
narrowing “steeple sign”
Normal “shouldering” of the
subglottic airway for comparison
Home
Croup (Laryngotracheobronchitis)
• Clinical: Stridor, barking
cough, fever
– Peak incidence 6 mo to 3 yr
• Etiology: Viral
• Imaging
– Frontal radiograph: loss of the
normal shoulders at subglottic
airway with narrowing
Frontal radiograph shows
straightening of the normally
convex subglottic airway with
narrowing “steeple sign”
• Differentials
– Normal epiglottis and
prevertebral space helps in
excluding epiglottitis and
retropharyngeal abscess
Epiglottitis
Lateral radiograph of the neck
demonstrates thickening of the
epiglottis (“thumb sign”) and
aryepiglottic folds
Home
Normal epiglottis for comparison
Epiglottitis
Home
• Clinical: Fever, stridor, dysphagia,
respiratory distress
• Etiology:
– Most common pathogen is H.
influenzae (decreasing incidence
due to vaccination)
• Imaging
– Lateral radiograph shows
enlargement of the epiglottis and
aryepiglottic folds
Lateral radiograph of the neck
demonstrates thickening of the
epiglottis (“thumb sign”) and
aryepiglottic folds
• Differential
– Croup: diffuse narrowing of the
subglottic airway
– Retropharyngeal abscess: widening
of the prevertebral soft tissue
Foreign body aspiration
Home
• Clinical: Cough, respiratory
distress
• Etiology:
– Most common at ages 1-3 yr
– Typically lodges in the right main
stem bronchus
Foreign body aspiration
Home
• Imaging
– Majority (80%) of aspirated FB
radiolucent -> CXR may appear
normal
– Air trapping may be seen on
expiratory or lateral decubitus
views
• Differentials
– Asthma and viral respiratory tract
infections typically result in
symmetric lung volumes
– Swyer-James syndrome: lucent lung
may be smaller
– Congenital lobar emphysema:
confined to a single lobe
Home
Foreign Body Aspiration
Right lateral decubitus
Left lateral decubitus
Lateral decubitus chest radiographs of a patient with confirmed right
main stem bronchus foreign body demonstrate persistent
asymmetric lucency of the right lung consistent with air trapping
Home
Deep Neck Infections
Tonsillar Disease
Retropharyngeal
Abscess
Odontogenic
Infection
Home
Tonsillar Disease
• Clinical: Fever, sore throat,
dysphagia
• Imaging
• Tonsillitis: Enlargement and
enhancement of the tonsil
• Peritonsillar abscess: Rimenhancing fluid collection between
the tonsillar pillar and capsule
• Differentials
• Retropharyngeal abscess: Rim
enhancing fluid in the
retropharyngeal space
• Branchial cleft cyst: typical location
in the lateral neck but rare cases of
type II may have inner opening in
the palatine tonsil
Home
Peritonsillar Abscess
Coronal, sagittal, and axial contrast enhanced CT images show
enlargement of the right palatine tonsil with associated rimenhancing fluid collection
Home
Retropharyngeal Abscess
• Clinical: Sudden onset of
fever, stiff neck, dysphagia
• Imaging
– Lateral radiograph:
thickening of
retropharyngeal soft tissues
+/- gas
– CT: Rim enhancing fluid
collection in retropharyngeal
space
• Differential
– Diagnosis based on location
and presence of fluid
collection with rim
enhancement
Axial CT shows fluid/thickening in
the retropharyngeal space with
small rim-enhancing collection
Home
Odontogenic Infection
• Clinical: Tooth pain,
fever, facial swelling,
dysphagia
• Imaging
– Empty socket or lucency
about the tooth root
with focal cortical break
or fistula
– Adjacent rim enhancing
fluid collection
• Differential
– Inflammatory changes
associated with dental
disease is characteristic
Home
Odontogenic Infection
Coronal and axial contrast enhanced CT images show
periapical lucency at a right maxillary molar with focal
cortical defect communicating with a rim-enhancing
abscess and adjacent inflammatory stranding
Home
Orbital Emergencies
Orbital Infections
Optic Neuritis
Home
Orbital Cellulitis
• Clinical: Periorbital swelling, erythema,
proptosis
• Etiology: Most commonly 2° to sinusitis
• Complications:
• Cavernous sinus thrombosis, meningitis,
intracranial abscess
• Imaging: Sinus disease, retrobulbar
stranding, extraconal fluid collection
• Look for non opacification of the
cavernous sinus
• Imaging plays an important role in the
differentiation of preseptal vs postseptal
cellulitis
Preseptal cellulitis: Limited to soft
tissues anterior to orbital septum
Post septal cellulitis
Home
Orbital Abscess with Cavernous Sinus
Thrombosis
*
Contrast enhanced axial CT images demonstrate ethmoid sinusitis,
subperiosteal-orbital abscess, and nonopacified cavernous sinus
Home
Optic Neuritis
• Clinical: Eye pain, monocular vision loss,
relative afferent pupillary defect
(RAPD)and visual field defect
• Etiology: MS, sarcoidosis, SLE, syphilis,
Lyme dz, viral, etc
• Imaging (MR is the modality of choice):
• Optic nerve size normal to mildly enlarged
with increased signal on T2 and
enhancement
• Diffusion restriction can be seen (rare)
• Differentials
• Acute onset makes glioma less likely
• Meningioma involves the optic nerve sheath
• Sarcoidosis typically involve the lacrimal gland
and extraocular muscles with optic nerve
Home
Optic Neuritis secondary to Lyme Disease
T2
DWI
T1 post gad
MR images (T2, DWI and post gad T1) demonstrate T2
hyperintense signal, diffusion restriction, and
enhancement of the right optic nerve
Home
Temporal Bone/Ear Emergencies
Otomastoiditis
Acute labrynthitis
Otomastoiditis
Home
• Clinical: Otorrhea, retro-auricular pain,
swelling, erythema
• Complications:
•
•
•
•
•
Labyrinthitis
Facial nerve paralysis
Meningitis
Dural venous thrombosis
Epidural and subperiosteal abscess
• Imaging: Fluid opacification of middle ear
and mastoid air cells with destruction of
mastoid septations
• Differentials
• Petrous apicitis: Fluid filled petrous apex with
surrounding enhancement
• Cholesteatoma: Itself does not enhance but
can coexist with mastoiditis
• Otitis externa has predominant involvement
of the EAC
Mastoiditis complicated by
epidural abscess
Home
Mastoiditis with Bezold Abscess
• Bezold abscess develops when pus erodes the cortex of
mastoid bone and extends medial to the attachment of the
SCM muscle and spreads along the SCM
Fluid opacification of the left middle ear and mastoid air cells
with overlying rim-enhancing fluid collection
Home
Acute Labyrinthitis
• Clinical: Sudden onset of hearing loss and/or vertigo
• Etiologies: Viral (typically unilateral), bacterial (may be bilateral from
meningitis), idiopathic, autoimmune
MR axial and coronal post gad T1 images demonstrate enhancement
of cochlea, vestibule and lateral semicircular canal
Home
Acute Labyrinthitis
• Imaging: Contrast enhancement of the normally non-enhancing fluid filled spaces of
the labyrinth
• Differentials
• Schwannoma: more focal, intense enhancement
• Labyrinthine ossificans: chronic complication of meningitis, shows loss of T2 hyperintensity
and ossification rather than enhancement as acute labyrinthitis
MR axial and coronal post gad T1 images demonstrate enhancement
of cochlea, vestibule and lateral semicircular canal
Home
Sinonasal Disease
Sinusitis and associated complications
Sinusitis
• Clinical: URI symptoms, nasal
discharge, fever
• Complications: Orbital cellulitis,
osteomyelitis, intracranial abscess, Pott
puffy tumor, mucocele
• Imaging: Mucosal
thickening/enhancement, sinus
opacification, air-fluid levels
• Look for intracranial and intraorbital
extension for early complication detection
• Differentials
• Allergic fungal sinusitis: Typical appearance
is hypointense signal on T2
• Mucocele: expanded sinus
Home
Home
Sinusitis with Epidural Abscess
T2
T1 post gad
T1 post gad
MR images show fluid signal intensity and enhancement in the left
maxillary, ethmoid, and frontal sinuses with underlying pachymeningeal
enhancement and rim-enhancing epidural abscess along the anterior
frontal convexity
Home
Pott’s Puffy Tumor
CT images show fluid opacification of the frontal sinuses with fluid
and air containing abscess in the overlying soft tissues.
Home
Complications of Neoplasms
• Neoplasms can result in a variety of secondary
complications which may present in the emergency setting
• The following cases are illustrative examples including
epistaxis, proptosis, and airway compromise
Epistaxis: Juvenile Nasopharyngeal
Angiofibroma
Home
• Clinical: Adolescent males, recurrent
atraumatic epistaxis, nasal
obstruction
• Imaging
• Avidly enhancing mass centered in SPF
• Flow voids can be seen on MR
• Classically involves PPF
• Osseous erosion nasal cavity, hard
palate, pterygoid plates common
• Differential
• SCC: rare in children
• Mucocele: Expanded paranasal sinus
• Typical imaging features, age, sex and
clinical history make JNA most likely
Soft tissue mass involving PPF
with associated osseous erosion
Home
Juvenile Nasopharyngeal Angiofibroma
T1 post gad
T2
DSA
• MR images show an avidly enhancing mass with flow voids centered
in the left pterygopalatine fossa extending to the nasopharynx
• DSA shows a vascular mass supplied by branches of the ECA
Home
Proptosis: Bone Metastasis
• Clinical: Depends on location, pain,
fracture
• In children, neuroblastoma and
leukemia/lymphoma most common
• Imaging: Enhancing mass with
aggressive periosteal reaction
• Differentials
• Fibrous dysplasia: Ground glass, benign
appearance
• Meningioma: Benign appearance, dense
sclerosis
• Osteomyelitis: Clinical history and
location/association with soft tissue
changes may be helpful
Axial CT shows aggressive lesion
involving the right sphenoid
wing/zygoma with “sunburst”
periosteal reaction resulting in
proptosis
Home
Neuroblastoma Metastasis
Axial
CTlesion
from involving
the same the
patient
an
Axial contrast
CT showsenhanced
aggressive
rightshows
sphenoid
enhancing
left suprarenal
mass extending
the resulting
midline with
wing/zygoma
with “sunburst”
periostealacross
reaction
in
associated vascular
encasement
proptosis
Airway compromise:
Venolymphatic Malformation
• Clinical: Most present early in life, if
large can produce airway compromise
• Location: Neck (75%), axilla (25%)
• Imaging
– Trans-spatial extension
– Macrocystic/mixed/microcystic:
macrocystic type responds best to
sclerosing Rx
– Thickened septa contain venous
component
– Hemorrhage into the cyst forms fluid-fluid
levels
• Differentials
– Thyroglossal duct cyst is usually midline
and uncommon at this age
– Branchial cleft cyst has cystic contents,
different location (depending on the
types) and typically seen in young adults
– Rhabdomyosarcoma is a reasonable
choice but age and fluid-fluid levels argue
against it
Home
Home
Venolymphatic Malformation
• Frontal radiograph: Soft tissue mass at the left lateral neck with rightward
deviation of the trachea
• US: Mixed cystic/solid mass with internal vascularity
• T2W MR: Large mass with fluid-fluid levels
Summary
•A wide variety of pediatric head and
neck pathologies can present in the
emergency room setting
•Being familiar with the typical imaging
findings of these common entities is
important for providing timely and
accurate diagnoses
References
• Donnelly, Lane. Pediatric Imaging: The Fundamentals. Philadelphia:
Saunders, 2008.
• Ludwig et al. Diagnostic imaging in nontraumatic pediatric head and
neck emergencies. Radiographics. 2010 May;30(3):781-99.
• Yousem, DM and RI Grossman. Neuroradiology: The Requisites.
Philadelphia: Mosby, 2010.
• www.statdx.com.
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