Neck Cases 41-50

Periapical Abscess Subperiosteal Abscess Masticator Space Abscess

Case 41: What is the most likely diagnosis?

This patient had a large dental cavity (blue arrow) and periapical abscess of tooth # 1. A periapical abscess that originates in molar teeth can result in subperiosteal abscess that can involve several spaces of the head and neck including the masticator space (MS) (red arrows). These abscesses can easily extend into the MS because the medial pterygoid and masseter muscles attach to the angle of the mandible in close proximity to the roots of the 3rd mandibular molar teeth. A periapical abscess in the mandible can perforate the bone at the least resistant and weakest portion, which is the lingual side of the molar region.

DDx: Masticator Space Abscess 1.

2.

3.

4.

Masticator Metastasis From H&N SCCA Masticator Space Hemangioma Subacute Denervation Atrophy Pterygoid Muscle Submandibular Sialoadenitis

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Ludwig’s Angina

Case 42: What is the most likely diagnosis?

Ludwig’s angina is a dramatic, life-threatening, soft-tissue infection of the floor of the mouth and neck. Airway control is of paramount importance combined with immediate antibiotic therapy, and surgical drainage to decrease mortality. Etiology is usually from an odontogenic infection. Ludwig’s angina is a rapidly progressing polymicrobial cellulitis and myofascitis that spreads via connective tissue to the anterior neck and inferiorly to the mediastinum. CT can confirm the presence of gas in the soft tissues and extensive edema of the floor of the mouth and anterior neck (red arrows). CT will also reveal the extent of soft-tissue swelling as well as severity of airway compromise (blue arrows).

DDx: Ludwig’s Angina 1. Sublingual Sialadenitis 2. Lymphangioma 3. Oral Tongue Carcinoma 4. Sublingual Hematoma 5. Angioneurotic Edema

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Intratonsillar Abscess

Case 43: What is the most likely diagnosis?

CT shows enlargement and low attenuation (red arrows) within the left palatine tonsil with faint rim enhancement. The tonsil is not displaced anteromedially as would be the case with peritonsillar abscesses. Intratonsillar abscesses are caused by obstruction of a tonsillar crypt leading to post-obstructive abscess formation. A true peritonsillar abscess may develop if the intratonsillar abscess does not spontaneously rupture and evacuate. Intratonsillar abscesses, in most cases, may be successfully treated with antibiotics while peritonsillar abscesses usually require surgical drainage.

DDx: Intratonsillar Abscess 1.

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4.

Tonsillitis Peritonsillar Abscess Tonsillar Neoplasm Mononucleosis

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Peritonsillar Abscess

Case 44: What is the most likely diagnosis?

Peritonsillar abscess is the most common deep infection of the head and neck in children and young adults, often progressing from pharyngitis or tonsillitis. Peritonsillar abscesses form in the potential space between the palatine tonsil and its capsule, posterolaterally. A distinguishing clinical feature is inferior and anteromedial displacement of the infected tonsil (blue arrows) with contralateral deviation of the uvula. Many patients will have a thickened, muffled voice often described as having a “hot potato” quality. Contrast-enhanced CT in these 2 patients show areas of low attenuation surrounded by peripheral enhancement (red arrows) suggestive of abscess formation. Diffuse soft tissue edema with loss of the fat planes, retropharyngeal adenopathy, retropharyngeal abscess, and carotid sheath abscess, airway compromise may also be seen on CT.

DDx: Peritonsillar Abscess 1.

2.

3.

4.

Tonsillitis Intratonsillar Abscess Tonsillar Neoplasm Mononucleosis

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Case 45: What is the most likely diagnosis?

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Acute Calcific Prevertebral Tendonitis

Case 45: What is the most likely diagnosis?

Acute calcific prevertebral tendonitis often presents in patients with pain and stiffness in the neck associated with odynophagia and retropharyngeal soft-tissue swelling. Deposition of calcium hydroxyapatite in the oblique tendon and fibers of the longus colli and capitus muscles is seen (red arrows). Calcific crystals are presumed to be deposited from secondary inflammatory tendonitis. These calcific densities are best seen on 2D sagittal reformatted images and are often accompanied by fluid collection extending into the retropharyngeal space.

The retropharyngeal fluid collection extends in all directions and shows no enhancing wall versus abscess.

DDx: Acute Calcific Prevertebral Tendonitis 1. Retropharyngeal Abscess 2. Infectious Spondylitis 3. Traumatic Effusion

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Case 45a: A 2nd Case of Acute Calcific Prevertebral Tendonitis

Courtesy of Pat Hudgins

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Case 45b: A 3rd Case of Acute Calcific Prevertebral Tendonitis

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Courtesy of Doug Phillips

Periapical Abscess  Subperiosteal Abscess Sublingual Space Abscess

Case 46: What is the most likely diagnosis?

A periapical abscess that originates from the 1 st or 2nd molar teeth as well as from the premolar, canine, and incisor teeth can result in a sublingual space abscess if they erode into through the lingual cortex of the mandible (red arrows). A periapical abscess usually perforates the mandibular cortex where there is less resistant which is on the lingual side in the molar region. Sublingual space abscesses may then lead to the development of Ludwig’s angina.

DDx: Sublingual Space Abscess 1.

2.

3.

4.

5.

Ludwig’s Angina Sublingual Space Neoplasm Sublingual Gland Sialoadenitis Lymphangioma Ranula

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DDx: Multinodular Goiter

Case 47: What is the 1. Lymphoma most likely diagnosis?

2. Hashimoto’s Thyroiditis 3. Graves Disease

Multinodular Goiter The incidence of goiter, diffuse and nodular, is very much dependent on the status of iodine intake of the population. In areas of iodine deficiency, goiter prevalence may be very high. Especially in goiters of longstanding duration multinodularity frequently develops. The incidence of multinodular goiter in areas with sufficient iodine intake has been found to be around 6% with a female/male ratio of 13:1. There is an increased frequency over 45 years of age. Nodular goiter may be the result of any chronic low-grade, intermittent stimulus leading to thyroid hyperplasia. In response to iodide deficiency, the thyroid first goes through a period of hyperplasia as a consequence of the resulting TSH stimulation, but eventually, possibly because of iodide repletion or a decreased requirement for thyroid hormone, enters a resting phase characterized by colloid storage and the histologic picture of a colloid goiter. Repetition of these two phases of the cycle would eventually result in the formation of nontoxic multinodular goiter .

By the time the goiter is well developed, serum TSH levels and TSH production rates are usually normal. (red arrows).

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DDx: Hodgkin’s Lymphoma

Case 48: What is the most likely diagnosis?

1. Reactive Adenopathy

2. Non-Hodgkin’s Lymphoma 3. SCCA Adenopathy 4. Malignant Melanoma 5. Cat-Scratch Fever 6. Rosai-Dorfman Disease

Hodgkin’s Lymphoma Hodgkin's lymphoma, a neoplasm originating from lymphocytes, was named after Thomas Hodgkin, who first described abnormalities in the lymph system in 1832. Hodgkin lymphoma begins when a lymphocyte (usually a B cell) becomes abnormal and forms the multinucleated Reed-Sternberg cell. Hodgkin's lymphoma is usually characterized by the orderly spread of neoplasm from one lymph node group to another (red arrows). The spleen and liver may be involved. Waldeyer’s ring is not as frequently involved with Hodgkin’s lymphoma as compared to non-Hodgkin’s lymphoma. The disease occurrence shows two peaks: the first in young adulthood (age 15–35) and the second in those over 55 years old. There is an estimated 9,000 new cases in the United States with 1,300 annual deaths. Past infection with the Epstein-Barr virus (EBV) is thought to contribute to some cases. Patients with HIV infection are more at risk than the general population. The 10-year overall survival rate is more than 90% for all stages.

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DDx: Retropharyngeal and Carotid Space Abscesses

Case 49: What is the most likely diagnosis?

1. Retropharyngeal and Carotid Space Hematoma 2. Retropharyngeal Effusion

3. Acute Calcific Prevertebral Tendinitis 4. Retropharyngeal Sarcoma

Retropharyngeal and Carotid Space Abscesses Retropharyngeal space abscesses (red arrows) can easily spread to the carotid spaces (blue arrows) since the two spaces share part of the same fascia (deep cervical fascia). The infection within the carotid space can also result in severe spasm of the internal carotid arteries, venous thrombophlebitis, occlusion of the internal jugular veins, and spread downward into the mediastinum.

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DDx

DDx: Osteochondroma of Zygomatic Arch

Case 50: What is the most likely diagnosis?

1. Osteosarcoma

2. Chondrosarcoma

3. Fibrous Dysplasia 4. Post-traumatic Myositis Ossificans

Osteochondroma of Zygomatic Arch Osteochondromas of the facial bones are quite uncommon. This lesion seen to arise from the inferior aspect of the zygomatic arch (red arrows) and is partially embedded within the masseter and temporalis muscles (blue arrows). No periosteal bone formation or true bony matrix is seen to suggest an aggressive bone neoplasm. The sharp outer cortex, presence of normal appearing internal bony septa, and normal cancellous bone would be atypical for fibrous dysplasia.

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