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Case 14 - Phlegmon

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0:01

This is a different patient,

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but they all have sort of similar histories,

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and that is they have sore throat pain,

0:07

they may have some drooling,

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they usually have a fever, and we give

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the contrast and do the neck CT.

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Images of the brain look fine.

0:16

Images of the orbits look fine.

0:18

We come from above. We see the parotid glands,

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no abnormalities there. And the

0:25

nasopharynx.

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Once again, some element of adenoid hypertrophy.

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However,

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in a young person, this is within normal limits.

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When we come to the level of the palatine tonsils,

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we see that there is a symmetric enlargement

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of the palatine tonsils.

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The right, in this case, is larger than the left.

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When we come down to the level of the lower

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palatine tonsils, we once again see a relatively

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ill defined area of low density.

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This really doesn't have as sharp walls,

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more likely to use the term

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a phlegmon in this situation.

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Also, along the lateral aspect of the palatine

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tonsil. So not really in the tonsil,

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but in the peritonsillar space.

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You notice also that there is some edema of the

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parapharyngeal fat as we come

1:11

to this inflammatory process.

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One of the things that we should always look for

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in dealing with an inflammatory process in

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the oropharynx is to make sure

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that the jugular vein is intact

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and there's no thrombus associated with it,

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no irregularity of the internal carotid artery to

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suggest vasculitis from the infection.

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We want to make sure that the floor of the mouth

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does not show a large collection or in the

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submental space or some mandibular space,

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that there is no evidence of a collection.

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All those things are important pertinent

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negatives because of the possibility of such

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syndromes as Lemierre's syndrome,

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which is thrombophlebitis after an oropharyngeal

2:00

infection that can lead to septic emboli into the

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lungs. And then we have Ludwig's angina,

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which is usually an abscess that's seen in the

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submandibular space, associated more

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commonly with dental infections,

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but can occur secondary to tonsillitis

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and peritonsillar abscess.

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And then we just have the usual state

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of the lymph nodes. So in this case,

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we see enlarged lymph nodes

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bilaterally in the level two,

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a jugular chain, and coming down

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to the level of the hyoid bone.

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Most of those lymph nodes have gone away.

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So we're now into the level three jugular chain.

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Small lymph node here on the right side.

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We notice also, as we scroll down,

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as opposed to the previous case,

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that the epiglottis looks fine,

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the area of epiglottic folds look fine and

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the piriform sinus looks fine.

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No extension into the hypopharynx

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in this particular case.

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Of course you will extend into the apices of the

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lungs and make sure that there are no infections,

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particularly in the COVID era.

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We want to look for incidental inflammatory

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process that may be occurring in the lungs and

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we would have to window that with our lung windows

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and identify if there is an incidental nodule

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or incidental infection in that location.

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These lung windows also give you a nice sense of

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the absence, in this case, of significant airway

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narrowing from the inflammatory process.

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Use of the sagittal and coronal reconstructions

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are particularly helpful when we are looking at the

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degree of the lymphadenopathy associated

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with the inflammatory process.

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And you can see those large lymph nodes that are

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evident in the jugular chain, and they also

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show bilateral lymphadenopathy.

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This also is a good plane to look for any impression

3:59

or irregularity to the carotid arteries

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or the jugular vein on either side.

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Jugular vein here and the carotid artery

4:07

here with the carotid bifurcation.

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You also want to look at the spine,

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make sure that there is no inflammatory process in

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the retropharyngeal space or in the pre vertebral

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space, and that the patient's neck pain is not

4:23

from degenerative disease of the cervical

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spine with an acutely herniated disc.

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Coronal imaging, also useful for looking at the

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palatine tonsils and showing the superior

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inferior extent of the inflammatory process

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represented by the lower density here

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at the level of the palatine tonsils.

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It also is useful for looking at right left

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indentation on the airway by the enlarged

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palatine tonsils. So lots to cover,

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but this is a very common indication for contrast

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enhanced CT scan of the neck in

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the emergency department.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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