0:01

This is a different patient,

0:02

but they all have sort of similar histories,

0:04

and that is they have sore throat pain,

0:07

they may have some drooling,

0:09

they usually have a fever, and we give

0:12

the contrast and do the neck CT.

0:14

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,

0:22

no abnormalities there. And the

0:25

nasopharynx.

0:25

Once again, some element of adenoid hypertrophy.

0:29

However,

0:29

in a young person, this is within normal limits.

0:32

When we come to the level of the palatine tonsils,

0:35

we see that there is a symmetric enlargement

0:38

of the palatine tonsils.

0:39

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

0:42

When we come down to the level of the lower

0:46

palatine tonsils, we once again see a relatively

0:49

ill defined area of low density.

0:51

This really doesn't have as sharp walls,

0:54

more likely to use the term

0:56

a phlegmon in this situation.

0:58

Also, along the lateral aspect of the palatine

1:01

tonsil. So not really in the tonsil,

1:03

but in the peritonsillar space.

1:05

You notice also that there is some edema of the

1:08

parapharyngeal fat as we come

1:11

to this inflammatory process.

1:14

One of the things that we should always look for

1:16

in dealing with an inflammatory process in

1:19

the oropharynx is to make sure

1:21

that the jugular vein is intact

1:25

and there's no thrombus associated with it,

1:28

no irregularity of the internal carotid artery to

1:31

suggest vasculitis from the infection.

1:35

We want to make sure that the floor of the mouth

1:38

does not show a large collection or in the

1:41

submental space or some mandibular space,

1:44

that there is no evidence of a collection.

1:47

All those things are important pertinent

1:50

negatives because of the possibility of such

1:54

syndromes as Lemierre's syndrome,

1:56

which is thrombophlebitis after an oropharyngeal

2:00

infection that can lead to septic emboli into the

2:03

lungs. And then we have Ludwig's angina,

2:06

which is usually an abscess that's seen in the

2:09

submandibular space, associated more

2:12

commonly with dental infections,

2:14

but can occur secondary to tonsillitis

2:16

and peritonsillar abscess.

2:18

And then we just have the usual state

2:21

of the lymph nodes. So in this case,

2:24

we see enlarged lymph nodes

2:26

bilaterally in the level two,

2:28

a jugular chain, and coming down

2:31

to the level of the hyoid bone.

2:33

Most of those lymph nodes have gone away.

2:35

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

2:39

Small lymph node here on the right side.

2:42

We notice also, as we scroll down,

2:45

as opposed to the previous case,

2:47

that the epiglottis looks fine,

2:50

the area of epiglottic folds look fine and

2:53

the piriform sinus looks fine.

2:55

No extension into the hypopharynx

2:57

in this particular case.

3:00

Of course you will extend into the apices of the

3:03

lungs and make sure that there are no infections,

3:06

particularly in the COVID era.

3:08

We want to look for incidental inflammatory

3:11

process that may be occurring in the lungs and

3:13

we would have to window that with our lung windows

3:16

and identify if there is an incidental nodule

3:20

or incidental infection in that location.

3:23

These lung windows also give you a nice sense of

3:25

the absence, in this case, of significant airway

3:28

narrowing from the inflammatory process.

3:31

Use of the sagittal and coronal reconstructions

3:36

are particularly helpful when we are looking at the

3:39

degree of the lymphadenopathy associated

3:41

with the inflammatory process.

3:44

And you can see those large lymph nodes that are

3:48

evident in the jugular chain, and they also

3:52

show bilateral lymphadenopathy.

3:55

This also is a good plane to look for any impression

3:59

or irregularity to the carotid arteries

4:03

or the jugular vein on either side.

4:05

Jugular vein here and the carotid artery

4:07

here with the carotid bifurcation.

4:10

You also want to look at the spine,

4:12

make sure that there is no inflammatory process in

4:16

the retropharyngeal space or in the pre vertebral

4:20

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

4:23

from degenerative disease of the cervical

4:25

spine with an acutely herniated disc.

4:28

Coronal imaging, also useful for looking at the

4:32

palatine tonsils and showing the superior

4:35

inferior extent of the inflammatory process

4:39

represented by the lower density here

4:41

at the level of the palatine tonsils.

4:43

It also is useful for looking at right left

4:46

indentation on the airway by the enlarged

4:50

palatine tonsils. So lots to cover,

4:53

but this is a very common indication for contrast

4:57

enhanced CT scan of the neck in

4:59

the emergency department.