Interactive Transcript
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
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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
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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
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the emergency department.
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