There are many lymph nodes of the neck that may potentially contain spread of cancer from the thyroid gland. We begin by describing a protocol for CT of the neck. The abscess or phlegmon most commonly develops superior to the palatine tonsil, between the capsule of the tonsil (which lies medial to the abscess) and the superior pharyngeal constrictor muscle (which lies peripheral to the abscess) (21). Branchial cleft anomalies can manifest as a cyst where there is no internal or external connection, as a sinus where there is only an external connection, or as a fistula where there are openings on the skin and pharyngeal surfaces (11). The subcutaneous tissues may be the primary site of inflammation or an indication of adjacent inflammation. Septic pulmonary emboli should be included in the “Lung Apices” section. (b) Axial contrast-enhanced CT image obtained 3 days later, by which time the patient’s condition had worsened such that intubation was required, shows that the suppurated lymph node (arrow) has ruptured into the retropharyngeal space (black arrowhead). MRI should be performed when intracranial extension is suspected. Therefore, the carotid and vertebral arteries should be traced at every neck CT examination. At standard CT evaluation of the neck, the craniocervical junction and the entire cervical spine are included, and abnormalities of the cervical spine are commonly seen. Rim enhancement cannot be assessed because contrast material was not administered. Bland thrombus is frequently associated with indwelling venous catheters, such as hemodialysis catheters, and can also be seen in thrombophilic conditions. At our institution, when contrast material is administered, we use a biphasic contrast agent injection protocol to achieve good parenchymal and vascular opacification, although a monophasic protocol also can be used. 127 (3): 318-22. In Lemierre syndrome, septic thrombophlebitis of the internal jugular vein occurs secondary to a pharyngeal infection such as pharyngitis or PTA (Fig 17). Figure 18. Wooden foreign bodies have air attenuation in the acute phase and therefore are best detected by using lung windows, and they may mineralize and increase in attenuation with time (30). There is also bone dehiscence (black arrow) along the dorsal aspect of the petrous apex. Ultimately, individual findings must be synthesized to derive a diagnosis or differential diagnosis that can guide further management. (c) Sagittal nonenhanced CT image (bone window) shows calcification (arrow) inferior to the anterior arch of C1, in the typical location for calcific tendinitis of the longus colli. The involved glands and their ducts should be inspected for stones. (c) Axial contrast-enhanced CT image (lung window) obtained inferior to a shows a nodular opacity (arrow) at the left lung apex, consistent with a septic pulmonary embolus. Figure 17a. Chong V. Cervical lymphadenopathy: what radiologists need to know. If there is an obstructing ductal stone (Fig 14), ductal dilatation also is present. Epiglottitis and supraglottitis refer to life-threatening acute inflammation of the epiglottis, aryepiglottic folds, and/or arytenoids. Most patients with acute sinusitis do not require imaging. The oral cavity (black * in b) is obliterated. Goiters with mediastinal extension, thymomas, congenital cysts, esophageal masses, and neurogenic tumors are among the most common mediastinal masses that can be discovered incidentally at neck CT. After specific findings are evaluated and reported in the proper sections of the report, the “Impression” section provides the opportunity to synthesize these findings into a unified diagnosis (Figure E14). Causes of bilateral sialadenitis include viral infection, radiation, immunoglobulin G4–related sialadenitis (of the submandibular glands), and Sjögren syndrome (of the parotid glands). Owing to the permeative nature of this process, it may mimic a tumor (9). Figure 6b. As such, it is possible that pneumonia that was not appreciated on a previously obtained chest radiograph may be visible in the lung apices on a neck CT image. If there is tracheal compression, the craniocaudal length of the compression and the degree of reduction of the cross-sectional area should be estimated. The teeth and surrounding structures are common culprits in cases of head and neck infection and are linked to systemic disorders such as cardiovascular disease (31,32). The trachea (black arrow) and esophagus (black arrowhead) also are seen. Swollen nodes that are close to your collarbone or the lower part of your neck when you're over 40 are more likely to be cancer. Mycobacterial cervical lymphadenitis, referred to as scrofula, may be tuberculous or nontuberculous (47). From the Division of Emergency Radiology (M.H.S. Under normal circumstances, the superior mediastinal fat should be homogeneous, without fat stranding or a pneumomediastinum. (b) Image in a obtained in soft-tissue windows shows an overlying or developing abscess (arrow). Vascular clot or occlusion should be included in the “Vascular Structures” section. 247 (3): 477-82. (a) Axial contrast-enhanced CT image shows a left retropharyngeal low-attenuation lymph node (arrow), consistent with internal suppuration. Axial contrast-enhanced CT image (a) shows an enlarged hyperenhancing right submandibular gland (black arrowhead) with internal and surrounding edema (black arrow) and overlying thickening of the platysma muscle (white arrow). In a recent single-center study (1), neck CT had a positivity rate of 87%, indicating that it is generally performed for good reason and, therefore, imaging findings should be expected. Injectable filler agents such as collagen, silicone, and hyaluronic acid can mimic subcutaneous infection or inflammation, and this possibility should be considered when isolated subcutaneous infiltration or highly symmetric infiltration is detected (6). Cervical lymph node involvement is the most common manifestation of Hodgkin disease involving the head and neck (48). The lung apices are visible on all CT scans of the neck. Aortic dissections, penetrating ulcers, and large atheromas are other aortic pathologic conditions that can be seen at neck CT and are important to recognize. In this setting, extensive arterial wall thickening may be seen and usually also involves the visualized mediastinal arteries (Fig E10). Infection of the spinal facet (zygapophyseal) joints is an uncommon cause of neck pain. Usually, diagnosing them means pinpointing what’s causing the swelling. (a, b) Acute right submandibular sialadenitis in a 57-year-old woman. If the infected nodes rupture, a retropharyngeal abscess forms. Figure 4a. In tonsillitis, the tonsils are enlarged and demonstrate a striated enhancement pattern (Fig 3). (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). Pneumonia appears as nodular and/or consolidative opacities in the lung parenchyma. Cranial nerves V, VI, and IX–XII also may be affected as infection spreads in the soft tissues (7). 7. CT atlas of thoracic lymph node stations as defined by IASLC, with ambiguous regions designated as per El-Sherief et al. Normal lymph nodes demonstrate an ovoid morphology, a fatty hilum, smooth margins, and homogeneous isoattenuation to muscle at CT. Cervical lymph nodes can be classified into levels (I–VII) and anatomic groups (supraclavicular, parotid, retropharyngeal, and occipital stations) according to established criteria (45). Axial (a) and coronal (b) contrast-enhanced CT images show submandibular and sublingual edema (white *) with internal fluid pockets (arrowheads) consistent with pus. (b) Axial nonenhanced CT image obtained just superior to a shows an abscess with a low-attenuation center (*), a thicker abscess rim (white arrow), and surrounding edema (black arrow). Although acute conditions are the first that come to mind, malignancy must remain in the differential diagnosis. The trachea (black arrow) and esophagus (black arrowhead) also are seen. Note the thickening of the left platysma muscle (arrow). Following a 60-second delay, an additional 40 mL of the agent is administered at 2 mL/sec for 20 seconds. Classic periantral fat stranding (black arrow) is seen on the left, as compared with the normal periantral fat (white arrow) on the right. Thyroid nodules are commonly encountered at neck imaging. Associated imaging abnormalities may include mural thickening of the affected carotid artery and stranding of surrounding fat (Fig 16) (52). They measure up to 5 mm in diameter and, owing to their small size, generally are not well seen at routine CT of the neck (42). Traditionally, infectious etiologies are the main cause of lymphadenitis. If there has been a perforation, extraluminal gas and fluid may be present. Also, when the carotid artery has a medial course, this variant should be noted because it may be mistaken clinically for tonsil-related disease, or the artery may be injured in a tonsillar intervention (23). (a) Axial contrast-enhanced CT image shows left peritonsillar edema (arrows), consistent with tonsillitis. Surgical drainage was performed. The above classification is not inclusive of several important nodal groups in the head and neck: Other classification systems include some of these regions, but a consensus approach has not been reached. Such nodes usually result from a spread of cancer on the scalp or back of the neck. An imaging-based classification for the cervical nodes designed as an adjunct to recent clinically based nodal classifications. On CT images, the subcutaneous fat and muscular structures should have sharp definition without infiltration of the subcutaneous fat. 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