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84Emergency Imaging

Approach to Inammatory or Neoplastic Conditions

Suspected inflammatory or neoplastic conditions of the face and neck should be evaluated using postcontrast CT. Because of its anatomic complexity, neck CT in-terpretation is aided by grouping related structures.

Nontraumatic Face/Neck Checklist

Airway and Related Structures

• Nasal cavity

• Nasopharynx

• Oropharynx

• Hypopharynx

• Larynx

• Trachea

• Lung apices

• Esophagus

• Thyroid gland

Soft Tissues and Bones

• Muscles

• Blood vessels

• Lymph nodes

• Cervical spine and skull base

Oral Cavity and Salivary Glands

• Tongue

• Tongue base

• Mandible, maxilla, and dentition

• Floor of mouth

• Submandibular glands

• Parotid glands

Orbits

• Globes

• Muscles

• Optic nerve

• Orbital fat

• Orbital walls

Everything else

• Skull base

• Brain

• Temporal bones

Soft Tissue Survey

• Superficial soft tissues

• Nasal septum

• Sinus contents

• Orbital fat (with attention to any orbital stranding, emphysema, or subperiosteal hematoma)

• Globes

• Optic nerves

• Extra-ocular muscles

• Brain (pneumocephalus, hemorrhage)

Indications for Neck CT Angiogram in Trauma

Blunt neck trauma is associated with clini-cally occult vascular injury in up to 3% of hospitalized patients. Early detection of vascular injury and therapeutic antico-agulation or endovascular occlusion can significantly reduce the incidence of stroke in this group. The Denver Modified Blunt Cerebrovascular Screening Criteria define a high-risk group of trauma patients for whom urgent CT angiographic imaging is indicated:

• Direct signs of vascular injury (hemorrhage, bruit, hematoma)

• Focal neurologic deficit or CT demonstrating acute cerebral infarct.

• Le Fort II or III fracture

• Cervical spine fracture

• Basilar skull fracture involving carotid canal

• Severe brain injury (diuse axonal injury, GCS < 6)

• Hanging injury• Neck contusion

Patients with penetrating injuries who do not undergo immediate surgical ex-ploration should be imaged by CTA or conventional angiography. Typical vascu-lar injuries in both blunt and penetrating trauma include dissection, occlusion, pseu-doaneurysm, and arteriovenous fistula. Urgent CTA should also be considered in patients who present with focal neurologic findings, as vascular dissection with mini-mal or no trauma is an important cause of stroke, particularly in younger adults.