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Radiology 2 > Face and Neck Imaging > Flashcards

Face and Neck Imaging Flashcards

1
Q

Imaging modalities of the face

A

-Plain Xrays-CT-Ultrasound

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2
Q

Plain films of the face

A
  • Rarely ordered, CT is far superior, ordered anyway. Usually ordered if no CT
  • Advantages: fast, less radiation, cheap
  • Disadvantages: poor detail, overlap = easy to miss pathology
  • 4-views standard: AP, lateral, Water’s view (money), submental vertex view (“jughandle” view)
  • Nasal bone: single lateral view
  • Looking for: Symmetry, Fluid collections, FB’s, Fractures, depressions
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3
Q

CT of the face indications

A
  • Indications: Significant trauma, Fracture present or suspected, Infections (Sinusitis, Periorbital cellulitis, Retrobulbar pus, Cavernous sinus thrombosis)
  • CT usually first test
  • Detail, clarity are far superior to plain film
  • Sagittal, coronal, axial recons – standard
  • Maxilo-facial views, Orbits thin cuts - these are specially ordered
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4
Q

Blow out fracture

A
  • “blow out” fracture - fx of bony orbit with “tear drop” sign (orbital fat) on plain film
  • CT - blood, fat opacifies maxillary sinus
  • suspect it post trauma to the orbit. If the affected eye EOM’s impaired, they have double vision and/or pain on looking up or out – suspect “entrapment” – when the orbital muscle or orbital fat is stuck in the fracture. Most commonly affected orbital muscle is the inferior rectus. If you get a plain film, this fx is best visualized on Water’s view. CT of the face and orbits follows plain film anyway – now days. It is first choice in most institutions. Orbital “cuts” are special and must be ordered separately – they are thin “slices” – 1-1.5mm.
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5
Q

Nasal Trauma - CT v. Xray

A
  • CT is clearly superior to plain film in outlining anatomy, surrounding structures
  • Plain films of the nose are not routinely ordered. Only ordered if VERY minor injury. If significant swelling, deformity and/or suspected associated injury, order a CT instead.
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6
Q

Tripod and LeFort Fractures

A
  • Fractures involving maxilla, zygoma and orbit. NOT subtle
  • Tripod fractures –> Direct blow to cheek, Zygomatic arch, orbit, wall of max sinus, CT initial study
  • LeFort fractures –> Significant mechanism, 3 basic types, Maxilla or maxilla plus maxillary sinus/orbits/nose/arch in various degrees, CT initial study
  • if you suspect one of these, you need CT, NOT XRAY
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7
Q

Mandible

A
  • Panorex – 1 view
  • Plain film series used less – 3 views (AP, 2 lateral)
  • CT if fracture, OMFS specialists request CT
  • Describe: Location & number of fx’s, Open or closed, Distraction (separation)
  • OMFS = oral maxillofacial surgeons
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8
Q

Mandible plain films

A
  • rarely ordered unless no Panorex or CT
  • AP and 2 lateral views standard
  • mandible often fractures in >1 place due to shape
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9
Q

Facial CT - facial infection

A

CT is the diagnostic test of choice for suspected deep space infections involving the face, mouth, neck

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10
Q

The cervical spine

A
  • Plain film: may be useful as initial study for non-trauma neck pain, mild radicular pain, very minor trauma, persistent neck sx’s
  • Plain films not ordered if significant trauma. CT first (unless no CT), great for bone-MRI for spinal cord injuries, radiculopathy
  • Indications for CT imaging in trauma (NEXUS, Canadian Rules, etc…, Significant mechanism, Midline pain, Any paresthesia/numbness/weakness, Cannot rotate or flex w/o pain, ALOC/intoxication, Age >65)
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11
Q

Plain films: neck

A
  • 3 views standard - AP, lateral (money), open mouth odontoid view
  • lateral is most useful: 85% fx’s seen here-odontoid view: specifically for C1, C2
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12
Q

Plain Xray: AP, Water’s view

A
  • lots of overlap, easy to miss fractures

- OK for opacified sinuses, foreign bodies

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13
Q

Lateral and submental vertex view

A
  • submental vertex or “jughandle” view

- best for suspected zygomatic arch fxs

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14
Q

how to tell if its pus or blood on plain film

A

-ASK RADIOLOGIST FOR HOUNDSFIELD UNITS

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15
Q

Lateral Neck Films

A
  • is the film adequate?
  • must be able to see the anterior superior corner (top of) T1 below C7 to evaluate alignment
  • must see base of skull
  • must see tips of C6, C7 spinous processes
  • cant get view of C7-71? Get a swimmer’s view (one arm up)
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16
Q

Swimmer’s view

A
  • When unable to see entire cervical vertebral column AND/OR anterior corner (top) of T1 on lateral view
  • Body habitus, disability, injury, etc.
  • Goal: to see C7/T1 and see if they line up
  • Technique: lateral with one arm above head
17
Q

reading lateral films

A
  • Systematic Approach
  • Count: ensure you can see the bottom of C7, top of T1
  • Check 4 lines of alignment
  • Look for consistent height/shape of vertebrae
  • Look for consistent disc spaces between bones
  • Look at soft tissue contours and spaces – measure if in doubt
  • Check all spinous processes for fx
  • Prevertebral Soft Tissues and Pre-dental Space
  • Edema signals fracture/trauma
  • Look at contour; measure (<6mm at C2, <5mm at C3/4, <22mm at C6, Kids: < ½ width VB)
  • Pre-dental space (atlanto-dens interval) (< or = 3mm adults, < or = 5mm kids)
18
Q

lateral: alignment

A 
1. Anterior longitudinal ligament line
Anterior vertebral line
2. Posterior longitudinal ligament line
Posterior vertebral line
3. Spinolaminar line
4. Spinous process line
19
Q

AP view

A
  • Alignment
  • Disc spaces
  • Height, contour of vertebral bodies
  • Spinous processes
  • Transverse processes
20
Q

reading the odontoid view

A
  • Do the vertebral bodies of C1 and C2 line up?
  • Look at symmetry of spaces between C1 and C2 (Is the pt rotated? Radiologist)
  • Look at contour of odontoid (dens) itself (Can you see the entire dens?)
  • Check lateral for clues too!
21
Q

Special neck views

A

Oblique views (Neural foramina, facet joints, Less common, CT (fx) or MRI (cord) are far superior)

Flexion/Extension Views (Less common, NOT used in trauma, Controversial, CT/MRI superior)

22
Q

CT neck, cervical spine

A

-No contrast for fracture
-Great for bone, not great for spinal cord
-Reconstructions
-Indications (Trauma, Suspect fracture/dislocation, Fracture/dislocation present on plain xray, Deep space infection, abscess ->
Mass

23
Q

MRI cervical spine

A
  • Definitive study for: Spinal cord injury, Radiculopathy, Abscess, Tumor, Pre-surgery
  • GET SCAN 1ST, THEN MRI
24
Q

Neck Fractures

A
  • 50% motor vehicle accidents, 25% falls, 10% sports
  • Mechanism important – flexion, extension, axial load, distraction, compression
  • Stable or Unstable fracture?
  • Look for misalignment, soft tissue swelling, uneven disc spaces
  • Significant trauma, ALOC, neuro deficit – CT all
  • CT best for bone detail, MRI for spinal cord injury
25
Q

Odontoid fractures

A
  • Exact mechanism unknown: combination
  • Odontoid fractures are unstable
  • Quite often, the patient is also unstable
  • CT when stabilized, MRI follows
26
Q

Jefferson Fracture

A
  • Fracture of the ring of C1
  • Best seen on odontoid view
  • C1 lateral masses are not lined up with C2 vertebral body
  • Increased or uneven spacing between C1 and odontoid
  • Mechanism: axial load
  • Unstable fracture
  • CT when stabilized, MRI follows
  • Confirm all fractures on CT scan by looking at image above and below for consistency
27
Q

Hangman’s fracture

A

-Mechanism: hyperextension and compression
(face vs. windshield)
-Soft tissue edema
-C2 often seen “over-riding” C3 – subluxed
-Spinal cord damage at C2 common
-Unstable fx
-CT when stabilized, MRI follows
-True “judicial” hangman’s fracture is not the fracture above. When hanged, traditionally - with a long drop and the knot lateral – there is complete transection of the spinal cord

28
Q

Burst fracture

A
  • Mechanism: axial load compression
  • Vertebral body in multiple pieces
  • Posterior elements enter spinal canal, compromise spinal cord
  • Unstable fracture
  • CT when stabilized, MRI follows
29
Q

Wedge Compression Fx

A
  • Mechanism: hyperflexion with axial load compression
  • Anterior vertebral body compressed into a “wedge”
  • If posterior elements intrude on spinal canal, considered a burst fx
  • Unstable fracture
  • CT when stabilized, MRI follows
30
Q

Flexion teardrop fx

A
  • Mechanism: hyperflexion and compression
  • Ligamentous disruption avulses bone – disruption can cause cord compromise
  • Widening of facet joint and/or spinous process spacing
  • Unstable fracture
  • CT when pt is stabilized, MRI follows
31
Q

Subluxation, Jumped or “perched” facets

A
  • Mechanism: hyperflexion with distraction
  • +/- Fracture w/ subluxation
  • Perched facets is essentially a ligamentous injury
  • Anterior and posterior vertebral lines of alignment are off
  • Cord compromise possible
  • Unstable
  • Describe: top vertebrae is “subluxed onto” the lower one - % of vertebral body
32
Q

Anterior Avulsion Fx

A
  • Mechanism: hyperextension
  • Anterior corner of vertebral body avulsed off by ligament tear
  • Hyperextension itself may squish and damage cord
  • Usually unstable
  • CT all when stabilized
33
Q

Clay Shoveler’s and Spinous Process Fxs

A
  • Clay Shoveler’s: spinous process fx at C6 or C7
  • Mechanism: Sudden hyperflexion; clay stuck to shovel when tossing overhead.
  • Also caused by a direct blow to area.
  • Classically, a ligamentous avulsion. Usually stable
34
Q

Neck: soft tissue lateral

A
  • Special view – must request it
  • Do not need C7/T1 – but nice to have it
  • Useful for epiglottitis, retropharyngeal abscess, swallowed foreign bodies
  • Exposure is underpenetrated to highlight the soft tissues
  • Lateral is only useful soft tissue view
  • CT scan often ordered first
  • CT scan ordered first with high suspicion, any mass, unstable patient
35
Q

Epiglottitis

A
  • Soft tissue lateral ok as first test unless high suspicion – then get a CT first as is definitive
  • Do not need C7/T1
  • Epiglottis is an anterior structure, usually a thin fingerlike soft tissue density at level of the hyoid bone
  • See enlarged epiglottis, classic “thumb” sign
  • Classic presentation: man with no IMZs and grew up outside US and has thumb sign
36
Q

Retropharyngeal abscess

A
  • Kids, adults too
  • Fever, severe sore throat, trismus (cant open mouth properly), anterior neck pain, pharyngeal findings don’t match
  • See soft tissue edema/mass in retropharyngeal space
  • Soft tissue lateral ok unless high suspicion
  • CT when stable for detail, extent
37
Q

Imaging thyroid nodules/masses

A
  • Ultrasound is initial imaging test: Size, composition, US-guided fine needle aspiration (FNA) biopsy, US alone cannot be relied upon to dx cancer (need biopsy)
  • Thyroid scintigraphy: Nuclear medicine study, Determines the functional status of a nodule (warm/hot/cold), No longer initial test, Low TSH plus nodule
  • CT reserved for complex cases, eval adjacent structures
38
Q

Vascular Studies - neck

A
  • Duplex Ultrasound -> Carotid/vascular flow, Part of CVA work up
  • CT angiography (CTA): CVA, carotid dissection, trauma
  • 3-D (enhanced) CT angiography
  • MR angiography (MRA)
  • Traditional angiography: Plain film after dye, Used less – CT or MRA preferred for detail

Radiology 2 (3 decks)

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