Transcript About Face! * Causes of Non-traumatic Facial Swelling

About Face! –
Causes of Non-traumatic Facial Swelling
Ari J. Spiro, MD
Judah Burns, MD
Andrew Friedman, MD
Matthew H. Neimark, MD, PhD
Meir H. Scheinfeld, MD, PhD
R. Joshua Dym, MD
eEdE-150
Disclosure
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Nothing to disclose
Introduction
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Facial swelling is a common presenting
scenario in the UrgiCare or ED setting.
Inflammatory causes are common, particularly
with rapid onset of swelling; malignancy and
acquired etiologies must also be considered.
Imaging helps to narrow the differential
diagnosis.
The purpose of this exhibit is:
› To present a space-based diagnostic approach to the
differential diagnosis of facial swelling
› To review both common and rare conditions that may
present with this clinical complaint
Topic Outline
▪ Orbit/Periorbital Space
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➢ Odontogenic Abscess
➢ Periorbital cellulitis
➢ Orbital Pseudotumor
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➢ Pott’s puffy tumor
▪ Submandibular Space
➢ Sialolithiasis
➢ Sialoadenitis
Sublingual Space / Potential
airway compromise
➢ Ludwig’s angina
➢ Angioedema
▪ Superficial/Subcutaneous
➢ Facial Cellulitis
➢ SCC
Masticator Space
▪
Parotid Space
➢ Infected branchial cleft cyst
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Mastoid related disease
➢ Bezold’s Abscess
Suprahyoid Neck Anatomy
Credit: Statdx: ( see suggested reading)
Axial graphic depicting the spaces of the suprahyoid neck.
Surrounding the paired fat-filled parapharyngeal spaces are
the four critical paired spaces of this region, the pharyngeal
mucosal, masticator, parotid and carotid spaces. The
retropharyngeal and perivertebral spaces are the midline
non-paired spaces.
Credit: Statdx: ( see suggested reading)
Coronal graphic of suprahyoid neck spaces as they
interact with the skull base. The masticator space has
the largest area of abutment with the skull base,
including CNV3. The pharyngeal mucosal space abuts
the basisphenoid and foramen lacerum.
Suprahyoid/Infrahyoid Neck
Credit: Statdx: ( see suggested reading)
Credit: Statdx: ( see suggested reading)
Axial graphic of the suprahyoid neck spaces at the level of
the oropharynx. The superficial (yellow line), middle (pink
line) and deep (turquoise line) layers of deep cervical fascia
outline the suprahyoid neck spaces. Notice the lateral
borders of the retropharyngeal & danger spaces are called
the alar fascia and represents a slip of the deep layer of
deep cervical fascia.
Axial graphic depicting the fascia and spaces of the
infrahyoid neck. The three layers of deep cervical fascia
are present in the suprahyoid and infrahyoid neck. The
carotid sheath is made up of all 3 layers of deep cervical
fascia (tri-color line around carotid space).
Case1 and Companion
2 different patients presenting to the Emergency
Department with recent onset of periorbital swelling.
Periorbital/Orbital Cellulitis
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Preseptal cellulitis – Periorbital soft
tissues anterior to orbital septum
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Postseptal cellulitis – Intraconal or
extraconal.
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Subperiosteal Abscess: Between
medial periosteum & lamina
papyracea.
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CECT: Enhancing, edematous orbital fatty
reticulum. Occasional myositis with
enhancement of rectus muscles.
NECT: Left periorbital swelling, with lowdensity phlegmon in the superior orbit,
obscuring the superior rectus muscle
Progression from phlegmon → subperiosteal
abscess
Treatment: Cellulitis/phlegmon – ABX;
Abscess – Surgical drainage
NECT: Right ethmoid sinus disease,
orbital swelling, subperiosteal abscess
Case 2
46 year old female with history of left upper lid
retraction and swelling, mild proptosis, and left
inferior rectus restriction.
Orbital Pseudotumor
▪ Idiopathic Orbital Inflammatory Disease
Top Differential Diagnosis:
▪ Diagnosis of exclusion
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➢ 3rd most common primary lesion of the orbit
▪ May involve any orbital structure
➢ Frequency of involvement: EOM>lacrimal
gland > globe or retrobulbar > diffuse >
apex
▪ 25% Bilateral
T2W MRI: Left
preseptal soft tissue
swelling. Enlarged
left lacrimal gland
and superior rectus
muscle.
Lymphoproliferative lesions
Thyroid ophthalmopathy
Sarcoidosis
Wegener granulomatosis
Orbital cellulitis
Case 3 and Companion
56 year old male with
history of chronic
sinusitis presents with 3
days of progressive
facial pain, and left
periorbital / scalp
swelling.
13 year old male with
history of sinusitis
presents with 5 days of
fever, facial pain, and
periorbital / scalp swelling.
“Pott’s Puffy Tumor”
56 yo male: CECT: Left frontal
sinusitis extending through frontal
cortex with periorbital and
subperiosteal extension
13 yo male: MRI: CE-T1W: Left
frontal sinusitis with subgaleal
phlegmon/abscess involving the left
scalp. Intracranial extension with
epidural abscess is also noted.
“Pott’s Puffy Tumor”
 Sinusitis is a common disorder that can
rarely result in serious complications
including:
 Periorbital or orbital cellulitis
 Intracranial abscess or meningitis
 Subperiosteal scalp abscess – “Pott’s puffy
tumor”
 Osteomyelitis
 Cavernous venous thrombosis
 Diagnosis of “Pott’s puffy tumor” can be
made with CECT or MRI. CECT is
preferred over MRI due to finer bony detail
 Treatment includes intravenous antibiotics
and surgical intervention.
 Early intervention significantly contributes to
favorable outcome and decreases the risk of
further complications.
Case 4
50 year old male presents to the Emergency
Department with left facial swelling and erythema.
Facial/Superficial Cellulitis
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Acute infection of the dermis and
subcutaneous tissues
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CT utilized to differentiate between
superficial cellulitis and cellulitis
associated with deep-seated infection
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Patients with diabetes melitis or peripheral
vascular disease are more susceptible
CT findings: Skin thickening, septation of the
subcutaneous fat, thickening of underlying
fascia
Deep-seated infection can lead to abscess,
myositis, necrotizing fasciitis
Treatment:
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Superficial- ABX
Deep - may require surgical intervention
CECT: Skin thickening, infiltration of
subcutaneous soft tissues and
platysma of the left face.
Case 5
60 year old female history of submandibular
gland swelling presents to the Emergency
Department complaining of 2 days of acute right
submandibular pain.
Sialadenitis and Sialolithiasis
▪ Acute sialadenitis is an infectious or
inflammatory disorder of the salivary glands
 Patients present with swelling exacerbated by eating
➢ Bacterial, viral, and autoimmune processes are the
most common etiologies
▪ CECT: Enlarged enhancing submandibular
gland with ductal dilatation secondary to an
obstructive calculus or stenosis
➢ Myositis or cellulitis often present in sublingual or
submandibular spaces.
▪ 80-90% of submandibular sialadenitis cases
are associated with ductal calculi (sialoliths),
while sialoliths are identified in 10-20% of
cases of parotid sialadenitis.
▪ Sialoliths occur more often in submandibular
duct (Wharton’s duct) due to large diameter,
ascending course, more mucinous salivary
content, and salivary stasis.
CECT: Enlargement of bilateral
submandibular glands and ducts containing
calculi (sialoliths). Inflammatory stranding
adjacent to the right submandibular gland c/w
sialadenitis.
Case 6
35 year old male presents to Emergency
Department with jaw pain and left cheek swelling.
Odontogenic Abscess
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Lower facial swelling should be
evaluated for potential infection arising
from pre-existing dental disease
CECT is the preferred modality for
evaluation of oral cavity infections and
suspected odontogenic abscess
Bone window settings may reveal
lucency surrounding dental roots
“floating roots”, cortical dehiscence, and
osteomyelitis.
2nd or 3rd molar tooth infection likely
involves the submandibular space,
infections of the more anterior teeth are
confined to the sublingual space
Treatment: tooth extraction, abscess
drainage, and ABX
CECT: Lucency surrounding the root of the
left 3rd mandibular molar with cortical
dehiscence adjacent to a superficial facial
abscess with associated cellulitis.
Case 7
44 year old male smoker and heroin user status
post hospitalization for mouth abscess after tooth
extraction.
Ludwig’s Angina
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Infection of the floor of the mouth that
extends bilaterally to soft tissues of oral
cavity
➢ Rapid extension-potentially life- threatening
➢ Establishing a secure airway is a priority as soft
tissue swelling displaces the tongue into the
pharyngeal airway
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Termed “Ludwig’s angina” to account for
the experience of pain described by
patients
Most often caused by infection of 3rd
mandibular molar tooth or pericoronitis
CECT to assess airway patency, presence
of gas-forming organisms, underlying
dental infection, or drainable abscess
CECT: Floor of mouth abscess. Edema
of the bilateral submandibular space,
right parapharyngeal space, and
aryepiglottic fold.
Case 8
45 year old female presents to the Emergency
Department with mandibular swelling after
recent increase in dosage of her ACE inhibitor.
Rule out abscess.
Angioedema
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Transient swelling
Primarily affects the face, tongue, lips and
larynx, possible airway compromise
ACE inhibitor most common cause
➢ Can develop shortly after starting therapy,
however reaction can occur months or even years
later.
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Treatment includes cessation of ACE
inhibitor, initiation of steroid and
antihistamine therapy, and airway
support.
CECT: infiltrative edema with
circumferential mucosal thickening,
however unilateral mass like areas have
also been described
CECT: Enlarged lower lip with heterogeneous
enhancement consistent with angioedema in the
setting of recent ACE inhibitor dose increase.
Lat XR: Soft tissue swelling of the epiglottis,
and upper and lower lips in this patient 1 day
after starting ACE-I therapy.
Case 9
33 year old male presents to Emergency
Department with left neck pain.
Branchial Cleft Cyst
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Best diagnostic clue: Cystic neck mass
posterolateral to submandibular gland,
lateral to carotid space, anterior (or
anteromedial) to SCM
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If infected, wall is thicker & enhances with
surrounding soft tissue cellulitis
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Differential diagnosis:
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Lymphatic malformation
Cervical thymic cyst
Lymphadenopathy/abscess
Cystic metastatic nodes
Carotid space schwannoma
Rim enhancing cystic structure
posterior to the submandibular gland
and anterior to the sternocleidomastoid
muscle. DDX infected 2nd branchial
cleft cyst vs necrotic lymph node
Case 10
11 year old male presents to the emergency
department with posterior auricular edema.
Bezold’s Abscess
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Rare complication of mastoiditis with
necrosis of the mastoid tip, infectious
spread into the adjacent soft tissues,
and abscess formation - “Bezold’s
abscess”
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The abscess may lie deep relative to the
superficial planes that surround the
sternocleidomastoid muscle and
trapezius muscles, and may therefore
not be palpable
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Infection may spread as far inferiorly as
the larynx and mediastinum if untreated
➢ Involvement of the mastoid process in the
presence of a neck abscess may require
surgical exploration of the neck and temporal
bone
CECT: Coalescent mastoiditis with a
subperiosteal abscess just posterior to
the pinna
Case 11
37 year old female with no PMH presents to
the Emergency Department with 3 days of
fever and right face/neck swelling/mass.
Infectious Cervical Lymphadenopathy
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Broad differential diagnosis depending on
demographics, underlying systemic
disease, and presentation
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Increased prevalence of Tuberculous
lymphadenopathy (scrofula) in HIV patients
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Bilateral cervical lymphadenitis common;
however, may involve single lymph node
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CT or MRI may demonstrate enhancing and
necrotic lymph nodes
➢ DDX includes metastatic disease from entities such
as squamous cell or thyroid cancer.
CECT: Marked levels II-V necrotic
lymphadenopathy. Edematous
enlargement of the right SCM. Biopsy
proven TB adenitis.
Case 12
61 year old male with history of Stage IV
lung squamous cell carcinoma (SCC) and
SCC of nasal tip presents with left facial
swelling.
Post-treatment SCC
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Imaging overlap of post-treatment change and
tumor recurrence can make post-treatment
head and neck cancer imaging challenging to
interpret
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Acute inflammatory reaction
interstitial
edema
progressive connective tissue
thickening
further interstitial edema
progressive fibrosis is the expected sequence
of events after radiotherapy
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Knowledge of surgical dissection/resection and
surgical reconstruction is paramount to
differentiate post-operative complications from
typical post-procedural change
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Research has shown that tumor recurrence can
be detected earlier by systematic follow-up
imaging
NECT: ST mass overlying the nasal
bone c/w known SCC. Additional
mass in the left premaxillary soft
tissues with adjacent soft tissue
swelling. Findings c/w biopsy proven
metastatic disease
Conclusion
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Although a relatively small in size, the face is a
complex anatomical region.
Various types of pathology can lead to facial
swelling, some of which can lead to airway
compromise.
Most of these abnormalities require imaging
assessment.
Radiologists should be familiar with the diverse
entities and imaging findings in patients with facial
swelling to recognize expected and unexpected
findings in order to improve patient care.
Suggested Reading
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Castillo M, Albernaz VS, Mukherji SK, Smith MM, Weissman JL. Imaging of Bezold’s Abscess. AJR 1998;171:1491-1495
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LeBedis CA, Sakai O. Nontraumatic orbital conditions: diagnosis with CT and MR imaging in the emergent setting.
Radiographics. Oct 2008; 28(6):1741-1753.
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Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: clinical, radiologic, and pathologic review.
Radiographics. Oct 2013;33(6):1739-1758.
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Rahmouni A, Chosidow O, Mathieu D et-al. MR imaging in acute infectious cellulitis. Radiology. 1994;192 (2): 493-6.
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Capps EF, Kinsella JJ, Gupta M, Bhatki AM, Opatowsky MJ. Emergency imaging assessment of acute, non-traumatic
conditions of the head and neck. Radiographics 2010 Sep;30(5):1335-52.
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ReBannon PD, McCormack RF. Potts’ puffy tumor and epidural abscess arising from pansinusitis. The Journal of
Emergency Medicine, Vol. 41, No. 6, pp. 616–622, 2011
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Kubal WS, Face and neck infections: What the emergency radiologist needs to know. Radiol Clin N Am 53 (2015) 827-846
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Zurlo A, Sancesario G, Bernardi G, Loasses A. Orbital Pseudotumor: Case report and literature review. Tumori. 85: 6870, July 1998.
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StatDx, Koch BL, 2nd branchial cleft cyst. https://app.statdx.com/document/2nd-branchial-cleft-cyst/417aa034-e152-4c67b1fa-a25c03a8c83d?searchTerm=branchial%20cleft%20cyst
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Hermans R. Post-treatment imaging of head and neck cancer. Cancer Imaging (2004) 4, S6-S15
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Images on slides 4-5: Statdx, Elsevier, inc, Suprahyoid and Infrahyoid Neck Overview. Graphics.
https://app.statdx.com/document/suprahyoid-and-infrahyoid-neck-ove-/002dc4b8-c8b8-438a-82f4-d3fb5e5a8b15, 4/27/16.