The imaging presentation of head and neck oncologic emergencies

Abstract

This review describes the radiographic findings in emergencies of head and neck cancers (HNCs) in both undiagnosed and previously treated patients, with an emphasis on the temporal urgency of each presentation and in association with the relevant clinical presentation and necessary treatments to enhance understanding and recognition. The various presentations of HNC will be described by the organ system of their presenting complaint. The development and complications of each will be elaborated, with a focus on the clinical presentation in the emergency department and the imaging findings that are critical to recognize in making the diagnosis. Each presentation will be exhibited with a specific patient case and the exact computed tomography, magnetic resonance imaging, ultrasound, or digital subtraction angiography images obtained will be shown. Cases include airway obstruction due to glottic tumor or metastatic cervical lymphadenopathy; airway obstruction due to surgical complications of hematoma, or post-radiation soft-tissue edema; vascular complications of tumor or nodal compression, carotid blowout, carotid stenosis, or occlusion; orbital complications of compartment syndrome; and orthopedic complications of osteomyelitis and osteoradionecrosis. Eleven HNC patient cases are presented with their associated 32 images. HNC patients present with challenging imaging features in the emergent setting. Difficulty in discerning the correct diagnosis arises from the complex head and neck anatomy, often compounded by an advanced stage at presentation and poor functional status. Radiologist familiarity with common HNC emergent presentations is essential for accurate diagnosis and timely treatment.

Keywords: Emergency; Head; Neck; Oncology; Vascular.

Figure 1:

A 57-year-old male smoker with 4–5 weeks of progressive dysphagia and dyspnea. (a) Prior axial contrast-enhanced computed tomography image demonstrates a left hypopharyngeal mass extending along the aryepiglottic fold (arrow). There is extralaryngeal extension through the thyrohyoid membrane (arrowhead), (b) Axial T1 fat-saturated post-contrast image after emergent tracheostomy placement now shows near complete obliteration of the supraglottic airway with a larger mass (arrow).

Figure 2:

A 59-year-old man with a history of carcinoma of the base of the tongue status post-radiation treatment presenting for symptoms of worsening dysphagia and dyspnea. (a) Axial contrast-enhanced computed tomography (CT) image demonstrates irregular mucosal nodularity along the left base of the tongue and posterolateral oropharyngeal wall. Note the significant resultant narrowing of the oropharyngeal lumen posterior to the uvula (white arrow), This obstruction has rapidly grown from the axial contrast-enhanced CT image approximately 1 month prior, (b) which demonstrated relative patency of the lumen.

Figure 3:

A 62-year-old man with biopsy-proven squamous cell carcinoma status post high-dose radiation treatment. Computed tomography (CT) images demonstrate submucosal edema in the posterior pharyngeal wall causing supraglottic airway stenosis (b), which progressed from the prior CT soft tissues of the neck approximately 6 months prior (a). Imaging was obtained just over 2 weeks into the start of a 6-week radiation treatment course. (CT: computed tomography)

Figure 4:

A 63-year-old man with a history of p16 positive tonsillar squamous cell cancer s/p chemoradiation, completed 3.5 years prior. Serial outpatient cancer surveillance endoscopies showed stable curled epiglottis and arytenoid edema. Later, the patient presented acutely with several hours of increased dyspnea and inability to speak in full sentences. In (a and b) sagittal and axial contrast-enhanced computed tomography images demonstrate severe edema of the supraglottic airway (white arrow), bilateral aryepiglottic folds (white arrowhead), and vocal folds (white arrow). (c) Reformatted images of endoscopic view with left greater than right supraglottic obstruction (large white arrow). (d) Endoscopic images after emergent tracheostomy and 12 h of racemic epinephrine and Decadron still demonstrate significant edema through the supraglottic larynx and a curled “omega-shaped” epiglottis that collapses with inspiration (small white arrows).

Figure 5:

A 41-year-old woman with a history of metastatic melanoma status post-chemotherapy. (a) Sonography demonstrates a thrombus in the lower internal jugular vein (IJV), extending into the brachiocephalic vein. (b) Axial contrast-enhanced computed tomography image demonstrates a large necrotic lymph node (black arrow) compressing and nearly completely occluding the left IJV (black arrowhead).

Figure 6:

A 58-year-old man with a history of metastatic renal cell carcinoma presenting with palpable nodular enlargement of the thyroid gland as well as a left neck mass. (a) Axial computed tomography images demonstrate multinodular enlargement of the thyroid gland with extracapsular extension on the left into the adjacent visceral space, suspicious for tumor extension into the left internal jugular vein (IJV) (tumor thrombus, white and black arrows). (b and c) Ultrasound performed demonstrates contiguous extension of tumor from the thyroid into the left IJV with color Doppler showing increased vascularity throughout the tumor thrombus.

Figure 7:

A 72-year-old man with a history of laryngeal squamous cell cancer after chemoradiation who subsequently developed laryngeal recurrence now status post salvage laryngectomy, pharyngectomy, and partial glossectomy is presenting with balance issues and ear pain. (a) Axial computed tomography angiogram of the neck demonstrates focal dissecting pseudoaneurysm of the right common carotid artery (CCA) (white arrow) with adjacent soft-tissue gas/necrosis (black arrowhead). Soft-tissue findings alone warrant prompt notification by the radiologist as this finding represents a threatened blowout. In this instance, a dissecting pseudoaneurysm elevates this to an impending blowout. (b) Digital subtraction angiography (DSA) demonstrates clear active extravasation from mid-CCA, representing an acute carotid blowout requiring intervention (black arrow). (c) DSA post-treatment shows covered stent graft placement.

Figure 8:

A 77 year old male (a) Demonstrates atherosclerotic disease within the left internal carotid artery with a focal 60% stenosis of the proximal portion. (b) Demonstrates complete occlusion of the left internal carotid artery at this level approximately 1 year later. The images demonstrate the rapid rate of occlusive changes in patients with prior radiation. The patient received 60 Gy over 30 fractions to the right surgical bed and cervical lymph node levels I–V, as well as 52.5 Gy over 30 fractions to the left cervical lymph node levels II–IV.

Figure 9:

A 64-year-old woman with several weeks of left eye swelling, pain, and drainage leading to concern for orbital cellulitis. (a) Axial contrast computed tomography demonstrates a large lobulated soft-tissue mass centered within the left orbit involving both pre-septal and post-septal soft tissues (white arrow). (b) Demonstrates extension along the left inferior anterior cranial fossa where there is dural-based enhancement (black arrowheads) and parenchymal edema (white arrowheads). (c) Coronal T1 post-contrast images demonstrate a large contrast-enhancing mass with a mass effect on the adjacent intraorbital space. (d) Axial T2 at the level of the globe demonstrates proptosis and tenting of the posterior globe resulting in a “guitar pick” sign (white arrow), indicating increased intraocular pressure.

Figure 10:

A 38 year old female (a) Demonstrates the typical destruction pattern of osteomyelitis, which begins in the avascular disc space as can be seen by the complete collapse of the C5–6 disc space (white arrowhead). Furthermore, destructive changes and marrow edema are seen extending upward from the disc space (black arrows) most notably at the adjacent endplates. Prevertebral and ventral epidural fluids are also present. In contrast, (b) demonstrates a focal metastasis centered in the highly vascularized C6 vertebral body. The disc spaces are preserved and there is adjacent reactive endplate edema without erosion.

Figure 11:

A 56-year-old woman with a history of laryngeal cancer after total laryngectomy and adjuvant radiation completed 2 years prior presents with neck pain. (a-c) sagittal computed tomography neck in the bone window showing the progression of osteoradionecrosis 3, 7, and 10 months after radiation. (d and e) MRI images show heterogeneous short tau inversion recovery signal, a non-enhancing prevertebral collection spanning C4–C5, mixed sclerosis, and edema/enhancement with the C3–C5 vertebral body marrow. Notably, there is no fluid in the disc spaces, which would be more suggestive of infection.