Imaging of Head and Neck Infections:
Diagnostic Considerations, Potential Mimics,
and Clinical Management
Jason R. Chalifoux, MD, PhD,* Behroze Vachha, MD, PhD,†,‡ and
Gul Moonis, MD*
E mergency head and neck imaging studies often elicit a
unique apprehension because of the complex anatomy
and subtle imaging findings. In this article, we present
commonly encountered head and neck infections, with an
emphasis on clinical presentation, imaging characteristics,
potential mimics of infection, and clinical management.
Acute Rhinosinusitis
Rhinosinusitis is an inflammatory process involving the
mucous membranes of the paranasal sinuses and the nasal
mucosa. Disease lasting less than 1 month is considered acute
rhinosinusitis (ARS), with subacute disease persisting for 1-3
months.1 Chronic rhinosinusitis lasts longer than 3 months
and is generally related to incompletely treated acute or
subacute disease.2 ARS is a common clinical diagnosis with
symptoms of purulent nasal discharge, nasal obstruction, facial
pain and fullness. Most cases result from viral spread of an
upper respiratory infection into the sinonasal mucosa. Super-
infection with bacterial pathogens (acute bacterial rhinosinu-
sitis [ABRS]) occurs in 0.5%-2.0% of viral rhinosinusitis,3 and
it should be considered if the symptoms or signs of ARS persist
without improvement for at least 10 days beyond the onset of
upper respiratory infection or if the symptoms or signs of ARS
worsen within 10 days after initial improvement. Physical
examination in patients with suspected ARS should always
include a thorough cranial nerve assessment to assess for
sequela of extrasinonasal involvement.
*Columbia University Medical Center, New York, NY.
†
Department of Radiology, Memorial Sloan Kettering Cancer Center, New
York, NY.
‡
Department of Radiology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA.
Address reprint requests to Gul Moonis, MD, Columbia University Medical
Center, 161 Fort Washington Ave, New York, NY 10032. E-mail:
gmoonis@yahoo.com
10 http://dx.doi.org/10.1053/j.ro.2016.07.004
0037-198X/& 2017 Elsevier Inc. All rights reserved.
Most people with sinusitis would not benefit from imaging
and they should be treated conservatively. However, if a
complication of ABRS (orbital, intracranial, or soft tissue
involvement) is suspected or if alternative diagnoses including
malignancy are considered as a cause of patient symptoms,
contrast-enhanced computed tomography (CECT) should be
performed.2 Imaging findings of ABRS include sinonasal
mucosal thickening, aerosolized secretions, and air-fluid levels
(which also can be seen in intubated patients). Magnetic
resonance imaging with gadolinium can also be performed
for the evaluation of complicated ABRS if computed tomog-
raphy (CT) scan is unrevealing. Treatment of uncomplicated
bacterial sinusitis consists of outpatient oral antibiotics that
cover aerobic and anaerobic bacteria.4 In cases of complicated
sinusitis, clinical and surgical management is specific to each
entity, as described below.
Pott Puffy Tumor
Persistent bacterial infection can spread from the sinus through
adjacent bone, resulting in osteomyelitis with extracranial
abscess (subgaleal) or intracranial empyema. This is most
commonly encountered when infection of the frontal sinuses
spreads through the frontal bone (Fig. 1). The name derives
from the first description by Sir Percival Pott in the mid-18th
century of the physical examination finding of a “puffy,”
swollen forehead.5 Patients present with signs and symptoms
of bacterial sinusitis, forehead swelling, headaches, and altered
mental status. Abscess formation can be intracranial or extrac-
ranial.6 CECT is the preferred initial imaging modality because
of its accessibility, high resolution of osseous structures, and
ability to detect abscess formation. Contrast-enhanced magnetic
resonance imaging (MRI) can be performed to assess for
intracranial involvement of the meninges and the brain
parenchyma (Fig. 2). Demonstration of cranial osteomyelitis
and abscess is a surgical emergency, which almost always
requires aggressive management with surgical debridement and
broad-spectrum antibiotics.
Imaging of head and neck infections 11

neurovascular anatomy.7 Patients present with painful eye

movements, proptosis, ophthalmoplegia, and sometimes
changes in visual acuity. CECT should be performed rapidly
to assess for infectious involvement of the intraconal fat,
extraocular muscles, or boney orbital walls.8 Approximately
1 in 4 patients present with subperiosteal abscess, most
frequently through the lamina papyracea, the thin bone
separating the ethmoid sinus from the postseptal orbit
(Fig. 3). Orbital cellulitis requires aggressive intravenous
broad-spectrum antibiotics to prevent further complications
such as vision loss, cavernous sinus thrombosis (CST), intra-
cranial abscess, and meningitis.9 Some suggest surgical drain-
age for subperiosteal or orbital abscesses that are greater than
10 mm in largest diameter.10

Acute Invasive Fungal Sinusitis

Figure 1 Pott puffy tumor. Axial noncontrast head CT demonstrates
erosion of the anterior frontal bone and spread of infection from the
frontal sinus into the subgaleal soft tissues of the forehead.
Orbital Cellulitis
Preseptal cellulitis (anterior to the orbital septum) occurs
mainly in children, results from minor trauma or from
contiguous spread of an infection of the face, teeth, or ocular
adnexa, and is managed conservatively. Orbital cellulitis
typically develops from extension of a sinus infection into
the postseptal orbit and is managed as an emergency because of
the high morbidity of infection involving the adjacent
This is a rapidly progressing infection seen predominantly in
neutropenic immunocompromised patients (systemic chemo-
therapy, systemic steroid therapy, bone marrow transplanta-
tion, or immunosuppressive therapy for transplant) and in
patients with poorly controlled diabetes. Fungi belonging to
the order Zygomycetes, such as Rhizopus, Rhizomucor,
Absidia, and Mucor account for most invasive fungal infections
in diabetics, whereas Aspergilllus species accounts for most of
these infections in neutropenic immunocompromised indi-
viduals.11 Although the symptoms and imaging findings are
similar to those of bacterial sinusitis, because of spread of
hyphae into intraosseous blood vessels, fungal infection
frequently result in rapid erosion of bone with extrasinus soft
tissue involvement and extension of infection to the brain and

A B

Figure 2 Intracranial abscess. In the same patient as Figure 1, MRI of the brain was performed to assess for intracranial
complications. (A) Diffusion-weighted imaging of the brain demonstrates a focus of diffusion restriction in the medial left
frontal cortex. (B) Axial contrast-enhanced T1-weighted sequence shows a thick ring-enhancing focus, consistent with
abscess.
12
Figure 3 Subperiosteal abscess. Axial noncontrast head CT demon-
strates opacification of the anterior and posterior ethmoid sinuses with
erosion of the left lamina papyracea and formation of a left orbital
subperiosteal abscess (arrows). There is stranding of the intraconal fat
and proptosis of the left orbit.
orbit11 (Fig. 4). Spread of infection beyond the sinuses may
occur with intact bony walls, and periantral fat stranding is a
subtle finding that should raise suspicion for an invasive fungal
infection in the appropriate clinical setting.12 Mucosal thicken-
ing may be subtle or insignificant in these patients. Although
CT is better to assess for bone changes, MRI of the sinuses is
superior in evaluating intracranial and intraorbital extension of
the infection.11 Early intervention by an otolaryngologist is
crucial for pathologic diagnosis. Fungal sinusitis spreads
Figure 4 Invasive fungal sinusitis. Axial contrast-enhanced sinus CT
demonstrates opacification of the left maxillary sinus with spread of
infection to the premaxillary soft tissues (arrow). There is soft tissue
infiltration of the periantral fat (arrowhead) and extension of
inflammation into the left pterygopalatine fossa and left
masticator space.
J.R. Chalifoux et al
Figure 5 Tonsillar abscess. Axial contrast-enhanced CT demonstrates
mild enlargement of the right palatine tonsil with a focus of central
fluid density and peripheral rim enhancement.
rapidly and it should be treated immediately with a broad-
spectrum antifungal agent, usually amphotericin B.
Peritonsillar and Intratonsillar
Abscess
Peritonsillar abscess (PTA) is a collection of pus between the
tonsillar capsule and the pharyngeal constrictor muscles and is
the most frequent suppurative complication of pharyngitis.
Intratonsillar abscess (ITA) is rare and represents necrosis
within the parenchyma of the tonsil. Blair et al hypothesize that
acute tonsillitis results in tonsillar surface ulceration, and
normal rapid lymphatic transit of the bacteria toward the
fibrous capsule results in the more common PTA accumulating
between the capsule and the constrictor muscle. Alteration of
lymphatic flow may allow adequate time for accumulation of
virulent bacteria within the tonsillar parenchyma leading to
ITA instead of PTA.13 PTA and ITA generally present as severe
sore throat, dysphonia, and, in up to two-thirds of patients,
trismus (related to irritation and spasm of the internal
pterygoid muscles).14 Physical examination can show devia-
tion of the uvula, secondary to an enlarged and inflamed tonsil.
CECT should be performed to differentiate between the
swelling and loss of fat planes in cellulitis and phlegmon and
the discrete fluid collection with rim enhancement of a PTA
(Fig. 5), as well as to identify the spread of infection into
adjacent deep neck spaces.15 However, distinction between
phlegmon and abscess may be difficult based on imaging,
owing to overlap in CT attenuation values.16 Correlation with
the patient's clinical status is important to direct further
management, which could range from oral or parenteral
antibiotics to incision and drainage.17
Imaging of head and neck infections
Figure 6 Ludwig angina. Axial contrast-enhanced CT shows hetero-
geneous low-attenuation soft tissue in the sublingual and subman-
dibular space without evidence of discrete fluid collection.
Ludwig Angina
Ludwig angina, named after the German physician who first
described it, refers to an infection in the submandibular space
(which encompasses the sublingual and submylohyoid
spaces).18 The disease most often arises because of the spread
from an infected second or third mandibular molar. Unlike
other neck spaces, rapid, nonlymphatic spread of infection
infrequently results in abscess formation. Patients present with
macroglossia, dysphagia, mouth pain, drooling, and, in severe
cases, rapid respiratory compromise.19 CECT demonstrates soft
tissue enhancement and fatty infiltration in the submandibular
Figure 7 Suppurative adenitis of retropharyngeal node in a pediatric
patient. Axial contrast-enhanced CT demonstrates a right retrophar-
yngeal fluid collection with enhancing rim, consistent with abscess in
expected location of the retropharyngeal node.
13
space (Fig. 6). Imaging also is valuable to document possible
spread of infection to the epiglottis and parapharyngeal space.
Management consists of rapid airway assessment and treatment
with broad-spectrum intravenous antibiotics.20 If there is a
discrete collection or palpable fluctuance, needle aspiration or
incision and drainage should be performed.
Retropharyngeal Space
Infections
The retropharyngeal (RP) space refers to the midline space just
posterior to the pharyngeal mucosa in the suprahyoid neck and
posterior to the hypopharynx and cervical esophagus in the
infrahyoid neck. The space contains mostly fat and lymph
nodes in the suprahyoid portion, but only fat in the infrahyoid
part. Infections in this compartment represent medical emer-
gencies, because spread into the adjacent danger space can
result in inferior migration into the mediastinum.21 In adults,
the most common source of infection is penetrating trauma,
usually from ingestion of bones or other sharp foreign bodies.22
In the pediatric population, RP abscess results from spread of
upper respiratory tract infection to the RP lymph nodes with
subsequent suppuration.23 Patients typically present with sore
throat, difficulty breathing, and dysphagia and dysphonia.
CECT of RP abscess demonstrates a midline fluid collection
with rim enhancement. Abscess in the RP lymph nodes is seen
in pediatric patients with suppurative adenitis (Fig. 7). An RP
abscess requires intravenous antibiotics and surgical drainage.21
Longus colli tendinosis (LCT) can mimic RP abscess on
imaging studies. LCT is an inflammatory response to deposi-
tion of calcium hydroxyapatite in the longus colli tendons, and
fluid accumulating in the RP space can mimic an infectious
process. Imaging features of LCT include calcification within
the tendon and a simple fluid collection without peripheral
enhancement24 (Fig. 8).
Necrotizing Fasciitis
Necrotizing fasciitis (NF) is a rapidly progressive infection of
the skin, subcutaneous tissue, and fascia characterized by
fulminant soft tissue breakdown with high morbidity and
mortality.25 NF in the head and neck is frequently due to
polymicrobial bacterial infection of the oropharynx. Other risk
factors include odontogenic infections, poorly controlled
diabetes, and an immunocompromised state. Patients initially
present with erythema, swelling, and tenderness. Advanced
infections lead to skin breakdown with bullae formation, often
associated with severe edema resulting in airway compromise.
As with RP infections, mediastinitis is a feared complication
owing to its high mortality. Although the diagnosis is largely
clinical and surgical, the finding of soft tissue gas on CT is
highly specific for NF.26 However, most cases have nonspecific
findings as infiltration and edema of the skin and underlying
fat, and enhancement or thickening of the superficial and deep
fascia, and neck muscles (Fig. 9). Treatment involves broad-
spectrum intravenous antibiotics with prompt surgical explo-
ration for debridement, frequently in a 2-stage procedure to
adequately remove necrotic tissue.
14 J.R. Chalifoux et al

A B

Figure 8 Longus colli tendonitis. Axial noncontrast CT demonstrates dystrophic calcification (black arrow) of the longus
colli tendon (A) with retropharyngeal low density (B) (white arrow) consistent with retropharyngeal effusion from longus
colli tendonitis.

Lemierre Syndrome progresses to fevers, rigors, respiratory distress, and neck

The physician Andre Lemierre in 1936 described approx-
imately 20 cases of pharyngitis that led to anaerobic septicemia
from septic thrombophlebitis.27 Owing to the widespread
availability of antibiotics, Lemierre syndrome is known as the
“forgotten disease,” with an incidence of only 0.6 cases for
every million persons.28 Most cases result as a complication of
tonsillar or peritonsillar infection. Patients are usually healthy
young adults with a history of antecedent pharyngitis that
pain.29 Physical examination may demonstrate tender, indu-
rated, and swollen tissue over the course of the jugular vein.
Septic emboli to the lungs are a common complication. CECT
shows a filling defect within the jugular vein with surrounding
inflammation (Fig. 10). Treatment consists of intravenous
antibiotics and surgical drainage of associated collections. The
rare cases that remain refractory to antibiotics and surgical
drainage may require ligation or excision of the involved
portion of the jugular vein.30

Figure 9 Necrotizing fasciitis. Axial contrast-enhanced CT demon- Figure 10 Lemierre syndrome. Axial contrast-enhanced CT demon-
strates air within the anterior subcutaneous tissues and the retro- strates a bulging filling defect (asterisk) within the left internal jugular
pharyngeal and visceral spaces and thickening of the fascial planes. vein with mild inflammatory enhancement of the vessel wall.
Imaging of head and neck infections
Figure 11 Cavernous sinus thrombosis. Axial contrast-enhanced CT of
the sinuses demonstrates filling defects (arrows) within both caver-
nous sinuses in this patient with cavernous sinus thrombosis from
adjacent sphenoid sinusitis.
Cavernous Sinus Thrombosis
Septic thrombosis of the cavernous sinus is a fulminant and
potentially lethal complication of midface, odontogenic, and
orbital infection.31 The most commonly identified pathogen in
CST is Staphylococcus aureus (identified in 60%-70% of
patients), with Streptococcal species, gram-negative bacilli and
anaerobes as less frequent causes.20 Acute bacterial sinusitis can
spread directly from the sphenoid sinus or, in the cases of
postseptal orbital cellulitis, via the superior opthalmic vein. Less
commonly, odontogenic infections can spread via the pterygoid
venous plexus. The most common clinical complaint is acute or
chronic headache, which is unique in its extreme severity.31
Other less reliable symptoms include eye swelling, diplopia,
and altered mental status. On physical examination, there
frequently are defects in the oculomotor, trochlear, and
abducens cranial nerves. Although clinical manifestations of
orbital cellulitis can mimic CST, CECT or MRI can differentiate
between these 2 diagnoses. In CST, there is abnormal cavernous
sinus enhancement in the venous phase, associated with filling
defect, thickening of the lateral walls, and sometimes bulging of
the sinus and enlargement of the superior ophthalmic vein 32
(Fig. 11). Although most or all patients with CST are treated
with intravenous antibiotics, there is less agreement on the use
of anticoagulation, steroids, and surgery, which vary by
institution and on a case-by-case basis.
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