Clinical question answered: 10 month old male with fever x 2 days with swelling behind right ear. Access versus tendinitis. Look for retropharyngeal extension. Signs and symptoms: Fever swelling behind right ear. Examination demonstrates extensive area of soft tissue swelling with stranding of subcutaneous fat and effacement of fascial planes on the right side of neck extending from the right occipital region inferiorly into the right parapharyngeal space and retropharyngeal space with extension into the right submandibular region and inferiorly into the right submental region. At the level of right submandibular region there are multiple loculated necrotic cavities which are believed to represent necrotic lymph nodes. There is significant mass-effect and anterior and medial displacement of right carotid artery. There is complete occlusion of right internal jugular at the level of skull base. There is fixation of edema and swelling into the retropharyngeal space allover no evidence of cavity formation is detected. No evidence of any significant airway compromise is detected. The mastoid air cells and middle ear cavity as well as the external auditory canals remain within normal limits. There is normal enhancement of the right lateral (transverse) sinus and sigmoid sinus as well as the right jugular bulb however as mentioned above the internal jugular vein is occluded exactly at the level of the skull base. Soft tissue swelling with subtle enhancement overlapping the right occipital bone demonstrates suspected minimal lytic changes of the bone. This finding is best appreciated on axial images 62 through 65. This finding is not associated with any abnormality of the lateral or the sigmoid sinus on the right and the inner table of the skull remains intact at this level. This finding may be normal anatomical variation of irregularity of the bone and I believe possibly two of an overlapping infectious process (osteomyelitis) is considered less likely. Entirely exclude possibility of osteomyelitis an MRI examination might be helpful.
1.Extensive soft tissue thickening extending from the right occipital region into the right parapharyngeal space, right retropharyngeal space, right submandibular region and right submental region as detailed.2.Enhancement of abnormal soft tissue thickening contains areas of internal necrosis in the right submandibular region which are believed to represent the chronic lymph nodes.3.Edema of retropharyngeal space with no evidence of abscess formation or any significant airway compromise.4.Mass effect and anterior displacement of right internal carotid artery by the above findings.5.Complete occlusion of right internal jugular at the level of skull base and inferior.6.Normal enhancement of right lateral and sigmoid sinuses and jugular bulb.7.Minimal irregularity of outer table of the skull in the right occipital region may be anatomical variation and unlikely osteomyelitis. Please see above comments.8.No evidence of spread of infection into the intracranial space or spinal canal.9.Normal pneumatization of right external auditory canal, right middle ear cavity and mastoid air cells.