Head & Neck

Head & Neck Emergencies: The On-Call Management Forks

Fellowship-level neuroradiology teaching by E. Brooke Schrickel, MD. Open this topic in the interactive reading room →

Core clinical idea

Head and neck infection on call is a set of management forks — pre- vs post-septal, abscess vs phlegmon, suppurative node vs retropharyngeal abscess vs retropharyngeal edema, retropharyngeal vs prevertebral — each flipping the patient between oral antibiotics/no treatment and IV antibiotics/surgical drainage/secure-the-airway. Underneath nearly every facial infection: hunt the odontogenic source.

Bottom line

Head and neck infection on call is a set of management forks — septum, enhancement-and-midline in the retropharyngeal space, and retropharyngeal-vs-prevertebral — read to land the patient on the right side of each, hunt the odontogenic source, and flag the airway/vascular/orbital complication.

Core workstation questions

Pre- or post-septal? (Oral vs IV antibiotics — and is there a subperiosteal abscess or optic nerve tension?)
For any facial infection: where's the odontogenic source?
Does this midline-crossing RP collection enhance and how much does it expand the space — abscess (emergency) vs edema vs suppurative node?
Is this collection retropharyngeal (ENT) or prevertebral (spine — get MRI if CT is negative)?
With sinusitis: have I excluded intracranial abscess, cavernous sinus thrombosis, and arterial pseudoaneurysm?
Is there a stone along the sialadenitis duct — and could this be calcific longus colli tendinitis mimicking infection?

What changes reporting / management

Distinguish preseptal (oral antibiotics, often no imaging) from post-septal/orbital cellulitis (IV antibiotics); image when orbital signs or failure to improve.
Report subperiosteal abscess (IV antibiotics + drainage) and flag optic nerve tension signs (sheath straightening, posterior globe tenting) as an ophthalmologic emergency.
From sinusitis, actively exclude intracranial/subperiosteal abscess, Pott puffy tumor, cavernous sinus thrombosis, and mycotic pseudoaneurysm.
For Ludwig angina report extent of spread, airway integrity, drainable abscess, and dental source.
RP triage: suppurative node does not cross midline (antibiotics); RP abscess crosses midline + enhances + mass effect (surgical emergency); RP edema crosses midline but bland and barely expanded (treat the cause/nothing).
Distinguish retropharyngeal (anterior to prevertebral muscles; ENT) from prevertebral (spinal pathology; get MRI if CT negative).
For sialadenitis, follow the draining duct for an obstructing stone or mass.

Practical traps

Calling a midline-crossing RP collection an abscess without checking enhancement/expansion (edema and suppurative node are not surgical emergencies).
Reassuring on preseptal disease when chemosis or other orbital signs warrant excluding a post-septal component.
Missing the odontogenic source driving a sinus/orbital/facial infection.
Mistaking zygomaticus major calcification/thickening for parotid duct pathology in the buccal triangle.
Mistaking calcific longus colli tendinitis (amorphous C1–C2 calcification + RP edema) for infection.
Confusing a prevertebral abscess (spine source) with a retropharyngeal abscess (head/neck source).

Teaching pearls

Pre- vs post-septal is the management line — and a bony defect isn't required for infection to spread.
Every facial infection sends you to the teeth — the odontogenic source is what gets treated.
Crosses midline + enhances + expands the space = retropharyngeal abscess, a surgical emergency; crosses midline but bland and barely expanded = edema.
Retropharyngeal is ENT's problem; prevertebral is the spine's — if the spine looks clean on CT, get MRI.
Amorphous calcification anterior to C1–C2 with RP edema is calcific longus colli tendinitis, not infection.

Source lectures

Head & Neck Nontraumatic Emergencies - Case-Based Approach

Educational material for radiology residents and neuroradiology fellows. Nothing here drives individual patient care, and it contains no patient data.