Head-Neck

• Thyroid ophthalmopathy
• Acute epiglottitis
• Will be uploaded soon

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THYROID OPHTHALMOPATHY

Adults, Female > Male
Usually hyperthyroid. Note ~10% are euthyroid.
Usually bilateral, but ~10% are unilateral
Some patients with thyroid ophthalmopathy may have normal muscles ~10%

Pathology:
- Deposition of mucopolysaccharides into the EOMs.
- Sparing of the tendons (vs tendon involvement in orbital pseudotumor)
- Most affected to least affected EOMs: I'M SOL (Inferior > Medial > Superior > Oblique > Lateral)
- Most commonly: affect all EOMs

Clinical features:
- Diplopia, reduced eyes ROM
- Painless (vs painful in orbital pseudotumor)
- Proptosis
*see differentiating factors between thyroid opthalmopathy vs orbital pseudotumor

Complications:
- Increased intra-orbital pressure => orbital fat herniating through the superior orbital fissure/ obliteration of fat at the orbital apex => compressing the optic nerve and opthalmic vein.
- Progressive optic neuropathy

Best assessed with:
- Coronal plane

Findings:
- Fusiform swelling of the muscle bellies of the EOMs
- Sparing of the tendons
- Protrusion of orbital fat
- Displacement of orbit (proptosis)
- Displacement of lacrimal glands
- Displacement of the orbital septum (anteriorly)
- Dilatation of superior opthalmic vein / optic nerve sheath
- Optic nerve thickening (advanced stage)
- Bony erosion (advanced stage)
- MR: EOMs enhancement, increased T2 signal (increased water content)

THYROID OPHTHALMOPATHY
Green arrow: Oedematous inferior and medial recti muscles bilaterally

THYROID OPHTHALMOPATHY
Green arrow: Oedematous recti muscles with sparing of the tendons, giving a 'coke bottle' appearance

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ACUTE EPIGLOTTITIS

Posted is a cervical x-ray single lateral projection.

Normal soft tissue of the neck for comparison. See the difference

Description points:

- Enlarged epiglotitis (>8mm / larger than your thumb) (Thumbprint sign)
- associated with effacement at the valleculla
- Enlarged aryepiglottic fold (>7mm)
- Enlarged soft palate
- Enlarged adenoid

Check points in other x-ray of similar cases.
- Widened retropharyngeal soft tissueDiagnosis:

- Epiglottitis (Supraglottitis)

Diagnostic procedure:

- Direct laryngoscopy only if necessary! (secure the airway first!)

Clinical features:

- classic triad: Drooling, Dysphagia, Distress
- sniff dog position
- stridor: caused by aryepiglottic oedema

Complication of this disease condition:

- Acute airway obstruction

Rx:

- Medical emergency
- IV Antibiotic
- Secure airway (with or without intubation)

Susceptible population:

- young population 3-7yo
- elderly, immunocompromised

Aetiology:

Viral:
- Haemophilus influenza B (HiB) incidence caused by Hib has reduced since introduction of vaccine.-
- Less frequently: H.parainfluenza, HSV

Bacterial:
- GrpA beta-haemolytic Strept (S.pyogenes, Strept.pneumoniae)
- Less frequently: Staph.aureus, Pneumococcus

Non-infective causes:
- Traumatic: Caustic ingestion/Thermal injury
- Angioneurotic edema
- Lymphoproliferative disorders (eg. Lymphoma)
- Granulomatous disorders (Sarcoidosis, Wegener granulomatosis, TB)

Anatomy:

Waldeyer's ring: Formed by
-- Pharyngeal tonsils (lateral walls of oropharynx)
-- Lingual tonsils (base of tongue)
-- Adenoids (supero-posterior of nasopharynx)

- Nasopharynx: From posterior choanae to the lower limit of the soft palate
- Oropharynx: From the lower limit of the soft palate to the epiglottis
- Laryngopharynx: From the epiglottis to C6 level

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