Clinical Scorecard: Key Insights on Acute Head and Neck Infections: Clinical Guidelines from the European Society of Head and Neck Radiology

At a Glance

Key Highlights

• Cross-sectional imaging is not indicated in uncomplicated dental, tonsillar, sinonasal, and middle ear infections.
• Contrast-enhanced CT is recommended in emergency settings for complicated acute sinusitis or middle ear infections to delineate soft tissue infection and abscesses.
• Contrast-enhanced MRI is valuable for detecting orbital, skull base, and intracranial complications and is evolving in assessing soft tissue neck infections.

Guideline-Based Recommendations

Diagnosis

• Do not rely on imaging for diagnosis of uncomplicated acute rhinosinusitis or tonsillitis; clinical diagnosis is sufficient.
• Prompt imaging is warranted in complicated sinusitis presenting with severe headache, neck pain, proptosis, decreased vision, diplopia, or facial/orbital swelling.
• Imaging is required for complicated acute otitis media presenting with worsening symptoms and neurological signs.
• Use imaging to confirm abscess formation in facial and neck soft tissue infections, especially when surgical drainage is considered.
• Ultrasonography may be used initially for local facial and neck swelling but has limitations in assessing deep neck space involvement.

Management

• Surgical drainage is indicated for abscesses identified on imaging, particularly if large or multicompartmental.
• Necrotizing fasciitis of the neck requires prompt surgical debridement.
• Contrast-enhanced CT is preferred for rapid assessment of bony involvement and abscess delineation.
• Contrast-enhanced MRI is recommended for evaluation of orbital, skull base, and intracranial complications.

Monitoring & Follow-up

• Monitor patients with complicated infections for progression to orbital, intracranial, or mediastinal complications.
• Use imaging to assess treatment response and detect potential complications such as vascular thrombosis or abscess extension.

Risks

• Complications include orbital abscesses, cavernous sinus thrombosis, meningitis, brain abscess, vascular thrombosis, and descending mediastinitis.
• Acute invasive fungal sinusitis has a high mortality rate (~50%) and occurs mainly in immunocompromised patients.
• Delayed diagnosis or inadequate imaging may lead to life-threatening complications.

Patient & Prescribing Data

Patients with suspected complicated acute head and neck infections requiring imaging for diagnosis and management

Imaging guides the need for surgical intervention and helps identify complications; uncomplicated infections generally do not require imaging.

Clinical Best Practices

• Reserve cross-sectional imaging for complicated infections or when abscess formation or complications are suspected.
• Use contrast-enhanced CT as the first-line imaging modality in emergency settings for complicated infections.
• Employ MRI for detailed evaluation of orbital, skull base, and intracranial involvement.
• Utilize ultrasonography for initial assessment of superficial facial and neck swellings and for image-guided drainage.
• Avoid imaging-based diagnosis of uncomplicated acute rhinosinusitis or tonsillitis to prevent unnecessary investigations.

References

• European Society of Head and Neck Radiology Clinical Guidelines
• Acute Rhinosinusitis Clinical Criteria and Management
• Imaging in Complicated Acute Sinusitis
• Acute Otitis Media Epidemiology and Imaging
• Necrotizing Fasciitis of the Neck: Diagnosis and Management