HEAD AND NECK and GI Radiology🗸

Stenver’s view

Schullers view

• Citelli's abscess:
• Abscess into posterior belly of digastric muscle.
• Mnemonic: Telli → Belli

• Bezold's abscess:
• Pus tracks into sternocleidomastoid muscle.

• Luc's abscess:
• Pus extends into the external auditory meatus.
• Mnemonic: Look at EAC

• HRCT is the investigation of choice before FESS

• Keros classification
• before FESS

• 1st step → Uncinectomy

• f/b Maxillary antrostomy→ Bullectomy → Frontal sinusotomy → Sphenoidotomy

Concha bullosa

• Pneumatization of middle turbinate
• Concha-turbinate.
• Bulla-air containing.

• Types: Fungal ball, Allergic fungal rhinosinusitis

• Seen in immunocompetent and immunocompromised

• Cause: Aspergillus

• Peanut butter discharge

• Mnemonic: HIV AIDS → Kuninj bent cheythapo sinusitis vann

• Bent and Kuhn criteria for AFRS:
• Major Criteria
• Mnemonic: Mr KUHN
• Test Mucus
• Eosinophilic Mucin
• KOH Fungal smear: Positive

---

• CT scan:
• Hazy sinuses + Heterogeneous opacities
• Double density sign / Serpiginous sign
• Gray mucous with white fungal matter





---

• Endoscope
• Nasal polyps → Ethmoidal polyps more associated
• Serum
• Uno → 1 → Type 1 hypersensitivity (↑IgE levels)
• Minor Criteria
• Mnemonic: CURE AF
• no major features like culture, asthma
• Charcot–Leyden crystals
• Unilateral predominance
• Radiological Bony erosion
• Serum Eosinophilia
• Asthma
• Fungal culture: Positive

• Treatment:
• FESS
• Endoscopic surgical drainage, along with drainage and ventilation.
• Steroids
• Pre- and post-operatively.
• Antifungal therapy: Itraconazole.

• CT scan:
• Hazy sinuses + Heterogeneous opacities
• Double density sign / Serpiginous sign
• Gray mucous with white fungal matter

• Black turbinate sign:
• Due to necrosis- no enhancement.

• Air Crescent sign/DODD's sign:
• Differentiates primary from secondary nasopharyngeal mass.
• Mnemonic: Dodd → Dad → AC Polyp
• Blackish shadow on X-ray
• between the mass and posterior pharyngeal wall
• Seen in antrochoanal polyps.
• Polyp in the maxillary sinus extending into the nasopharynx.

• Expanded, thinned out wall containing mucus.

• Occurs from obstruction to sinus drainage.

• Causes retention of secretion.

• Caused by:
• Oedema, Inflammation.
• Polyp.
• Trauma.

• Least common site: Sphenoid sinus.

• Most common site: Frontal sinus.
• Frontal mucocele → proptosis
• occur post trauma.

• Frontal Sinus Mucocele
• Site: Superiomedial quadrant of orbit.
• Eye is displaced forward, downward, and laterally (proptosis).
• Swelling:
• Cystic.
• Non-tender.
• Exhibits eggshell cracking.
• X-ray: Shows loss of scalloped margin.
• Treatment:
• Frontosinusotomy
• Drainage of mucocele
• Open the sinus → ↑ size of ostium
• Frontoethmoidectomy.

• Known as Blow-out fracture.

• Blunt Trauma to Orbit

• Occurs due to tennis ball injury (trauma direct to orbit)

• Orbit contents may herniate into maxillary sinus.

• Floor is more susceptible than medial wall.

• Radiological sign: Teardrop sign.

• Infraorbital nerve is involved.

• Other symptoms
• Enophthalmos (sunken eye)
• Diplopia on upward gaze
• Loss of sensitivity over the cheek

• CECT scan is investigation of choice.

• Hollman Miller sign.
• Anterior bowing of the posterior wall of the maxillary sinus

• Hondusa's sign.
• Increased distance between maxillary sinus and mandible on CT scan.

• Carotid angiography for vascularity.

• Staging
• a. Radkowski staging
• I: Medial spread
• Ia: Limited to nose & nasopharynx
• Ib: Extension into one or more sinuses
• II: Lateral spread
• IIa: Minimal extension to sphenopalatine fossa (SPF)
• IIb: Complete filling of SPF & spread to orbit
• IIc: Extension to infratemporal fossa (ITF)
• III: Intracranial spread
• IIIa: Minimal
• IIIb: Extensive
• b. Fisch classification

• Lyre sign on angiography : Splaying of carotids.

• Highly vascular tumor.

• (1) Cerebellar lobe abscess.

• (2) Temporal lobe abscess.
• Peripheral enhancement of abscess is seen.

• (3) Sclerosis of mastoid bone

Brain abscess:

• Organism: Aerobic, anaerobic or mixed infection.

• Specifically temporal lobe
• MC abscess secondary to CSOM

• Infection breaks the tegmen and spreads to the middle cranial fossa.

• CF
• Headache, projectile vomiting +
• Foul smelling, blood stained ear discharge.

• MRI shows a space occupying lesion.
• Central hypodense area and enhancing ring on the outside.

• Treatment:
• Drainage of abscess, antibiotics, MRM.

• At C2 > 7mm.

• At C7 > 22mm.

• An air-filled diverticulum from the larynx that develops due to increased pressure.

• (Enlargement of saccule) → Pierces thyrohyoid membrane → Extrinsic laryngocele (External neck swelling)
• ↑ Size on valsalva manoeuvre
• Hissing sound on compression : Bryce sign.

• Seen in trumpet blowers.

• Coke bottle sign/ Coco cola sign:
• Tendon sparing enlargement of the muscle.
• Order of muscle involvement
• IM SLO

Submandibular stones

• Air in peritoneal cavity due to ruptured hollow viscus organ (perforation, post laparoscopy).

• On CT, jet black appearance shows air.

Signs on X ray:

• Air in peritoneal cavity due to ruptured hollow viscus organ (perforation, post laparoscopy).

• On CT, jet black appearance shows air.

---

---

1. On erect chest X ray:

• Free air under the diaphragm.

2. Decubitus abdomen sign:

• Left lateral decubitus position with horizontal X-ray beam.

• Provides good contrast against liver.

• Air around lesser sac can escape through epiploic foramen.

• Black air seen above liver.

3. Football sign:

• Patient supine.

• In neonate

• Air beneath anterior abdominal wall.

• Suggestive of Massive pneumoperitoneum.

4. Rigler's sign

• Double bowel sign.

• Air inside and outside the bowel makes bowel loops clearly visible.

• Important Information:
• Rigler's triad: Seen in gall stone ileus.

5. Cupola sign:

• Air beneath the central diaphragm.

Ligament sign:

• Falciform ligament seen



• Falciform ligament connects anterior abdominal wall and liver.
• Ligament visualized due to air on either side.
• All ligament signs are seen in pneumoperitoneum.

7. Inverted V sign:

• Paired umbilical ligament sign (seen due to air around the ligament).

Pseudo Pneumoperitoneum

• Air in the bowel beneath the diaphragm.

• Bowel markings are seen.

Chilaiditi syndrome:

• Presence of colonic loop between diaphragm and liver.

• Colonic interposition.

Stages of NEC → BPG

Diaphragmatic Injuries

• Most Common: Left side >> Right (protected by liver)

• Clinical Features:
• Breathlessness
• Bowel sounds present in thoracic cavity
• Coiling of Ryle’s tube in thoracic cavity

• BERGVIST TRIAD
• Diaphragm injury
• Rib #
• Spine/Pelvic #

• IOC: Diagnostic Lap > CECT

• Management:
• ICD is contraindicated → Risk of bowel injury
• Laparotomy:
• Reduce bowel contents,
• Repair diaphragm (Prolene sutures)

• Triad: Dysphagia, Regurgitation, Halitosis.

• Age group: Elderly.

• IOC- Barium swallow.

• AKA Cricopharyngeal achalasia.

 

• Outpouching of diverticulum in this area.

• Causes:
• Old age.
• Tight upper esophageal sphincter (UES).
• Aerophagy, Allergy, Acid reflux.

NOTE

NOTE:

Features

Clinical Features

• Regurgitation (Earliest).

• Halitosis.

• Aspiration pneumonitis (m/c complication).

• Late: Dysphagia from compression.

• Sleep cough: Regurgitation into larynx.

• Boyce's sign: Gurgling sound on swallowing.

Investigation

• Barium swallow (IOC).

Characteristics

• M/C motility disorder.

Clinical Features

• Triad: Dysphagia, regurgitation (Earliest) & weight loss.

• Dysphagia:
• Initially: Liquids > Solids.
• Later: Solids > Liquids.

• Heart burn.

• Nocturnal coughing.

• Post prandial choking.

• Complication: Aspiration pneumonitis (m/c).

Investigations

• Barium swallow: 
• Bird beak sign/ Rat tail sign.
• gradual tapering → Rule out cancer.

• Endoscopy.

• Gold standard/ IOC - Manometry.

• Achalasia → look like chiks mouth

Chicago classification

• DCI> 8000 → Hypercontractile/Jackhammer Esophagus

• Distal latency <4s → Diffuse Esophageal spasm

Eckardt Score

• Weight loss.

• Dysphagia.

• Retrosternal pain.

• Regurgitation.

• Ekki ekki varunn → Kazhikkumbo vedana + Thiratti varum + Irakkan budhimuttu → Weight loss

Hurst phenomenon

• During barium swallow,
• lower esophageal sphinctre opens
• contents pass to stomach

• Hurst → Burst open

Treatment

• Botox:
• Highest recurrence.
• Repeated injections → Scarring.
• Restricted to elderly patients with co-morbidities.

• Heller's Myotomy:
• Laparoscopic myotomy: 6 cm proximal to 2-3 cm distal.
• Better outcome in Type I & II.
• M/C complication: GERD.
• Prevention: fundoplication.

• Pneumatic dilatation:
• Similar efficacy as myotomy.
• Indications:
• Elderly, female
• undilated esophagus, 
• Type II achalasia.

• POEM (Per-oral endoscopic myotomy):
• Best for Type III & other spastic conditions.
• Submucosal tunnelling → Muscles cut → mucosa sutured.
• ↑ Rate of esophagitis.

• Boat (Botulinum) pidich Hellil (heller) Poi (Poem)

Clinical Features

• Progressive dysphagia (solids > liquids.).

• Weight loss.

• Hoarseness: Sign of advanced disease (Left Recurrent laryngeal nerve (RLN) involvement).

• Chronic cough.

Investigations

• Endoscopic biopsy: IOC.

• PET-CT: IOC for staging (FIB-FDG).

• Endoscopic USG: IOC for T-staging.

• Barium swallow:
• Rat tail appearance
• Apple core deformity
• Shouldering effect
• Irregular narrowing

Sievert's classification:

• used for GE junction tumours.

Features

• 5 times less common than achalasia.

• F > M.

• Simultaneous, repetitive, high amplitude contractions.

Clinical Features

• Chest pain (Angina like).

• Dysphagia.

Investigations

• ECG.

• Manometry.

• Barium study: Corkscrew/Rosary bead appearance.

Treatment

• First-line therapy
• Calcium channel blockers
• Nitrates

• Second-line therapies.
• Endoscopic botulinum toxin injection
• pneumatic dilation

• 1st and 2nd line have only transient effects.

Surgical treatment

• Includes extended myotomy of the esophageal body or

• Peroral endoscopic myotomy (POEM):
• Safe and effective
• Especially for patients refractory to medical therapy

 

 

• Prominent Transverse folds in esophagus.

• Lines markings on imaging.

• Endoscopy: Stacked up appearance.

• Seen in:
• GERD (m/c), lower 1/3rd
• Eosinophilic esophagitis, upper 1/3rd

• Retrocardiac opacity containing air fluid level.

Types

• Type I/Sliding Hiatal Hernia:



• M/C diaphragmatic hernia 
• (Note: m/c congenital diaphragmatic hernia: Bochdalek)
• GE junction moves proximally.
• GERD/Asymptomatic (Not life threatening).
• IOC: CT with oral contrast.
• Mx: Surgery only in large/symptomatic hernia.

• Type II/Rolling/Paraesophageal Hiatal Hernia:



• Portion of stomach herniates into thoracic cavity → volvulus & necrosis
• Life threatening
• GE junction: N.
• Mx: Surgery.

• Type III: Sliding + Rolling.
• Mx: Based on rolling component.

• Type IV: Paraesophageal
• Content: Not stomach

Features

• Pyloric hypertrophy 
• Gastric outlet obstruction.
• Due to hypertrophy of circular muscle layer

• MEDICAL EMERGENCY
• Correct fluid electrolyte imbalance with NS.

• Usually affects first born male child.

• Normal at birth → 2-6 weeks → Projectile, non-bilious vomiting.

On examination:

• Easiest to palpate just
• During feeding
• after an episode of vomiting

• Visible and palpable olive-shaped mass
• best appreciated in the Mid-Gastric Area.

• Visible peristalsis (Left → Right)

Diagnosis:

• Hypokalemic metabolic alkalosis with paradoxical aciduria.
• K ↓, Na ↓, Cl ↓

USG s/o

• IOC → Pyloric channel:
• Target / Donut sign
• Muscle thickness ≥ 4mm thick.
• Pylorus length ≥ 16mm long.

• Thickened Pylorus.

Contrast study:

• Mushroom sign.
• narrow pylorus entering duodenum.

• Double track sign.

• String sign → narrowing of pylorus.

String Sign:

• TB

• CHPS

• Crohns Disease

Bubble sign:

• Image A → Incomplete haustrations of colon → large bowel obstruction.

• Image B → valvulae conniventes of jejunum → small bowel obstruction.

Image C shows multiple air fluid levels

• Erect X-ray

• >3 air fluid levels

• Step ladder pattern

• indicates small bowel obstruction.

 

String of pearl sign: (D)

• Seen in small bowel obstruction.

• Air locules arranged one behind another.

• Dilated bowel pushes air between valvulae conniventes to the periphery.

Supine X-ray

• Telescoping of bowel loop.

• M/c in weaning age group.

• Red currant jelly stools.

Investigations

1. X-ray abdomen: Erect & supine (Initial).

2. USG: Target/Donut/Pseudokidney sign.
• good sensitivity in diagnosis.
• Note: IOC in children.
• Note: IOC in adults: CECT.
 

Barium enema sign:

• Claw sign.

• Coiled spring sign.

• Pick pocketer () → got coins () with red blood (hematoma) like coiled spring ()

Sigmoid Volvulus

Caecal Volvulus

• Haustrations present with single loop.

• Embryo sign.

 

Ileo Cecal TB

• Pulled up caecum.
• Pulled up contracted caecum (due to fibrosis).

• String sign:
• Narrowing of terminal ileum- Stricture.

• Inverted umbrella sign/ Fleischner sign:
• widening of ileocecal valve.

Ischaemic colitis:

• On X-ray:
• Colonic loops have thick, edematous haustrations
• Thumbprint sign.

 

• It is a type of superinfection.m

• MC bacteria involved: Clostridium difficile.

• Cause:
• Long-term use of antibiotics.
• Alters gut flora.

• Clinical features: Watery diarrhoea.

• Diagnosis:
• Toxigenic culture: Culture media: 100% sensitivity
• Cefoxitin cycloserine fructose agar (CCFA).
• Cefoxitin cysteine yeast extract agar (CCYA).
• Detection of toxins via ELISA and PCR.

• MC antimicrobials implicated are:
• 3rd Gen. Cephalosporins > Clindamycin > Ampi or Amoxycillin > FQ.

• Accordion sign — Thick edematous bowel.

• Treatment:



• DOC :
• Oral Fidaxomicin (Low chances of relapse).
• Alternative :
• Oral vancomycin
• Oral Metronidazole.
• Monoclonal Ab against toxin :
• Bezlotoxumab.

Virtual Colonoscopy (CECT with 3D Reconstruction)

• Use: Screening tool.

• Advantages:
• Better extracolonic details.
• Better patient compliance.

• Disadvantage: Mucosal details not well appreciated.

Diagnostics & Staging

• IOC for Diagnosis: 
• Colonoscopic biopsy.

• IOC for ca rectum:
• MRI

• IOC for Staging: 
• PET-CT.

• T & N Staging for Rectal Cancer: 
• MRI with endorectal coil.

Presentation

• Right-sided CRC:
• Ulcero-proliferative growth.
• Causes bleeding → Iron deficiency anemia.

• Left-sided CRC:
• Annular (constricting) growth.
• Altered bowel habits → Early onset symptoms.
• Bowel obstruction.
• Radiology: Apple core deformity.

Very very important PIC

• Garden hose or hose pipe appearance:



• Thickening of bowel wall, fissures, fistula, and abscess.
• Leads to fibrosis and strictures.

• Fissure ulcers: Rose thorn appearance.

• String Sign of Kantor: Fibrosis in terminal ileum.

• Creeping mesenteric fat:
• Thickened mesentery encasing bowel wall.

 

• Atrophic, featureless, short, and narrow colon in UC

• Lead pipe or pipestem colon (with no haustrations).

• Loss of Crypt Architecture.

• Cryptitis and crypt abscess:
• non-specific
• UC>CD

• m/c Site: Sigmoid colon

• Asymptomatic diverticuli.

• Type: False diverticula (mucosal herniation)

• Formation: Along mesenteric border
• NOTE: Meckel's → True diverticula → Anti mesenteric border

• Demographics: 4th – 5th decade

• Association: Constipation

• m/c Cause of: Massive lower GI hemorrhage

• IOC-Barium enema.
• Saw tooth appearance.

• Inflammation of diverticulum.

• Patient presents with pain.

• IOC-CECT.

• Hinchey's classification.

 

Hinchey Staging System (Based on CECT - IOC)

• Stage I: Colonic inflammation with pericolic abscess
• 1a → Pericolonic Phlegmon and inflammation
• 1b → Pericolonic abscess ＜4cm

• Stage II: Colonic inflammation with pelvic abscess

• Stage III: Purulent peritonitis

• Stage IV: Fecal peritonitis
• Mnemonic: DaVinci → Dive Hinchey → Abcess→ PP → FP

Mesenteric Cyst

• IOC: CECT.

Tillaux Triad

1. Periumbilical swelling.

2. Tillaux sign: Swelling moves at right angle to attachment of mesentery.

3. Transverse band of resonance.

Line of mesenteric attachment

• Runs from the duodenojejunal flexure (left of L2 vertebra)

• To the ileocecal junction (right sacroiliac joint).

• So, it runs obliquely from left upper abdomen → right lower abdomen

Structures crossed by root of mesentery:

• 3rd part of duodenum

• Aorta, IVC

• Right gonadal vessels,

• ureter, genitofemoral N

• Right psoas

• AKA congenital megacolon.

• Mutation in GDNF (Glial derived neurotrophic factor).

• ENDOTHELIAL B RECEPTOR GENE MUTATION

Etiopathogenesis

• Adynamic/functional obstruction.

• NCC not migrated

• No passage of meconium

• Gold standard: Rectal biopsy.

• Only a segment of colon is affected.

• Aganglionic megacolon → Absence of ganglion cells in
• Meissner plexus → Submucosal
• Between mucosa and muscularis propria.
• Myenteric Plexus (Auerbach) → Muscular layer
• Between the inner circular muscle layer
• And the outer longitudinal muscle layer

• Common in Down's syndrome & MEN 2A/2B.

Clinical Features

• After 48 hrs, neonate present with
• Non-passage of meconium (m/c)
• Abdominal distension and bilious vomiting
• Per rectal examination → sudden propulsion of stools

• Distention.

• Constipation.

• M/c life threatening complication
• Enterocolitis

Investigations

• Rectosigmoid ratio <1 (normal > 1).

1. Full thickness rectal PUNCH biopsy: IOC.
• Loss of ganglion cells.
• Hypertrophied nerve trunks.
• Calretinin immunostaining > IHC: Acetylcholinesterase stain (negative).

2. Barium enema:
• Dilated normal proximal bowel → SIGMOID MEGACOLON
• Transition zone is seen (Normal colon to dilated colon).
• Constricted distal part (Lack ganglion cells).

• Transitional and constricted zones
• lack ganglion cells.

Management: Surgery

• Single Stage: 
• Definitive surgery.

• Two Stages (Severe Extension):
• 1st Stage: Colostomy.
• 2nd Stage: Definitive surgery.

Principles of Surgery

• Bypass abnormal segment.

• Resection and anastomosis.

• Intra-operative Frozen Section:
• Performed to confirm margin of resection.

PULL THROUGH Procedures:

• Swanthamano, Dukhamano, Sugamano → Hirschsprung
• Duhamel's
• Swenson's
• Suave's

Modified Alvarado (MANTRELS) Score

• Score >7: Likely appendicitis.

• Mnemonic: Two → Tenderness → Total count

Investigations

• 1st investigation: USG.

• Best investigation: CECT (visualizes retrocecal appendix).

• Distended appendix >6mm with surrounding fluid.

• Inflamed appendix is non compressible.

1. CECT: IOC in adults.
• CECAL BAR SIGN
• ARROW HEAD SIGN

2. USG: IOC in children.
• Blind ending tubular structure.
• Probe tenderness.
• Periappendiceal fluid collection.