Oncologic Emergencies in The Head and Neck

O n c o l o g i c Em e r g e n c i e s i n
the Head and Neck

Carlos Zamora, MD, PhDa,*, Mauricio Castillo, MDb, Paulo Puac-Polanco, MD, MScc,d,
Carlos Torres, MD, FRCPCe
KEYWORDS
Head Neck Cancer Emergencies MRI CT
KEY POINTS
Patients with head and neck cancers are susceptible to emergencies related to tumor infiltration,
systemic disorders, or treatment complications.
Hematologic disorders are common in patients with cancer and result in hypercoagulable states or
hemorrhage.
Infections in patients with cancer are secondary to immunocompromise, complications from sur-
gery, or use of indwelling devices.
INTRODUCTION IMAGING TECHNIQUE

Head and neck cancers are an important cause of Computed tomography (CT) is the mainstay for the
morbidity and mortality, with an estimated 562,328 evaluation of acute complications in the head and
new cases and 277,597 deaths worldwide in neck. It is fast and appropriate for patients who are
2020.1 Patients are susceptible to a wide range sick and unstable and can identify conditions
of emergencies caused by tumor infiltration of crit- necessitating urgent surgery or airway manage-
ical structures, impaired immune status, bleeding ment. Compared with CT, MRI has superior tissue
or thrombosis, or treatment complications. They contrast but is reserved for conditions that require
can also be affected by metabolic derangements further characterization in patients who are stable.
secondary to systemic effects from cancer, para- Administration of contrast material is important
neoplastic syndromes, or chemotherapy. Because when infection is suspected, and it may help
the neck houses life-sustaining structures, emer- discriminate it from enhancing tumor.
gencies in this region have dire consequences. For further evaluation of intra- and extracranial
Maxillofacial complications are important because conditions, contrast-enhanced MRI is superior to
of their potential to propagate to the orbits and CT. In the neck and maxillofacial structures, both
intracranially. Here, we present an overview of im- contrast-enhanced CT and MRI have appropriate
aging findings of various emergencies that occur in roles but CT is preferred in the acute setting. MRI
patients with head and neck cancer. We discuss evaluation of inflammatory or infectious complica-
their pathophysiological mechanisms and review tions in the neck, maxillofacial structures, and or-
clinical features that aid in diagnosis. bits, requires the use of fat suppression
a
Division Head of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine,
CB 7510, Old Infirmary Building, 101 Manning Drive, Chapel Hill, NC 27599-7510, USA; b Division of Neurora-
radiologic.theclinics.com
diology, Department of Radiology, University of North Carolina School of Medicine, CB 7510, Old Infirmary
Building, 101 Manning Drive, Chapel Hill, NC 27599-7510, USA; c Department of Radiology, McMaster Univer-
sity, St. Joseph’s Healthcare, Hamilton, Ontario, Canada; d Department of Radiology, Juravinski Innovation
Tower, Level 0, Room T0113, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada; e Department
of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Box 232, General Campus
Room 1466e, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
* Corresponding author.
E-mail address: carlos_zamora@med.unc.edu
Radiol Clin N Am 61 (2023) 71–90

https://doi.org/10.1016/j.rcl.2022.08.002
0033-8389/23/Ó 2022 Elsevier Inc. All rights reserved.
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72 Zamora et al
techniques for T2 and postcontrast T1 sequences Box 1

to better show edema and enhancement, respec- Most common CNS tumors associated with ITH
tively, but artifacts from hemorrhage, metallic
clips, and radiation seeds may hinder Benign Tumors
interpretation. Meningioma
CT arteriography (CTA) and/or venography
Schwannoma
(CTV) are the initial studies when there is concern
for vascular complications such as active Hemangioblastoma
bleeding, occlusion, pseudoaneurysm, or throm- Pilocytic Astrocytoma
bosis. Catheter angiography is the gold standard Pituitary Adenoma
to show active extravasation and arteriovenous
shunting that can be difficult to visualize on CTA Myxopapillary Ependymoma
when it involves small vessels. Catheter angiog- Malignant Tumors
raphy can also provide a route for endovascular Glioblastoma
treatment when indicated.
Oligodendroglioma
INTRACRANIAL COMPLICATIONS Ependymoma
Metastases
Neurologic complications in patients with cancer
are a common cause of morbidity and mortality. Melanoma
Diagnosis of intracranial complications is chal- Lung
lenging as clinical signs are usually nonspecific,
Breast
and diagnosis is based on ancillary tests such as
laboratory or imaging studies. Prompt recognition Germ Cell Tumor
is essential to institute appropriate treatment and Thyroid Carcinoma
prevent dire outcomes. Renal Cell Carcinoma
Bleeding Complications Abbreviation: ITH, Intratumoral hemorrhage.
Data from Refs.1–4
Tumor-related hemorrhage
Intracranial hemorrhage (IH) in patients with can-
cer is secondary to intratumoral hemorrhage
(ITH) in 25% to 61% of cases.2,3 Brain tumors vasogenic edema, enhancement on MRI, unusual
bleed spontaneously (3.5–14%) depending on tu- location for IH (gray-white matter interface or lobar
mor type. ITH may be the initial presentation of location), or high relative cerebral blood volume
cancer.4,5 Malignant or highly vascular tumors (rCBV) within the lesion (Fig. 1). Review of clinical
pose a risk for ITH (Box 1).2,3 Metastases and glio- information shows that almost half of patients
blastoma are the most prone to bleed.3,4 Patients have a history of cancer at the time of IH.3
present acutely in 57% to 93% of cases.3,4
The cause of ITH is unclear, but it is likely due to Hematologic disorders associated with cancer
presence of numerous thin-walled, poorly formed The second most common cause of IH in the can-
vessels, rapid tumor growth, vascular invasion, cer population is coagulopathy, being the leading
and tumor necrosis. Hemorrhage can mask an un- cause of IH in patients with hematologic malig-
derlying malignancy. This is particularly important nancies and the second most common cause of
in large hemorrhagic lesions, where finding IH in central nervous system (CNS) tumors after
neoplastic cells is prone to sampling errors by ITH.3 Leukemia is the most common hematologic
the neurosurgeon and the pathologist. Therefore, malignancy in patients with cancer and IH, fol-
information obtained in imaging studies helps lowed by lymphoma and myeloma.6 Conversely,
achieve the correct diagnosis. in patients with intracranial disease involvement,
Imaging findings in tumor-related hemorrhage lymphoma is more prone to cause IH than
are like those in other benign causes of IH, such leukemia.6
as hypertension or ruptured aneurysms and Thrombocytopenia, sepsis, and prolongation of
include a hyperdense parenchymal hematoma on prothrombin time are major predisposing factors
CT, associated mass effect, and vasogenic for IH in patients with hematologic malignancies.6
edema. Subarachnoid hemorrhage (SAH) or intra- Most hemorrhages associated with coagulopathy
ventricular hemmorrhage (IVH) can also be are intraparenchymal, but SAH, IVH, or multicom-
seen.2,3 Imaging features that suggest an underly- partmental IH also occur.2,3 Parenchymal hema-
ing tumor include presence of disproportionate tomas have a preference for the cerebral cortex,
Oncologic emergencies 73
Fig. 1. Tumor-related hemorrhage. Coronal noncontrast CT (A) shows acute hematoma with vasogenic edema in
the left frontal lobe. Vasogenic edema is slightly disproportionate relative to the size of the hematoma (A, ar-
rows). MRI reveals associated peripheral ring enhancement (arrows in B) and increased CBV (C, arrows). Single-
voxel spectroscopy from enhancing component (D) shows elevated Choline and low NAA. Final pathology re-
vealed glioblastoma.
basal ganglia, and cerebellum.6 Multifocal hemor- Malignancies often associated with ESUS include
rhages are seen in 46% of cases (Fig. 2).6 breast, lung, prostate, and gastrointestinal tract
Mortality is high regardless of the type of hema- cancers.8,9
tologic malignancy, with a median survival of Pathophysiology of stroke in patients with can-
1.5 months.3 Also, prolonged prothrombin time, cer is not elucidated but it is well established that
SAH, and multifocal cerebral hemorrhage are in- cancer-mediated hypercoagulability plays an
dependent prognostic factors of poor outcome.6 important role. Possible mechanisms include par-
adoxical embolism and nonbacterial thrombotic
endocarditis. Additional mechanisms unrelated to
Hypercoagulable States
hypercoagulability include atherosclerosis, radia-
Ischemic complications tion vasculitis, tumor embolism, and atrial
Up to one-third of strokes have no clear underlying fibrillation.10
mechanism and are considered embolic strokes of Stroke can be the initial presentation of cancer.
undetermined source (ESUS).7 Patients with active Up to 10% of ESUS patients are diagnosed with
cancer represent 5% to 10% of ESUS, which in- cancer within one year after stroke.8,11 The actual
creases as patients survive longer.8,9 rate and clinical indicators of occult cancer in
74 Zamora et al
Fig. 2. Multifocal hemorrhage in a patient with acute lymphocytic leukemia. Axial noncontrast CT (A) shows mul-
tiple hyperdense parenchymal hemorrhages with intraventricular extension. MRI SWI sequence (B) reveals addi-
tional hemorrhages with surrounding edema.
patients with ESUS remain uncertain. Smoking, death in this population.14 Although ischemic
weight loss, increased C-reactive protein and stroke and myocardial infarction are the main arte-
D-dimer, and anemia can raise the suspicion of rial thromboembolic events in patients with can-
underlying malignancy in ESUS.8,11 cer,14 other less known complications, such as
On imaging, multiple acute infarcts involving free-floating thrombus (FFT), can be seen.
more than one vascular territory are typical of can- FFT is recognized as a string-like soft tissue
cer.8,11 Patients with ESUS and cancer have density projecting into the arterial lumen on ultra-
worse long-term functional outcomes and survival sound or CTA, most commonly along the extracra-
rates than patients with ESUS and no cancer. nial carotid system.15 Presence of FFT increases
the short-term risk of transient ischemic attach,
Thrombosis stroke, or death up to 17%.16 Atherosclerosis is
Cancer-mediated hypercoagulability is influenced the most common condition associated with
by tumor histology, which requires the interaction FFT. However, hypercoagulability, thought to be
of different hypercoagulable promoters, such as the underlying mechanism in patients with cancer,
procoagulant factors, neutrophil extracellular trap also plays a role.15
formation, and platelet dysfunction.10 Adenocarci-
noma, particularly from lung, is the most common
Metabolic
cancer linked to hypercoagulability.12
The risk of cerebral venous thrombosis (CVT) is Osmotic demyelination
increased 5-fold in patients with cancer, particu- Osmotic demyelination syndrome (ODS) is caused
larly one year after diagnosis.13 Hematological ma- by rapid correction of an osmotic imbalance, most
lignancies convey a higher risk of developing CVT commonly hyponatremia that leads to demyelin-
than solid tumors.13 Severe headaches, focal ation.17 In patients with cancer, ODS can occur
neurological deficits, and seizures should raise without associated electrolyte imbalance and is
suspicion of CVT. Both CTV and contrast- thought to be secondary to the cancer itself or its
enhanced MR venogram (CE-MRV) are appro- treatment.18
priate studies and should be performed to confirm ODS affects the pons and pontocerebellar fibers
the diagnosis. Brain MRI is more sensitive than CT in the central variant or the basal ganglia, thalami,
to exclude complications including hemorrhagic and cerebral white matter in the extrapontine type,
and nonhemorrhagic lesions (eg, infarction, cere- although patients can present with overlapping
bral edema) that affect one-third of patients with findings. Clinical presentation correlates with site
CVT and cancer.13 of involvement, including pseudobulbar palsy, tet-
Cancer-mediated hypercoagulability also in- raparesis, ophthalmoplegia, and cranial nerve
creases risk for arterial thromboembolism, which palsy in pontine ODS, or seizures and extrapyra-
is associated with a threefold increased risk of midal symptoms in extrapontine ODS.17
On MRI, high T2-WI/fluid attenuated inversion Treatment-Related

recovery (FLAIR) signal changes are seen in
Radiation necrosis
affected regions with or without restricted diffu-
Radiation necrosis (RN) is the most severe late
sion. Pontine ODS shows symmetric signal
side effect of radiation therapy (RT). Our discus-
changes in the central pons with a characteristic
sion focuses on a population where the diag-
trident-shape and sparing of the tegmentum and
nosis is usually not considered firsthand:
ventrolateral pons (Fig. 3). Extrapontine ODS usu-
temporal lobe RN following RT for head and
ally involves the basal ganglia, thalami, cere-
neck tumors, particularly nasopharyngeal carci-
bellum, or supratentorial white matter.
noma (NPC).
It is well known that the higher the total radiation
Wernicke encephalopathy dose is, the higher the incidence of RN. The pre-
Wernicke encephalopathy is often under- scribed target volume is defined as the gross tu-
recognized, given that a minority of patients pre- mor volume plus a sub-clinical margin based on
sent the classic triad of confusion, ataxia, and oph- clinical experience, data inferred from pathology
thalmoplegia. This syndrome caused by thiamine results, and patterns of failure from previous treat-
deficiency is more readily diagnosed in alcoholics. ments. Thus, it is often inevitable to include the
In the absence of this risk factor, such as in pa- temporal lobes in the radiation field for tumors
tients with cancer, the diagnosis is complex and near or infiltrating the skull base. In cases of
often overlooked.19 NPC, intensity-modulated radiotherapy (IMRT)
In cancer, thiamine deficiency occurs due to has become mainstay given the lower 5-year inci-
decreased availability (eg, malabsorption in dence of temporal lobe RN (16%) compared with
gastrointestinal malignancies, malnutrition); accel- conventional RT (35%).21
erated use (eg, high cell turnover); or inactivation Patients’ symptoms in temporal lobe RN include
by breakdown products of chemotherapy.19,20 seizures, cognitive decline, decline in verbal mem-
MRI is abnormal in 80% of patients showing areas ory and language abilities (left temporal lesions),
of high T2-WI/FLAIR signal19,20 that may show and impaired visual memory (right temporal le-
contrast enhancement.20 Two-thirds of patients sions)22; whereas others could remain
present high T2-WI/FLAIR signal involving the asymptomatic.
tectum, periaqueductal gray, thalamus, mammil- MRI findings are similar to those of RN following
lary bodies, and surrounding the third ventricle RT 5 radiation therapy for CNS malignancies and
(Fig. 4).19,20 Atypical imaging findings include include a heterogenous intra-axial ring-enhancing
affection of the medulla, pons, frontal lobe, and lesion with thick irregular walls surrounded by
cranial nerves. vasogenic edema. Presence of a “Swiss-cheese”
Awareness of this syndrome in patients with or “spreading wavefront” type of contrast
cancer is needed to reduce treatment delays as enhancement, restricted diffusion in the non-
only one-third of patients fully recover.19 enhancing central component, and low rCVB of
Fig. 3. Osmotic demyelination syndrome (ODS). Axial T2-WI images (A, B) show high signal in the central pons
with sparing of the tegmentum and corticospinal tracts (arrows). Note the characteristic “trident-shaped” signal
abnormality (A).
76 Zamora et al
Fig. 4. Wernicke encephalopathy. Axial FLAIR images show abnormal symmetric high signal (arrows) in medulla,
periaqueductal gray matter, hypothalami, and medial thalami.
the enhancing component are findings that favor Hypophysitis is the second most common irAE
RN (Fig. 5). after thyroid dysfunction, with an incidence of
In RN following RT for NPC, other clues that may 14%.24 Incidence of hypophysitis in combined
suggest the diagnosis are bilateral asymmetric ICI is more significant, likely to be symptomatic,
temporal lobe involvement (seen in 70% of pa- and co-occurs with other irAEs (eg, skin, gastroin-
tients) and disproportionate symptoms relative to testinal, hepatic).24
imaging findings.23 RN develops with a median la- Median time from therapy to hypophysitis is be-
tency of 6 years (1–15 years) after initiation of RT.23 tween 2 and 4 months, occurring earlier in com-
bined regimens.24 Patients present with
Hypophysitis headaches, nausea, hypopituitarism, and visual
A therapy that has revolutionized cancer treatment changes.24
is the use of immune checkpoint inhibitors (ICIs) MRI is abnormal in 47%.24 Imaging findings
for melanoma, renal, and lung cancers. One draw- include mild to moderate enlargement of the pitu-
back is the unpredictable development of itary gland, loss of the posterior bright spot, and
immune-related adverse events (irAEs), particu- thickening and enhancement of the stalk (Fig. 6).
larly endocrinopathies, given their long-lasting Incidental pituitary enlargement on imaging in pa-
and irreversible side effects. tients receiving ICI should prompt a clinical and
Fig. 5. Temporal lobe radiation necrosis in a patient with prior radiotherapy for nasopharyngeal carcinoma.
There is a focal lesion with heterogeneous T2-WI signal (A, B) in the left temporal lobe, with surrounding vaso-
genic edema. On axial (C) and coronal (D) post gadolinium T1-WI, the lesion shows irregular ill-defined peripheral
enhancement with Swiss-cheese appearance (C, arrows).
laboratory assessment as it could be the initial disease-like orbital inflammatory syndrome.25 Pa-
manifestation of hypophysitis.24 tients present with diffuse symmetric enlargement
An emerging endocrine irAE related to ICI ther- of the extraocular muscles sparing the muscle ten-
apy that was recently described is a thyroid eye dons (Fig. 7).
Fig. 6. Immunotherapy-induced hypophysitis. Sagittal T1-WI post gadolinium (A) shows enhancement of a thick-
ened infundibulum and enlarged pituitary gland in a patient receiving immune checkpoint inhibitors for mela-
noma (arrow). Follow-up MRI (B) after immunotherapy discontinuation and steroid treatment shows the
resolution of findings.
78 Zamora et al
Fig. 7. Thyroid eye disease-like orbital inflammatory syndrome in a patient with immunotherapy for metastatic
RCC. Axial T2-WI (A), axial (B), and coronal (C) T1-WI post gadolinium show symmetric diffuse enlargement of the
extraocular muscles sparing the muscle tendons bilaterally (arrows). After steroid therapy, MRI shows interval res-
olution of abnormalities (D).
Posterior reversible encephalopathy syndrome Acute leukoencephalopathy

Posterior reversible encephalopathy syndrome Chemotherapy-induced toxic leukoencephalop-
(PRES) is typically seen in hypertension, preeclamp- athy is a progressive white matter disease due to
sia/eclampsia, or autoimmune disorders but can myelin damage most commonly caused by meth-
also occur in patients receiving cytotoxic agents or otrexate but also seen after cranial irradiation.28
targeted therapies. Patients present with confusion, Risk factors that increase the likelihood of devel-
seizure, visual disturbances, or headaches.26 MRI oping leukoencephalopathy include intrathecal
findings include cortical or subcortical T2-WI/ route of administration, dosage, associated irradi-
FLAIR hyperintensity in a “classic parieto-occipital ation, and patient-related risk factors, such as
pattern” (Fig. 8). However, 50% of cases show other malnutrition or liver dysfunction.29
imaging patterns including involvement of frontal or Clinical presentation is variable. Mild dizziness,
temporal lobes, thalami, basal ganglia, or brainstem. headaches, and depression are seen when the
Restricted diffusion and contrast enhancement may toxic agent is taken in low doses. Seizures,
be seen. IH can occur when associated with altered stroke-like symptoms, and altered mental status
coagulation states.27 occur with higher doses.30
Patients have a good outcome and most On MRI, diffuse T2-WI/FLAIR hyperintensity of
recover fully.26 Cancer treatment can be resumed the deep white matter and corpus callosum are
successfully in most cases. characteristic (Fig. 9). Signal changes are usually
Fig. 8. Chemotherapy-induced PRES in a patient with confusion and visual disturbances. Axial FLAIR images (A–C)
show high signal intensity in the cerebellum and in the subcortical parietooccipital regions (arrows in A, B). Sub-
arachnoid hemorrhage (arrow in C) is noted in the right frontal region.
bilateral, but unilateral involvement can occur. cellular immunity, or receiving immunosuppressive
Diffusion-weighted imaging (DWI) abnormalities treatments.31 Acute invasive fungal infection has
can precede others.29 This is particularly important high mortality and requires prompt aggressive sur-
in methotrexate-induced leukoencephalopathy, gical debridement and antifungal therapy. Most in-
where areas of restricted diffusion in the centra fections originate in a sinonasal cavity and extend
semiovale occur first (Fig. 10). intracranially or into the orbits directly or through
valveless emissary veins. Infection should be sus-
MAXILLOFACIAL STRUCTURES AND ORBITS pected in patients with cancer presenting with fe-
Acute invasive fungal infection ver and sinonasal discharge, congestion, or pain,
whereas patients with orbital involvement have
Angioinvasive fungal species such as aspergillus,
periorbital edema, proptosis, and abnormal ocular
mucor, or less commonly fusarium, can cause a
motility.31,32 Cranial neuropathies raise concern
rapidly progressive sinonasal infection compli-
for cavernous sinus involvement, whereas altered
cated by orbital and/or intracranial disease. Infec-
mental status and focal neurologic deficits sug-
tion is usually seen in patients with neutropenia,
gest brain extension.
poorly controlled diabetes, impaired humoral or
Fig. 9. Treatment-induced toxic leukoencephalopathy in a patient with acute myelogenous leukemia after intra-
thecal methotrexate administration. Axial FLAIR images (A–C) show symmetric high signal intensity in the middle
cerebellar peduncles, corona radiata, and centrum semiovale. There is also a subtle increased signal in the sple-
nium of the corpus callosum (B, arrows).
80 Zamora et al
Fig. 10. Methotrexate neurotoxicity following intrathecal chemotherapy administration. DWI (A) and ADC map
(B) show focal areas of restricted diffusion in the centra semiovale with subtle signal changes on FLAIR (C,
arrows).
Contrast-enhanced CT or MRI are acceptable in hemorrhage is present in approximately 3% of pa-

patients with suspected acute invasive fungal tients with uveal melanoma and may be secondary
infection. On CT, presence of sinonasal disease to vascular invasion by tumor or venous conges-
with periantral inflammatory changes is a concern- tion with stasis.37 Hemorrhagic ocular metastases
ing finding. Orbital fat should be scrutinized for in- are rare. A higher frequency of intraocular hemor-
flammatory changes, particularly in patients with rhage is reported in metastases from
ethmoid sinus disease. On MRI, devitalized sino- choriocarcinoma.38
nasal mucosa can appear abnormally T2 dark Ophthalmologic examination including high-
with lack of contrast-enhancement (“black turbi- resolution imaging techniques such as optical
nate” sign) (Fig. 11).32 Fungal elements can appear coherence tomography and ultrasound are often
markedly T2 hypointense due to accumulation of utilized in non-emergent patients and suspected
iron and other paramagnetic metals such as ocular metastases.39 Tumor visualization may be
manganese. obscured by hemorrhage. CT may be able to
detect membranous detachments as areas of
Hemorrhagic ocular malignancy and increased density due to hemorrhage. MRI is su-
membranous detachments perior but requires fat-suppressed T2 and post-
The eye is a rare site for hematogenous metasta- contrast T1 sequences. In patients with
ses but metastases represent the most common melanoma, tumors frequently have increased T1
ocular malignancy, most secondary to lung, and decreased T2 signal intensity due to the metal
breast, or gastrointestinal cancers.33 In breast chelating properties of melanin (see Fig. 13).40
cancer, ocular metastases occur in advanced However, signal intensity varies in presence of
stages with almost all patients having systemic hemorrhage depending on the stage of blood
disease. In lung cancer, only 50% of patients products.
with choroidal metastases have systemic disease
Osteoradionecrosis
(Fig. 12).34 The choroid is the most affected site
owing to its rich vasculature, but any ocular struc- Mandibular osteoradionecrosis (ORN) is a serious
ture may be involved. Primary intraocular malig- complication of radiation therapy for head and
nancies are less common but can present with neck cancers and can occur months to years
hemorrhage. Most primary tumors in adults are following treatment.41 Its incidence has decreased
melanomas (Fig. 13), whereas primary intraocular and recently currently occurs in 4% to 9%.41,42
lymphomas are rare. In children, retinoblastomas Mandibular ORN is defined as exposed bone per-
(Fig. 14) are most common, whereas medulloepi- sisting for greater than 3 to 6 months in absence of
theliomas are rare.35 local disease recurrence. A subset of patients may
Choroidal metastases present with large present with intact overlying mucosa and radio-
amounts of subretinal fluid but can lead to com- graphic evidence of ORN. Severe cases can lead
plete retinal detachment even when small. In to hemorrhage, fracture, and infection with drain-
contrast, melanomas need to grow larger before ing fistulae and sepsis. Septic ORN presents with
causing retinal detachment.36 Intraocular severe pain.43 Several risk factors associated
Fig. 11. Invasive fungal sinusitis. Axial (A) and coronal (B) T2 show opacification of ethmoid and sphenoid sinuses
with areas of abnormally hypointense mucosa (arrowhead). Left retro-orbital stranding is seen on B indicating
orbital extension (arrows). Coronal (C) and axial (D) postcontrast fat-suppressed T1 show devitalized non-
enhancing mucosa (“black turbinate” sign, arrows).
Fig. 12. Metastasis to the eye from lung cancer with acute hemorrhage. Axial postcontrast T1 (A) shows an
enhancing mass in the left eye (arrow) with layering hemorrhage on T2 (arrowhead, B).
82 Zamora et al
Fig. 13. Uveal melanoma with acute hemorrhage. MRI shows a T1-hyper, T2-hypointense mass in the right eye (A
and C, thick arrows). Note subretinal hemorrhage (thin arrow in A). There is avid contrast enhancement (B,
arrowhead) and layering hemorrhage on T2 (D).
with the development of ORN include pre- or post- NECK COMPLICATIONS

radiotherapy tooth extraction, treatment of oral or Airway Compromise
oropharyngeal cancers, and greater than 14% vol-
Respiratory compromise is common with
ume of the mandible receiving a dose of
advanced tumors of the base of tongue, larynx,
60 Gy.41,44 In most patients, ORN affects the
and hypopharynx.46 It can be the result of direct
mandibular body, followed by the angle or ramus,
mechanical obstruction by tumor or may be sec-
and symphyseal or parasymphyseal regions.44
ondary to hemorrhage or superimposed infection.
CT findings include osseous permeative
In patients who receive chemoradiation, the tumor
changes with a mixed lytic/sclerotic appearance,
and surrounding tissues undergo acute inflamma-
loss of cortical and trabecular bone, and osseous
tion and edema in the first 2 weeks that can result
sequestra typically involving the buccal or lingual
in new or worsened obstruction.47 Advanced
surface.45 Bicortical involvement is seen in severe
laryngeal cancers are likely to result in airway
cases and predisposes to fractures (Fig. 15). On
compromise requiring tracheostomy or tumor
MRI, fat-suppressed T2/STIR and post-contrast
debulking and this can occur before, during, or af-
T1 sequences show abnormal bone marrow signal
ter chemoradiation.46 In addition, patients who un-
with edema and enhancement that may involve
dergo radiation have diminished salivary flow that
surrounding soft tissues and masticator space. In
affects mucosal integrity. Some patients have
some patients, soft tissue enhancement can be
increased secretions due to impaired swallowing.
masslike and indistinguishable from recurrent dis-
Rarely, airway compromise can be secondary to
ease.45 ORN can coexist with infection and cannot
metastatic disease from primaries outside of the
be differentiated by imaging unless there is an
head and neck. Contrast-enhanced CT is the
associated abscess.
Retropharyngeal effusion or edema is a common

finding (Fig. 17). Contrast-enhanced CT shows
areas of increased vascularity with prominent ves-
sels due to hyperemia. Soft tissue thickening on
MRI shows varying degrees of T2 signal intensity
depending on presence of edema and inflamma-
tion that are best seen on fat-suppressed se-
quences. Post-contrast T1 shows varying
degrees of enhancement.
Vascular injury. Several factors predispose pa-
tients with neck cancer to vascular injury, with ca-
rotid rupture being the most severe complication.
The carotid arteries may have insufficient soft tis-
sue covering following surgery that increases
exposure, desiccation, and weakening of the
vessel wall. There can also be enzymatic degrada-
tion of the carotid wall in patients with fistulas
where the vessel is exposed to saliva. The carotid
vessels can be directly infiltrated by metastatic
cervical lymphadenopathy or primary tumor.
Rapid tumor regression following chemoradiation
can lead to weakening and rupture of the vessel
wall. Patients present with imminent hemorrhage
from a clinically exposed but unruptured vessel,
contained sentinel hemorrhage, or full carotid
blowout (Figs. 18 and 19). Mortality after carotid
Fig. 14. Retinoblastoma and retinal detachment. blowout is approximately 40%, whereas 60% of
Axial T2 (A) shows a hypointense mass in the left pos- survivors sustain permanent neurological impair-
terior globe (white arrow) with retinal detachment ment.51 Carotid blowout is rare after radiation but
(arrowhead). ADC map (B) shows restricted diffusion is more frequent in patients undergoing salvage
due to high cellularity (black arrow).
reirradiation (3% of cases).52 Radiation causes
DNA damage in arteries leading to sustained upre-
imaging modality of choice in acute respiratory
gulation of inflammatory transcription factors and
compromise as it can be done rapidly and is able
production of free radicals and oxidative stress.53
to clearly depict the airway compared with MRI
This results in vessel wall thickening with stenosis
(Fig. 16).
and atherosclerotic-like changes increasing the
risk for cerebrovascular events.53
Treatment Related
Chondronecrosis. Chondronecrosis is a severe
Post-radiation edema and mucositis. Acute complication of radiation that occurs months to
oropharyngeal and laryngeal edema and mucositis years after treatment. Its incidence has decreased
are common in patients treated with radiation. owing to improved radiotherapy techniques and is
Their prevalence is higher in those who received seen in 1% to 5% of patients.54 Risk is increased in
chemoradiation compared with radiation alone.48 patients where cartilage has been subject to injury
In addition, pharyngeal constrictor muscles during surgery and infection. Inflammatory
become thickened and edematous following che- changes in irradiated tissue lead to obliterative
moradiation in patients receiving doses greater endarteritis of cartilage vessels, edema, ischemia,
than 50 Gy.49 These changes, along with iatro- fibrosis, and chondronecrosis.54 Devitalized carti-
genic anatomical alterations and nerve injury can lage is predisposed to deformity and fracture and
lead to dysphagia and aspiration pneumonia. Like- may collapse with resultant airway compromise.
lihood of dysphagia and pneumonia is higher in Patients present with hoarseness, severe pain,
patients undergoing chemoradiation than in those dysphagia, acute airway obstruction, and aspira-
treated with surgery alone and the risk of stricture tion. CT shows lytic or permeative changes of
is higher after combined therapies.50 On CT, the affected cartilage that may be accompanied
pharyngeal and laryngeal structures appear thick- by foci of gas, loss of normal architecture, or frac-
ened in a symmetric fashion. As opposed to tumor, ture (Fig. 20). MRI shows varying degrees of in-
soft tissue thickening related to radiation shows flammatory changes with edema and
decreased attenuation due to edema. enhancement of surrounding tissues.
84 Zamora et al
Fig. 15. Mandibular osteoradionecrosis in a patient with squamous cell carcinoma. Coronal (A) and axial (B) non-
contrast CT shows extensive lytic and sclerotic changes in the mandible with osseous sequestra (arrows). Follow-
up volume rendered 3D CT (C) after right hemimandibulectomy shows a pathologic left mandibular fracture. Fat-
suppressed T2 MRI shows increased signal in left mandible and masticator space (oval). Note large recurrent tu-
mor on the right (asterisk).
Fig. 16. Airway compromise due to thyroid gland tumor. Coronal (A) and axial (B) postcontrast CT show displace-
ment and narrowing of the airway (arrowheads) due to a massive thyroid carcinoma (arrows).
Fig. 17. Post-radiation mucositis and edema. Sagittal (A) and axial (B) postcontrast CT shows diffuse thickening of
the posterior pharynx, pre-epiglottic space, and supraglottis (white arrows). Note small retropharyngeal effusion/
edema (black arrowhead).
Fig. 18. Patient with laryngeal cancer post chemoradiation presenting with hemoptysis. Axial (A) and coronal (B)
postcontrast CT and lateral view DSA (C, D). CT shows a hypopharyngeal-prevertebral fistula (white arrowheads)
with an irregular contour of the common carotid artery (arrow). Note small focus of extravasation (black arrow-
heads) successfully treated with an endovascular stent (D). (Courtesy of Benjamin Y. Huang, MD, Chapel Hill, NC.)
86 Zamora et al
Fig. 19. Carotid blowout syndrome. Axial (A) and coronal (B) postcontrast CT shows large recurrent squamous
cell carcinoma in the left neck (asterisk). Note irregular contour of the left common carotid artery (arrow).
DSA (C) shows a large amount of active extravasation (arrowheads) that occurred during angiography. (Courtesy
of Christine Glastonbury, MD, San Francisco, CA.)
Infection. Patients with neck malignancies may (Fig. 21). Finally, indwelling devices represent
develop infection due to several causes. First, another potential source of infection.
they have an inherent risk of infection associated Contrast-enhanced CT is best for the initial
with surgery that involves the aerodigestive tract. assessment of patients with suspected infection.
Second, extensive resections for neck malig- It depicts phlegmonous changes or abscess and
nancies alter anatomical barriers that normally can discriminate these against post-radiation
protect against infection. Third, radiation-induced edema/mucositis or recurrent tumor and can
osteonecrosis predisposes bone to infection show gas along fascial planes in patients with
Fig. 20. Chondronecrosis. Coronal postcontrast CT (A, B) shows deformity of the thyroid cartilage with a mixed
lytic/sclerotic appearance (arrow) and pathologic fracture (arrowhead).
Fig. 21. Discitis-osteomyelitis in a patient with osteonecrosis of cervical spine following irradiation for nasopha-
ryngeal carcinoma. Sagittal STIR (A) and fat-suppressed postcontrast T1 (B) show extensive edema and enhance-
ment of the C2 and C3 vertebrae (arrows). There is fluid in the intervertebral disc with mild enhancement. Note
thin epidural phlegmon (arrowhead).
necrotizing infections. However, differentiation edema and contrast enhancement. In abscesses,

from infection may be difficult in patients with DWI shows restricted diffusion of pus, but
infiltrative and necrotic malignancies. MRI may restricted diffusion is also seen in the solid-
be helpful for additional characterization and re- enhancing components of necrotic tumors due
quires fat-suppressed techniques to visualize to high cellularity.
Fig. 22. Flap necrosis. Axial (A) and sagittal (B) post-contrast CT show right-sided mandibular reconstruction with
a myocutaneous flap. The devitalized flap is abnormally hypodense (arrows) and contains intravascular gas.
88 Zamora et al
Flap necrosis. Treatment of head and neck ma- Severe headaches, neurological deficits, and
lignancies frequently requires extensive surgical seizures in a patient with cancer should raise
resection to ensure negative margins. Several concern for cerebral venous thrombosis in
reconstruction techniques have been devised to addition to intracranial metastatic disease.
regain function and for cosmetic purposes. As Metabolic derangements are not always
opposed to surgical grafts, whose vascular supply accompanied by electrolyte imbalances or
depends entirely on angiogenesis, flaps are recon- the full spectrum of symptoms and are diffi-
structed with a dedicated blood supply and cult to diagnose.
achieve better soft tissue bulk and cosmesis. Acute invasive fungal sinusitis has high mor-
Local or regional flaps require anatomic rearrange- tality and should be suspected in patients
ment of surrounding tissues with preservation of with sinus disease who have adjacent inflam-
their native blood supply. On the contrary, free matory changes on imaging.
flaps are created by transposing tissue from other Patients treated for neck cancer are subject to
sites and creating microvascular anastomoses. immediate life-threatening complications
Free flaps are standard in many head and neck including airway compromise and carotid in-
reconstructions. Because their blood supply de- juries.
pends completely on the microvascular anasto-
mosis until there is sufficient neovascularization,
risk for necrosis and infection is greatest on days
DISCLOSURE
2 to 5 after surgery and declines thereafter.55
Smoking is a significant risk factor for flap necro- The authors have nothing to disclose.
sis.56 Overall, necrosis with modern techniques is
rare and flap survival is about 95%.57 On CT and
MRI, flaps normally show early contrast enhance- REFERENCES
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Oncologic Emergencies in The Head and Neck

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Oncologic Emergencies in The Head and Neck

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O n c o l o g i c Em e r g e n c i e s i n

the Head and Neck

INTRODUCTION IMAGING TECHNIQUE

Radiol Clin N Am 61 (2023) 71–90

techniques for T2 and postcontrast T1 sequences Box 1

On MRI, high T2-WI/fluid attenuated inversion Treatment-Related

Posterior reversible encephalopathy syndrome Acute leukoencephalopathy

Contrast-enhanced CT or MRI are acceptable in hemorrhage is present in approximately 3% of pa-

with the development of ORN include pre- or post- NECK COMPLICATIONS

Retropharyngeal effusion or edema is a common

necrotizing infections. However, differentiation edema and contrast enhancement. In abscesses,

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