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Lea Alhilali, MD

@teachplaygrub

Nov 26, 2022 • 13 tweets • 7 min read • Read on X

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1/Tonsillar or peritonsillar abscess? That is the question! When you look at a neck CT, do you know which one to say?
A #tweetorial on #tonsillitis complications
#medtwitter #radtwitter #neurorad #radres #meded #FOAMed #FOAMrad #HNrad #medstudenttwitter #RSNA2022

2/First some anatomy. Palatine tonsils (or faucial to the cool kids) sit in the oropharynx between the two palatine arches: the palatoglossus arch in front and the palatopharyngeus arch in back. These are easily visible on physical exam.

3/These archs are actually just mucosa draped over the palatoglossus and palatopharygeus musculature, like kids drape sheets over themselves to dress up for Halloween.

4/The palatine tonsils sit nestled in between these two arches in a space called the tonsillar fossa. The pillars are like the bed and blankets--and the tonsils are tucked in between

5/Tonsils are made up triangular folds w/crevices in between, called crypts. This anatomy increases tonsillar surface area to expose it to as many of the oropharyngeal antigens as possible. Just below the surface are many lymph node germinal centers to examine the antigens

6/The lymphatic channels from these germinal centers are valveless (in adults—I don’t do kids 😉). This allows for immediate transport of antigens. This makes sense, as you want to be aware of any bad antigen entering your oropharynx as soon as possible

7/Tonsillitis occurs when there is an infection of the tonsils, usually strep pneumo. Inflammatory debris is made in the crypts and excreted out, creating the white patches seen on physical exam

8/On CT, this inflammatory change causes enlargement of the tonsils and hyper-enhancement of the crypts. This results in the classic tiger-stripe appearance of tonsillitis.

9/An abscess occurs when one of these crypts gets obstructed and its inflammatory exudate turns into pus under pressure.

10/But the pus doesn’t stay in the tonsil. It’s under pressure, like a volcano. If it’s plugged, the lava will find a way out b/c of the pressure. Lava will flow out any cracks/pores in the rock. In the tonsil, pores are the valveless lymphatics that allow the pus to flow out

11/Trying to keep the pus in the tonsil is like trying to keep water in a bathtub when the drain is open. It will always pour out. Similarly, in adults, the pus never stays in the tonsil—it pours out the valveless lymphatics into the tonsillar fossa/peritonsillar space.

12/Once the pus is in the tonsillar fossa, it becomes a peritonsillar abscess. It does not have to go through the superior constrictor musculature to be considered a peritonsillar abscess

13/So, in adults, the answer to the question “Tonsillar or peritonsillar abscess?” is the same answer my kid knows to give when asked, “Which parent do you love the most?” The answer: both!

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More from @teachplaygrub

Lea Alhilali, MD

@teachplaygrub

Nov 11

1/Need help reading spine imaging? I’ve got your back!

It’s as easy as ABC!

A thread about an easy mnemonic you can use on every single spine study you see to increase your speed & make sure you never miss a thing!

2/A is for alignment

Look for:
(1) Unstable injuries

(2) Malalignment that causes early degenerative change. Abnormal motion causes spinal elements to abnormally move against each other, like grinding teeth wears down teeth—this wears down the spine

3/B is for bones.

On CT, the most important thing to look for w/bones is fractures. You may see focal bony lesions, but you may not

On MR, it is the opposite—you can see marrow lesions easily but you may or may not see edema associated w/fractures if the fracture is subtle

Read 11 tweets

Lea Alhilali, MD

@teachplaygrub

Nov 8

1/Raise your hand if you’re confused by the BRACHIAL PLEXUS!

I could never seem to remember or understand it—but now I do & I’ll show you how!

A thread so you will never fear brachial plexus anatomy again!

2/Everyone has a mnemonic to remember brachial plexus anatomy.

I’m a radiologist, so I remember one about Rad Techs.

But just remembering the names & their order isn’t enough.

That is just the starting point--let’s really understand it

3/From the mnemonic, we start with the roots—the cervical nerve roots.

I remember which roots make up the brachial plexus by remembering that it supplies the hand.

You have 5 fingers on your hand so we start with C5 & we take 5 nerve roots (C5-T1).

Read 20 tweets

Lea Alhilali, MD

@teachplaygrub

Nov 6

1/Asking “How old are you?” can be dicey—both in real life & on MRI! Do you know how to tell the age of blood on MRI?

Here’s a thread on how to date blood on MRI so that the next time you see a hemorrhage, your guess on when it happened will always be in the right vein!

2/If you ask someone how to date blood on MRI, they’ll spit out a crazy mnemonic about babies that tells you what signal blood should be on T1 & T2 imaging by age.

But mnemonics are crutch—they help you memorize, but not understand. If you understand, you don’t need to memorize

3/If you look at the mnemonic, you will notice one thing—the T1 signal is all you need to tell if blood is acute, subacute or chronic.

T2 signal will tell if it is early or late in each of those time periods—but that type of detail isn’t needed in real life

So let’s look at T1

Read 20 tweets

Lea Alhilali, MD

@teachplaygrub

Oct 29

1/To call it or not to call it? That is the question!

Feeling wacky & wobbly when it comes to normal pressure hydrocephalus?

Don’t want to overcall it, but don’t want to miss it either!

Check out the latest in NPH w/this month’s @theAJNR SCANtastic!

ajnr.org/content/45/10/…

2/NPH was first described in 1965—but, of the original 6 pts, 4 were found to have underlying causes for hydrocephalus.

This begs the question—when do you stop looking & call it idiopathic? When do you suggest it on imaging?

3/There’s an iNPH Radscale, which scores 7 different imaging features.

Score above 8 is very sensitive for iNPH.

But who’s going to take out calipers & evaluate SEVEN different imaging findings on every dementia MR?

Also this scale doesn’t predict who will respond to shunting

Read 14 tweets

Lea Alhilali, MD

@teachplaygrub

Oct 18

1/Do radiologists sound like they are speaking a different language when they talk about MRI?

T1 shortening what? T2 prolongation who?

Here’s a translation w/an introductory thread to MRI.

2/Let’s start w/T1—it is #1 after all! T1 is for anatomy

Since it’s anatomic, brain structures will reflect the same color as real life

So gray matter is gray on T1 & white matter is white on T1

So if you see an image where gray is gray & white is white—you know it’s a T1

3/T1 is also for contrast

Contrast material helps us to see masses

Contrast can’t get into normal brain & spine bc of the blood brain barrier—but masses don’t have a blood brain barrier, so when you give contrast, masses will take it up & light up, making them easier to see.

Read 20 tweets

Lea Alhilali, MD

@teachplaygrub

Oct 16

1/Time is brain!

So you don’t have time to struggle w/that stroke alert head CT.

If there’s no flow, what are the things you need to know??

Here’s a thread to help you with the five main CT findings in acute stroke.

2/CT in acute stroke has 2 main purposes—(1) exclude intracranial hemorrhage (a contraindication to thrombolysis) & (2) exclude other pathologies mimicking acute stroke.

However, that doesn’t mean you can’t see other findings that can help you diagnosis a stroke.

3/Infarct appearance depends on timing.

In first 12 hrs, the most common imaging finding is…a normal head CT.

However, in some, you see a hyperdense artery or basal ganglia obscuration.

Later in the acute period, you see loss of gray white differentiation & sulcal effacement

Read 13 tweets

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