Active upper aerodigestive tract hemorrhage in patients with head and neck cancers: the “dot-in-sludge” sign

Sep 24, 2026

Active extravasation into the upper aerodigestive tract represents a dramatic, potentially life-threatening complication in head and neck cancer patients, triggering emergency presentation and urgent contrast-enhanced imaging to locate the hemorrhage source. A retrospective review summarizes clinical and imaging findings from six oropharyngeal and oral cavity squamous cell cancer patients with active bleeding. Most had advanced-stage disease and prior radiation therapy. All CECT/CTA studies showed the “dot-in-sludge” sign, with a “dot” of avidly enhancing contrast layered on “sludge” debris, commonly from lingual, facial, or superior thyroid arteries.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

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Abstract

Introduction

External carotid artery anatomy

Case series

Emergency Radiology (2023) 30:225–233 [https://doi.org/10.1007/s10140-023-02118-9](https://doi.org/10.1007/s10140-023-02118-9) Active upper aerodigestive tract hemorrhage in patients with head and neck cancers: the “dot‑in‑sludge” sign Abhishek Goswami1 · Ryan A. Fisicaro2 · Brian M. Howard3 · Milind Patel4 · Ashley H. Aiken5 · Kristen L. Baugnon5 · Xin Wu2 Received: 12 December 2022 / Accepted: 14 February 2023 / Published online: 18 February 2023 © The Author(s) 2023 Abstract Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the “dot-in-sludge” sign of active extravasation, as demonstrated by a “dot” of avidly enhancing extravasated contrast material layered against a background “sludge” of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations. Keywords Aerodigestive tract hemorrhage · Squamous cell cancer · Oropharyngeal · Oral cavity · Head and neck Introduction Oropharyngeal and oral cavity squamous cell cancers (SCCs) affect over 54,000 new patients yearly in the USA [1]. Radiotherapy is a part of the treatment regimen for most oropharyngeal cancer patients, predisposing them to vasculopathies and hemorrhage [2] . Presenting as hemoptysis Abhishek Goswami and Ryan A. Fisicaro contributed equally to the manuscript. * Xin Wu [xin.wu@ucsf.edu](xin.wu@ucsf.edu) 1 Department of Radiology, University of Chicago, Chicago, IL, USA 2 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA 3 Department of Neurosurgery, Emory University, Atlanta, GA, USA 4 Orlando Health, Orlando, FL, USA 5 Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA or hematemesis, upper aerodigestive tract hemorrhage is an airway-threatening emergency which prompts imaging with contrast-enhanced CT (CECT) or CT angiography (CTA) of the neck. Imaging is critical to identify a source of hemorrhage and potentially guide urgent endovascular or surgical treatment. Given the inherent complexities of treatment-altered head and neck anatomy as well as the potential presence of tumor and radiation necrosis, interpretation of these exams may seem intimidating to any radiologist, especially when under the pressures of an emergent setting. The goal of this paper is to familiarize radiologists with characteristic findings of active aerodigestive tract hemorrhage and relevant external carotid artery (ECA) anatomy, so that one could accurately and rapidly detect the presence and source of hemorrhage. External carotid artery anatomy Knowledge of ECA branch anatomy is important for patients with aerodigestive tract hemorrhage to detect the source of hemorrhage and to improve communication with surgeonsand interventionalists (Fig. 1) . The first branch of the ECA is Fig. 1 Major external carotid artery branches, as viewed ina lateral projection schematic diagram (A) and lateral DSA image (B) . In B, the catheter is located beyond the origin of the ICA and SThA, whi

FAQs

What clinical situation prompts urgent imaging in these patients?

Active upper aerodigestive tract bleeding can present as hemoptysis or hematemesis and threatens the airway, so it requires rapid contrast-enhanced CT or CT angiography to identify the hemorrhage source.

What is the “dot-in-sludge” sign on CECT or CTA?

It is a pattern of a “dot” of avidly enhancing extravasated contrast layered against a background “sludge” of non-enhancing debris within the lumen of the upper aerodigestive tract.

Which arteries are common sources of hemorrhage?

Common sources include the lingual, facial, and superior thyroidal arteries.

Sep 24, 2026

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