Head and Neck Flashcards
Helpful Videos
EUSTACHAIN TUBE DYSFUNCTION
https://www.youtube.com/watch?v=H29571Ex-kY
SALIVARY GLAND TUMOURS
https://www.youtube.com/watch?v=bQVlqTx18ds
Le Fort
LEFORT ONE (HORIZONTAL) Anterolateral margin of nasal fossa. Palate separated from maxilla 'floating palate'
LEFORT TWO (PYRAMIDAL) Inferior orbital rim and orbital floor. Maxilla separated from face 'pyramidal'
LEFORT THREE (TRANSVERSE) Zygomatic arch and lateral orbital rim. Face separated from cranium 'floating face'
All three types have fractured pterygoid plates
Mucocoele
If fracture disrupts frontal sinus outflow tract (nasal-orbital-ethmoid types) you can develop adhesions with obstruct sinus and result in mucocoele development
‘airless expanded sinus’
T1 bright with thin rim enhancement. Frontal sinus most common due to trauma
CSF leak
Fractures of facial bones, sinus walls and anterior skull base can all lead to CSF leak. Anterior skull base most common. Recurent bacterial meningitis is association
Temporal bone fractures
LONGITUDINAL Long axis of temporal bone (ear to apex) More common. More ossicular dislocation. Less facial nerve damage 20% More conductive hearing loss.
TRANSVERSE Short axis tempral bone (perpendicular) Less common. More vascular injury (carotid/jugular) More facial nerve damage >30% More sensorineural hearing loss
Facial bone fractures
Nasal bone most common.
ZMC fracture is most common pattern and involves zygoma, inferior orbit and lateral orbit.
Le Fort high yield (1 floating palate, 2 pyramidal, 3 floating face)
Temporal bone fractures longitudinal and transverse. Otic capsule violation is better predictive factor.
Ear divisions
EXTERNAL
Everything superficial to tympanic membrane
MIDDLE
Tympanic membrane to medial wall tympanic cavity.
Epitympanum (attic) is everything above tip of scutum
Hypotympanum everything below tympanic membrane
Mesotympanum inbetween
INNER
Everything deep to medial wall of tympanic cavity.
Scutum is a shield like osseous spur formed via lateral wall of tympanic cavity. Involved with cholesteatomas
Cholesteatoma
Exfoliated/dead skin growing in wrong place. Creates inflammation ball that wrecks temporal bone and ossicles.
Restrict diffusion, can erode scutum.
PARS FLACCIDA
Flimsy part of tympanic membrane is superior.
Acquired more common, grow into Prussaks space.
Scutum eroded early.
Malleus head displaced medially
Long process of incus most common segment of ossicular chain to be eroded
Fistula to semicircular canal most commonly involves lateral segment
PARS TENSA
Inner ear structures involved earlier and more often.
Less common than pars flaccida type.
Prussaks space and scutum erosion
PRUSSAKS SPACE
Superior to scutum between lateral wall and ossicle (incus).
Most common location of pars flaccida choleseatoma (incus most commonly eroded)
SCUTUM
Shield like bony protuberance superomedial to tympanic membrane. Eroded first.
Labyrinthine/perilymphatic fistula
Potential complication of cholesteatoma (or iatrogenic/trauma).
Bony defect creating abnormal communication between fluid filled inner ear and air filled tympanic cavity.
Lateral semicircular canal most often involved.
‘sudden fluctuating sensorinerual hearing loss and vertigo’
Want to see soft tissue cholesteatoma eating through otic capsule into semicircular canal. Air in semicircular canal (pneumolabyrinth) is difinitive evidence of fistula, though uncommon.
Otitis media OM
Effusion and infection of middle ear. More common in children and Downs due to more horizontal Eustachian tube. Chronic if >6 weeks
COMPLICATIONS
Coalescent mastoiditis (erosion mastoid septae)
Facial nerve palsy (inflammation tympanic segment)
Dural sinus thrombosis (then venous infarct or otitic hydrocephalus)
Meningitis or labyrinthitis
Chronic OM vs cholesteatoma
CHRONIC OTITIS MEDIA Poorly pneumatized mastoids Middle ear can completely opacify Thickened mucosa Erosions of ossicles rare No displacement ossicular chain
CHOLESTEATOMA Poorly pneumatized mastoids Middle ear can completely opacify Non-dependent mass Erosions of ossicles common Can displace ossicular chain
Labyrinthitis ossificans
History of childhood meningitis, kids 2-18months.
Classic on CT with ossification of membranous labyrinth.
Sensorineural hearing loss
Calcification of cochlea is often considered contraindication to cochlear implant.
LABYRINTH
Vestibule, cochlea and semicircular canals
Bony is the series of canals tunneled out of bone and membranous is soft tissue lining them. Membranous can then be divided into cochlear or vestibular labyrinths.
Labyrinthitis
Inflammation of membranous labyrinth, usually viral infection. Acute otomastoiditis can also spread directly to inner ear. Bacterial meningitis can cause bilateral labyrinthitis
Cochlea and semicircular canals will be enhancing
Facial nerve
Intracranial (cisternal)
Meatal (canalicular in IAC)
Labyrinthine (from IAC to geniculate ganglion)
Tympanic (from geniculate ganglion to pyramidal eminence)
Mastoid (from pyramidal eminence to stylomastoid foramen)
Extratemporal (SMF onwards)
NORMAL ENHANCEMENT
Tympanic and mastoid segments, sometimes labyrinthine
NO ENHANCEMENT
Cisternal, canalicular or extratemporal
ABNORMAL ENHANCEMENT
Bells Palsy (viral) in canalicular segment
Ramsay Hunt (reactivation zoster)
Think cancer if nodular enhancement
Otosclerosis/otospongiosis
Classic conductive hearing loss in adult female. Bone becomes more lytic
FENESTRAL
Bony resorption anterior to oval window at fissula antefenestrum. If not addressed, footplate will fuse to window.
RETROFENESTRAL
More severe form progressed to demineralization around cochlea. Usually has sensorineural component and is bilateral and symmetric nearly 100%
May treat with flouride. Later may need stapedectomy with implantation of prosthetic device, or a cochlear implant.
Superior semicircular canal dehiscence
Longstanding elevated ICP. Noise induce vertigo “Tullios phenomenon”.
See on CORONAL, absence of bony roof over superior semicircular canal.Goes through into middle cranial fossa
Large vestibular aqueduct syndrome
Vestibular aqueduct is a bony canal that connects inner ear to endolymphatic sac. Enlargement >1.5mm is aunt minnie. Progressive sensorineural hearing loss. Apparently failure of endolymphatic sac to resorb endolymph
Most common cause of congenital sensorineural hearing loss. Usually bilateral. Associated with cochlear deformity nearly 100%. Not born deaf, get progressive sensorineural hearing loss.
See AXIAL, should be same diameter as adjacent (lateral) posterior semicircular canal.
Congenital malformations of inner ear
Earlier things go wrong, more severe malformation.
MICHELS APLASIA
Earliest and most severe.
Complete labyrinthine aplasia (CLA). Absence of cochlea, vestibule and vestibular aqueduct. Completely deaf. Association with anencephaly and thalidomide exposure.
MONDINI MALFORMATION
Cochlear hypoplasia where basal turn is normal but middle and apical turns fuse into cystic apex. 1.5 turns instead of 2.5. Association with enlarged vestibule and enlarged vestibular aqueduct. Sensorineural hearing loss but high pitch is preserved.
Mondini vs Michels
MONDINI Happens later, 7th week. Preserved high frequency Cochlea shows cystic apex Vestibule enlarged Vestibular aqueduct enlarged Frequency common
MICHELS Early, 3rd week. Total deafness Cochlea, vestibule and VA absent. Very rare
Endolymphatic sac tumour
Rare. Most are sporadic, first think VHL.
Almost all have internal amorphous calcification. T2 bright and intensely enhance. Very vascular with flow voids and tumour blush on angiography.
Next to aperture of vestibular aqueduct.
Paraganglioma
Can invade occipital bone and adjacent petrous apex.
40% time hereditary and multiple.
Most common presenting symptom is hoarseness from vagal nerve compression.
Salt and pepper appearance. Enhance avidly.
FDG avid
Petrous apex anatomical variation
ASYMMETRIC MARROW
Typically contains fat. When asymmetric can trick into thinking there is a mass, or overlook a cholesteatoma. Use STIR or fat sat imaging.
CEPHALOCOELES
Herniation of CNS content through defect. In petrous apex this can be cystic expansion and herniation of posterolateral portion of Meckels cave into superomedial petros apex. Unilateral or bilateral (more common)
ABERRANT INTERNAL CAROTID
Pulsatile tinnatus. Cervical segment ICA has underdeveloped and middle ear collaterals develop (enlarged caroticotympanic artery). Runs through tympanic cavity and joins horizontal carotid canal. Vascular mass pulsating behind eardrum.
Petrous apex anatomical variation
APICAL PETROSITIS
Rare complication of infectious otomastoiditis. Can progress to osteomyelitis of skull base, vasospasm of ICA, subdural empyema, venous sinus thrombosis, temporal lobe stroke, and meningitis. Children it can be primary process, adults in setting of chronic otomastoiditis or recent mastoid surgery.
GRADENIGO SYNDROME
Complication of apical petrositis when Dorellos canal (CN6) is involved. Lateral rectus palsy. Dorellos canal is most medial point of petrous ridge between pontine cistern and cavernous sinus.
Otomastoiditis, trigeminal neuropathy and lateral rectus palsy
Petrous apex inflammatory lesions
CHOLESTEROL GRANULOMA
Most common primary petrous apex lesion. Obstruction of air cell with repeated cycles of haemorrhage and inflammation leading to expansion and bone remodelling. Symptom is hearing loss. CT margins sharply defined. T1 and T2 bright. T2 dark haemosiderin rim with faint peripheral enhancement.
CHOLESTEATOMA
Basically an epidermoid (ectopic epithelial tissue). Petrous apex ones are congenital. Slow growing and produce well smooth expansile bony change. T1 dark, T2 bright and restrict diffusion.
External ear
REGULAR AND NECROTIZING OTITIS EXTERNA
Usually bacterial of external auditory canal. Necrotizing/malignant form almost only in diabetics and is more aggressive. Swollen EAC soft tissues, bunch of small abscesses and adjacent bony destruction. Usually diabetics and infected with pseudomonas.
EXTERNAL AUDITORY CANAL EXOSTOSIS
‘Swimmers ear”. Overgrowth of soft tissue in ear canal, classically surfers with repeated bouts of ear infections. usually bilateral and when chronic looks like bone. These patients are immunocompetent and not diabetic,
EXTERNAL AUDITORY CANAL OSTEOMA
Overgrowth of normal bone. Usually incidental and unilateral occuring near junction of bone and cartilage in ear canal.
EXTERNAL AUDITORY CANAL ATRESIA
Developmental. External auditory canal doesnt form. May or may not be mashed up ossicular chain. Key is whether tissue covering the area normally open is soft tissue or bone (atretic plate). Also need to know if there is aberrant course of facial nerve.
Pagets
Can have osteolysis circumscripta which is well defined large radiolucent region favoring frontal and occipital bones. Both inner and outer table involved.
Pagets skull related complications: Deafness Cranial nerve paralysis Basilar invagination to hydrocephalus to brainstem compression Secondary osteosarcoma
Chordoma and Chondrosarcoma
Midline and off midline - discussed in MSK
Fibrous Dysplasia
Ground glass. Can look similiar to Pagets but FD is young <30 and Pagets older.
Fibrous dysplasia spares otic capsule classically
McCune Albright syndrome is multifocal FD, cafe au lait spots and precocious puberty
Outer table favoured
Sinus disease strategy
CT for anterior 2/3 orbit. MRI for posterior 1/3 and cavernous sinus.
CT useful for characterization of anatomical variation, MRI for tumour progression/extension/PNI/marrow involvement
Fungal sinusitis
ALLERGIC FUNGAL SINUSITIS
Opacification of multiple sinuses, usually bilateral favouring ethmoid/maxillary.
Normal immune system (asthma common)
CT hyperdense centrally or with layers. Can erode and remodel sinus walls when chronic.
MRI T1 and T2 dark, high protein and heavy metals. Can mimic aerated sinus. Inflammed enhancing mucosa.
ACUTE INVASIVE FUNGAL SINUSITIS
Opacificaiton of multiple sinuses.
Stranding/extension into fat around sinuses is key.
Immunocompromised. Apergillus or Zygomycetes
CT opacified sinus not hyperdense. Fat stranding in orbit, masticator fat, pre antral fat or PPF suggests invasion. Does not require bone destruction
MRIT1 and T2 dark, mucosa doesnt enhance. Extension of disease out of sinus will be bright on STIR and enhance
Chronic inflammatory sinonasal disease
Inflammation of paranasal sinuses lasting at least 12 weeks. Issue is primarily anatomical patency of sinus ostia
See p254 vol 2 yellow book
INFUNDIBULAR PATTERN
Most common. Disease limited to maxillary sinus and occurs from obstruction at ipsilateral ostium/infundibulum
OSTIOMEATAL UNIT PATTERN
Second most common. Centred at middle meatus with disease involving ipsilateral maxillary, frontal and ethmoid sinuses. Contributors are: hypertrophied turbinates, anatomic variants, concha bullosa, middle turbinates curling wrong way, septal deviation.
SINONASAL POLYPOSIS PATTERN
Combination of soft tissue nasal polyps and variable degrees of sinus opacification. Fluids levels can be present. Bony remodelling and erosion are key. Widening of infundibula. Need to differentiate between erosion/remodelling and expansion (mucocoele). Associations are CF and aspirin sensitivity.
MUCOCOELE
Obstructed sinus. May have had prior trauma. May have CF with secretions clogging things up. Mucus accumulates, sinus becomes completely filled and starts to expand. buzzword is expanded airless sinus. Frontal sinus most common. Periphery may enhance.
Antrochoanal polyp
Young adults 30-40. Presents with congestion/obstruction. Arises within maxillary sinuses and passes through and enlarges sinus ostium.
Buzzword widening of maxillary ostium. Smooth enlargement of the sinus with no bony destruction.Polyp will extend into nasopharynx. Monster inflammatory polyp
Juvenile Nasal Angiofibroma JNA
Male teenager with nose bleeds.
Centred in sphenopalatine foramen. Bony remodelling (not destruction). Very vascular and enhancing with intratumoral flow voids on MRI.
Presugical embolization common via internal maxillary and ascending pharyngeal artery.
Maxillary sinus in front smaller due to bony remodelling.
Inverted papilloma
Uncommon tumour. Lateral wall of nasal cavity most frequently related to middle turbinate. Impaired maxillary drainage expected.
Focal hyperostosis occurs at tumour origin. 10% harbour a squamous cell Ca.
Cerebriform pattern.
Enthesioneuroblastoma
Neuroblastoma of olfactory cells, starts at cribriform plate. Dumbbell appearance with growth up into skull and down into sinuses with a waist at the plate. Often cysts in mass. Bimodal age distribution.
Dumbbell shape
Intracranial posterior cyst classic
octreotide scan positive - neural crest origin
Squamous cell/SNUC (sinonasal undifferentiated carcinoma)
Squamous cell is most common tumour head and neck. Maxillary antrum is most common location. Highly cellular, low T2. Relative to other sinus masses it enhances less. SNUC is monster version of regular squamous cell.
Epistaxis
Usually idiopathic though can be iatrogenic. Could be in setting of HHT (hereditary haemorrhagic telangiectasia). also called osler weber rendu).
Anterior septal area (Kiesselbach plexus) is most common and can be compressed manually. Posterior ones are less common but bleed more. Main supply posterior nose is sphenopalatine artery (terminal internal maxillary artery) and tends to be first target. Watch out for variant anatomy between ECA and ophthalmic artery.
Nasal septal perforation
Typically involves anterior septal cartilagenous area.
Surgery (Killian submucous resection) Cocaine use Too much nose picking Granulomatosis with polyangitis (Wegeners) which is renal masses, sinus mucosal thickening and nasal septal erosion and cavitatory lung nodules/fibrosis. cANCA positive. Syphillis
Sialolithiasis
Stones in salivary duct, most commonly submandibular gland duct (Whartons). Can lead to infected gland “sialoadenitis” and chronic obstruction which can lead to fatty atrophy.
Submandibular - Whartons duct
Parotid - Stensons duct
Sublingual - Rivinus duct
Odontogenic infection
Can be dental or periodontal in origin. More common from an extracted tooth than an abscess involving an intact tooth.
Attachment of mylohyoid muscle to mylohyoid ridge dictates spread of infection to sublingual and submandibular spaces. Above mylohyoid line (anterior mandibular teeth) goes to sublingual space. Below mylohyoid line (posterior mandibular teeth) goes to submandibular space.
Odontogenic abscess is most common masticator space mass in adult.
Ludwigs angina
Aggressive cellulitis in floor of mouth, will be shown with gas in tissues. Most cases start with odontogenic infection
Torus palatinus
Normal variant. Bony exostosis arising from hard palate in midline.
Osteonecrosis of Mandible
Related to prior radiation or bisphophanate treatment.
Ranula
Mucous retention cyst, typically lateral. Arise from sublingual space and are termed plunging if under mylohyoid muscle
Thyroglossal duct cyst
Anywhere between foramen cecum and thyroid gland. Usually in midline. Thin walled cyst.
Floor of mouth dermoid/epidermoid
Buzzword is ‘sack of marbles’ fluid sack with globules of fat. Typically midline
Cancer in mouth
Squamous cell most common in mouth. think drinker/smoker. In young person think HPV, usually with large necrotic level 2 node.
Periapical (radicular) cyst
Most common type. Result of inflammation of dental caries. Cystic degeneration around periodontal ligament.
Apex of non vital tooth.
Round with well corticated border.
Usually <2cm.
Dentigerous (follicular) cyst
Cyst around crown of unerupted tooth. Developmental cyst. Displaces and absorbs adjacent teeth. Can displace tooth into condylar regions or into floor of orbit
Keratogenic odontogenic tumour (odontogenic keratocyst)
Occur at mandibular ramus or body. Classic is multilocular.
Body/ramus Grow along length of bone No significant cortical expansion May have daughter cysts When multiple think Gorlin syndrome
Ameloblastoma (adamantinoma of jaw)
Locally aggressive. Multicystic with solid components and expansion of the mandible. "soap bubbles" Extensive tooth resorption. Mandibular expansion Solid component 5% arise from dentigerous cysts
Odontoma
Start out lucent. Most common odontogenic tumour of mandible. Tooth hamartoma.
Radiodense with lucent rim.
Can be large with fluffy calcifications.
Parotid space
Parotid gland
Portions of facial nerve
Retromandibular vein
Parotid gland only salivary gland to have lymph nodes
Parotid space pathology
PLEOMORPHIC ADENOMA
Most common salivary gland tumour. Usually in parotid and usually in superficial lobe. T2 bright. Small malignant potential. Superficial vs deep lobe is important for surgical approach. Benign mixed tumour.
WARTHINS
Second most common benign tumour. ONLY occurs in parotid. Cystic, male smoker, bilateral (15%). Takes up pertechnate.
MUCOEPIDERMOID CARCINOMA
Most common malignant tumour of minor salivary glands. Smaller the gland, more common the malignant tumour. Association with radiation
ADENOID CYSTIC CARCINOMA
Malignant salivary gland tumour that favours small but can be in large glands. Perineural spread.
Parotid space pathology continued
LYMPHOMA
Parotid is only salivary gland with lymph nodes, therefore can get lymphoma. If bilateral, think Sjogrens. Bilateral homogenous masses.
SJOGRENS
Autoimmune lymphocyte induced destruction of gland. Dry eyes and dry mouth. Typically women in 60s. Raised risk of Non-Hodgkins MALT lymphoma. Honeycombed appearance to gland
BENIGN LYMPHOEPITHELIAL DISEASE
Bilateral mixed solid and cystic lesions with diffusely enlarged parotids. Seen in HIV. Painless
ACUTE PAROTITIS
Obstruction of flow of secretions most common. Stone in Stensens duct which will be dilated. Stones are calcium phosphate. Post infectious parotitis usually bacterial. Mumps most common viral.
Parapharyngeal space
Mostly just fat with some branches of trigeminal nerve and pterygoid veins
Primary utility is when its displaced. Mets and infection can spread through in vertical direction (squamous from tonsils, tongue and larynx). Cystic mass could be branchial cleft cyst but more likely necrotic level 2 lymph node.
Posterior is carotid space
Lateral is parotid space
Superficial mucosal space is medial
Carotid space
Carotid artery
Jugular vein
Portions of CN9, 10 and 11
Internal jugular chain LNs
paragangliomas, schwannomas, neurofibromas, secondary spread of aggressive multispatial disease or malignant spread.
Paragangliomas
Hypervascular (intense tumour blush).
Salt and pepper on MRI - flow voids
Can be multiple and bilateral in familial conditions
In-Octreotide accumulates in these tumours
CAROTID BODY TUMOUR
Splaying ICA and ECA at carotid bifurcation
GLOMUS JUGULARE
Skull base often with destruction of jugular foramen.
GLOMUS VAGALE
Above carotid bifurcation but below jugular foramen.
GLOMUS TYMPANICUM
Confined to middle ear overlying cochlear promontory.
Schwannoma
Most commonly vagal nerve CN10 but if lesion is high up near skull base it could be involving 9, 11 or 12. Oval mass with heterogenous bright T2.
Enhance a lot. NF2 association
Neurofibroma
Less common than schwannoma. 10% of time related to NF1 in which case they may be multiple and bilateral.
Neck infection syndromes
LEMIERRES SYNDROME
Thrombophlebitis of jugular veins with septic emboli in lung. In setting of oropharyngeal infection or recent ENT surgery. Fusobacterium necrophorum
GRISELS SYNDROME
Torticollis with atlantoaxial joint inflammation seen in ENT surgery or retropharyngeal abscess
Masticator space
Muscles of mastication (masticator, temporalis, medial and lateral pterygoids)
Ramus of mandible and inferior alveolar nerve.
Extends superiorly along side of skull via temporalis muscle so infection can go right up there.
Masticator space pathology
ODONTOGENIC INFECTION
Most common cause of masticator space mass. Look at mandible on bone windows. Look out for spread via pterygopalatine fossa to orbital apex and cavernous sinus
SARCOMAS
Rhabdomyosarcomas in kids. Can get sarcoma from mandible or chondrosarcoma which favors the TMJ.
CAVERNOUS HEMANGIOMA
Given away by presence of phleboliths. Venous or lymphatic malformations may involve multiple compartments/spaces. Congenital/aggressive infection/cancer tend to be multispatial
PERINEURAL SPREAD
Can have spread along V3 of trigeminal. Should think either adenoid cystic or melanoma.
NERVE SHEATH TUMOUR
Can have schwannoma or neurofibroma of V3.
Retropharyngeal and Danger spaces
Midline space deep to oro and nasopharynx. Retropharyngeal space is anterior and true space which extends to C6/7. Posterior danger space extends to mediastinum. The two are separated by alar fascia.
Behind both is the prevetebral space where thinks like discitis/osteomyelitis go
Retropharyngeal and Danger spaces
INFECTION
Usually spread from tonsillar tissue. Central low density tissue and stranding in the space. Evaluate for spread into mediastinum. Delays critical to distinguish phlegmon from abscess.
NECROTIC NODES
Nodes of Rouviere. Located in lateral retropharyngeal region. Kids get suppurative infection in these but start to regress around age 4 with adults much less likely to get infection here. Can get mets or lymphoma here
Lymph node anatomy
Anterior belly digastric separates 1A from 1B.
Stylohyoid muscle separates 1B from 2A
Jugular vein separates 2A from 2B
VERTICAL BORDERS
2-3 is lower hyoid
3-4 lower cricoid
5A-5B lower cricoid, both posterior to SCM
6 is anterior and inferior to lower border cricoid
7 is upper mediastinal
Floor of mouth SCC
Smoker/drinker in old person, HPV in young person.
Necrotic level 2 nodes.
Nasopharyngeal SCC
Fossa of Rosenmuller is most common location
More common in Asians
Bimodal distribution (15-30 and >40)
Involvement of the parapharyngeal space results in worse prognosis
Unilateral mastoid effusion or pathological retropharyngeal LN check Fossa of Rosunmuller
Pathological retropharyngeal LN or supraclavicular LN chek clivus as 30% patients with nasopharyngeal tumours may have skull base erosion
Laryngocoele
When laryngeal saccule dilates with air you call it a laryngocoele. If filled with fluid it may still be laryngocoele but can now call it a saccular cyst. Saccule is appendix of laryngeal ventricle. Typically closed and not seen in adults.
Can dilate if obstructed (ball valve mechanics) and testable point is 15% time obstruction is a tumour. Can see in forceful blowers like trumptet players and glass blowers.
Internal and external version based on containment of violation of thyrohyoid membrane
Vocal cord paralysis
involved side will have expanded ventricle. If seen on left, look into chest for recurrent laryngeal nerve compression at AP window. Hoarseness is buzzword.
Laryngeal cancer
85% squamous cell.
RISK FACTORS
Smoking, alcohol, radiation, laryngeal keratosis, HPV, GORD.
SUPRAGLOTTIC
More aggressive, early LN mets, dont get hoarseness.
Epiglottic centered - anterior, likes to invade pre-epiglottic space/fat
False cord centered - posterolateral, likes to invade paraglottic space
Aryepiglottic fold mass
GLOTTIC
Most common, best outcome, grows slowly, late metastatic disease.
Usually involve anterior cord and spread to anterior commisure
Progressive and continuous hoarseness
SUBGLOTTIC
Least common, often small compared to nodal burden. Bilateral nodal disease and mediastinal extension.
Retinoblastoma
Most common primary malignancy of globe. Calcification in globe of child.
RB suppressor gene c13. Same chromosome osteosarcoma patients get so at risk of these after radiation.
Globe should be normal in size or slightly bigger (Coats disease its smaller). Usually seen before age 3.
Bilateral both eyes
Trilateral both eyes and pineal gland
Quadrilateral both eyes, pineal gland and suprasellar
Coats disease
Retinal telengiectasia resulting in leaky blood and subretinal exudate. Can lead to retinal detachment. Young boys, typically unilateral. NOT CALCIFIED
Persistent Hyperplastic Primary Vitreous (PHPV)
Failure of embryonic occular blood supply to regress. Can lead to retinal detachment. Small eye (microphthalmia) with increased density of vitreous. No calcification
Retinal detachment
Can be secondary to PHPV or Coats. Can also be just from trauma, sickle cell or old age. See V or Y shape due to uplifted retinal leaves.
Globe size comparison
Retinoblastoma - normal Toxocariasis - normal PHPV - small size (normal birth age) Coats - small Retinopathy of prematurity - bilaterally small
Melonoma
Most common intra-occular lesion in an adult. Enhancing soft tissue mass in back of an adults eye. “collar button shaped”. Strong predilection for liver mets.
Optic nerve glioma
90% under age 20. Expansion/enlargement of entire nerve. If bilateral think NF1. Usually pilocytic astrocytoma WHO1
Optic nerve sheath meningioma
Tram track calcifications. Doughnut appearance on coronal. Circumferential enhancement around nerve
Dermoid
Most common benign congenital orbital mass. Superior and lateral usually, arising from frontozygomatic suture and presenting <10yo. Has fat in it
Rhabdomyosarcoma
Most common extraoccular malignancy in children.Superior medial orbit and classicaly has bone destruction. Bulky orbital mass in a 7 year old. Rare
Lymphoma
Association with chlamydia psittaci (bird fever). and MALT lymphoma of orbit. usually involves upper outer orbit closely associated with lacrimal gland. Enhance homogenously and restrict diffusion.
Metastatic neuroblastoma
Raccoon eyes o/e. Periorbital tumour infiltration with proptosis. Bony involvement of greater wing of sphenoid. Usually bilateral.
Metastatic scirrhous breast cancer
Breast cancer met has desmoplastic reaction and enophthalmos
IgG4 in orbit
ORBITAL PSEUDOTUMOUR
Idiopathic inflammatory conditions involving extraoccular muscles. Looks like expanded muscle. Painful and unilateral, most commonly involves lateral rectus and does not spare myotendinous junctions. Give steroids
TOLOSA HUNT
Same thing as orbital pseudotumour but in cavernous sinus. Painful and presents with multiple cranial nerve palsies. Give steroids.
LYMPHOCYTIC HYPOPHYSITIS
Same as above but in pituitary. Enlarged pituitary stalk in postpartum/3rd trimester woman.
Thyroid orbitopathy
Seen in 1/4 of graves disease, most common cause of exophthalmos. Antibodies hat activate TSH receptors also activate orbital fibroblasts and adipocytes.
Risk of compressive optic neuropathy. Enlargement of only muscle belly (spares tendon). NOT painful. Order of involvement IMSLO
Orbital vascular malformations
LYMPHANGIOMA
Mix of venous and lymphatic malformations. Ill defined, lack a capsule. Multispatial and infiltrative. Preseptal, postseptal, extraconal and intraconal.
Fluid-Fluid levels. Do NOT distend with provocative maneuvers.
VARIX
Secondary to weakness in post capillary venous wall. Massive dilatation of valveless orbital vein. Disetent with provocative maneuvers. Most common cause of spontaneous orbital haemorrhage. Can thrombose and present with pain
CCAROTID CAVERNOUS FISTULA Direct is from trauma and indirect occurs randomly in postmenopausal women. Direct is a communication between intracavernous ICA and cavernous sinus. Indirect kind usually dural shunt between meningeal branches of ECA and cavernous sinus. Pulsatile exophthalmos (this can also be for NF1 with sphenoid wing dysplasia though)
Pre-septal/post-septal cellulitis
Orbital cellulitis is post septal
Periorbital cellulitis is preseptal
Orbital septum originates from periosteum of the orbit and inserts in the palpebral tissue along tarsal plate. Preseptal infections start in adjacent structures. Post septal infections usually from paranasal sinusitis. preseptal infections treated medically, post septal is surgical
Periorbital abscess can cause thrombosis of ophthalmic veins or cavernous sinus. In extreme cases, usualy aspergillosus, can cause carotid/cavernous fistula
Dacrocystitis
Inflammation and dilatation of lacrimal sac. Well circumscribed round rim enhancing lesion centered in lacrimal fossa. Typically from obstruction followed by bacterial infection (staph or strep). Usually diagnosed clinically unless there is an associated periorbital cellulitis in which case CT needed to exclude postseptal infection from simple dacrocystitis.
Orbital subperiosteal abscess.
Inflammation under periosteum which can progress to abscess formation. Usually associated with ethmoid sinusitis. Classic look.
Optic neuritis
Will be enhancement of the optic nerve without enlargement of the nerve/sheath complex. Usually 70% unilateral and painful. Often see intracrnial or spinal cord demyelination in setting of Devics (neuomyelitis optica). 50% patients with acute optic neuritis will develop MS
Papilledema
Can see dilatation/swelling of optic nerve sheath.
DRUSEN
Mineralization at optic disc. Association with age related maculopathy.
INTRAOCULAR LENS IMPLANT
Standard treatment for cataracts. Replaced lens has thin linear appearance.
ECTOPIA LENTIS (LENS DISLOCATION) Causes include trauma, marfans and homocystenuria
Coloboma
Focal discontinuity of globe (failure of choroid fissure to close). Usually posterior. If you see bilateral ones, think CHARGE syndrome
Odontoid fracture classification
TYPE 1
Rare, upper part of odontoid as result of avulsion of alar ligament. May be stable
TYPE 2
Fracture at base. High non-union rate. Unstable
TYPE 3
Fracture through dens into the body of C2. Unstable
Jefferson fracture
Axial loading injury. Anterior and posterior arches blow out laterally. 30% will also have a C2 fracture. Cord damage rare as all force directed into bones. Open mouth view will show slipping of lateral masses.
Os odontoideum/Os terminale
These variants can mimc a type 1 dens fracture. Ossicle located at the position of the odontoid tip. With os odontoideum, base of dens is hypoplastic.
Prone to sublaxation and instability. Associate with Morquios syndrome. Orthotopic position atop dens. Dystopic when fused to clivus.
Hangmans fracture
Seen usually when chin hits dashboard in MVA (direct blow to face). Fracture through bilateral pars at C2. ANterior subluxation of C2 on C3. Cord damage uncommon as acquired aprs defect allows for canal widening. Associated fracture at anterior/inferior corner of C2 from avulsion of ALL.
Teardrop flexion vs extension
FLEXION Teardrop shaped fracture fragment at inferior/anterior vertebral body. Bad as 85% will have anterior cord syndrome associated. Unstable fracture associated with posterior subluxtion of vertebral body Impaction injury Extremely unstable hyperflexion "ran into wall"
EXTENSION
Anterior inferior teardrop shaped fragment with avulsion of ALL. Less serious
Distraction injury
Stable in flexion (unstable in extension)
Hyperextension
“hit from behind”
Clay shovellers fracture
Avulsion injury of lower cervical/upper thoracic spinous process (usually C7). Forceful hyperflexion.
Chance fracture
Flexion distraction fractures classically associated with lap band seatbelt. These are3 column unstable fractures. Usually at upper lumbar and thoracolumbar junction. High association with solid organ trauma
Facet dislocation
Spectrum: subluxed - perched - locked
UNILATERAL
Usually from hyperflexion and rotation. Superior facet slides over inferior facet and gets locked. Unilateral is stable injury. Inverted hamburger sign on axial.
BILATERAL
Severe hyperflexion. Disruption of PLL. Dislocated vertebra displaced forward half AP diameter. Highly unstable and strongly associated with cord injury
Atlantoaxial instability
Transverse cruciform ligament straps dens to anterior arch of C1. Distance between anterior arch and dens shouldnt be >5mm. Association with Downs and JRA
Rotatory subluxation can occur in kids without fracture stuck in cock robin position. Looks like torticollis. Cannot happen in absence of fracture in adult.
Pars Interarticularis defects
Spondylolysis or adult isthmic spondylolisthesis.
Caused by repetitive microtrauma related to hyperextension. Nearly always at L5/S1 90%. Typically pain is L5 radiculopathy caused by foraminal stenosis at L5S1.
Occipitocervical instability
Can be traumatic or congenital (seen in Downs). two popular methods for evaluating this, Powers ration and Harris Lines rule of 12.
Denis 3 spinal column concept
Vertebral column divided into 3 vertical parallel columns. Instability suggested when all 3 or 2 contiguous columns are disrupted.
Anterior column: ALL, ant 2/3 body
Middle column: post 1/3 body and PLL
Posterior column: posterior ligaments, pedicles, factes, lamina, spinous processes
Canadian C spine rules
Age >65 Parasthesias in extremities Dangerous mechanism Fall >3ft or 5 stairs Axial load to head High speed MVA Pedestrian vs car
Nexus criteria
Focal neurological deficit Midline spinal tenderness Altered level of consciousness Intoxication Distracting injury
Unstable
Vertebral overriding >3mm Angulation >11 degrees Flexion tear drop Bilateral locked facets Odontoid fracture types 2 and 3 Two contiguous column fractures or 3 column Jeffersons Hangmans Atlanto-occipital and atlantoaxial dislocations
Stable
Extension tear drop in flexion Unilateral locked facet Odontoid fracture type 1 Single column vertebral fracture Clay shovelers Transverse process fracture
Spinal cord syndromes
CENTRAL CORD
Old lady with spondylosis or young person with bad extension injury
Upper extremity deficit worse than lower
ANTERIOR CORD
Flexion injury. Immediate paralysis. Anterior cord damaged. Motor function and anterior column sensation (pain and temperature) gone. Dorsal column (vibration and proprioception) still intact.
BROWN SEQUARD
Rotation injury or penetrating trauma
One side motor, other side sensory deficits
POSTERIOR CORD
Uncommon but can be seen in hyperextension.
Proprioception gone
AVFs/AVMs
TYPE 1
By far most common 85%. Dural AVF
Resukt of fistula between dorsal radiculomedullary arteries and radiculomedullary vein/coronal sinus with the dural nerve sleeve. Acquired and seen in old patients with progressive radiculomyopathy. Most common location thoracic spine. Gold standard is angiography. Swollen cord with high T2 signalin central cord with serpentine perimedullary flow voids
TYPE 2
Intramedullary nidus from ant spinal artery or post spinal artery. Can have aneurysms and can bleed. Mos common rpesentation SAH. Associated with HHT and KTS
TYPE 3
Juvenile, very rare, complex, bad prognosis
TYPE 4
Intradural perimedullary with subtypes depending on arterial supply. Near conus
Foix Alajouanine syndrome
Congestive mylopathy associated with dural AVF. 45m with lwoer extremity weakness and sensory deficits. Increased T2 signal conus or lower T spine with associated prominent vessels. Venous HTN due to vascular malformation
