Head and Neck Flashcards
Cholesterol granuloma
Smooth expansile, well marginated petrous apex lesion
High T1 and T2
Doesnt suppress fat
No diffusion restriciton
Cholesteatoma
Petrous apex lesion with smooth expansile bony changes
low T1, high T2
without central parenchymal enhancement restrict diffusions
Smooth lobulated cystic expansion of the petrous apex ?
Cephalocele
-Hernation of CNS through defect in cranium.
-In petroux apex, no brain tissue, just CSF/cystic, herniation from meckels cave into the petrous apex
Acute (children) or chronic suppurative otomastoiditis (adults) infection spreads via mastoid air cells or venous channels to Apical petrous. What is complication ‘Grendengio’ syndrome?
Grendengio triad of symptoms
Acute OM
deep facial pain (CNV),
lateral rectus palsy (CNVI)
Cortical erosion on CT
MRI enhancement of of PA, adjacent structures - clivus, dura, IAC, carotid canal
Complication - ICA narrowing ICA/vasospasm, subdural empyema, menigitis, venous sinus thrombosis
Permeative bone destruction of the posterior petrous ridge. T2 Bright and intense enhancement. lesion extending into the CPA?
Endolymphatic sac tumour
**Strongly associated with VHL **
Very vascular often with flow voids.
Retrolabyrinthine: Posteromedial T-bone
Large lesions can involve the CPA cistern, middle ear/mastoid, & jugular foramen
Bone CT: Central intratumoral bone spicules & posterior rim Ca⁺⁺
MR: High-signal foci on unenhanced T1 (haemorrhage and cholesterol). Heterogenous enhancement
Other lesion cause for permeative destruction of petrous apex?
- Paraganglioma of Glomus Jugulare
Invade the occipital bone/jugular foramen first . Jugular spine eroded
Then spread superolateral to PA and middle ear.
T1
“Salt” refers to hyperintense foci within tumor related to hemorrhage or slow flow.
= Hyperintense foci (quite rare)
+
“Pepper” refers to numerous hypointense foci within tumor, representing high-velocity arterial flow voids
=Hypointense foci common
T1+ C = intense enhancment
Sharply marginated, enlarged JF on bone CT
Fusiform, enhancing mass enlarging JF on T1WI C+ MR?
Jugular Foramen Schwannoma
NO Flow voids
Cranial nerve palsy of 9,10,11 (Vernet syndrome)
Permeative-sclerotic involvement of bone around JF on CT
Enhancing JF mass spreading centrifugally along dural surfaces on enhanced MR
Jugular Foramen Meningioma
permeative** sclerotic** changes along the JF and lateral clivus
Extend into middle ear, jugular tubercle marrow space and nternal auditory canal
Progressive sensorineural hearing loss. CT shows enlarged vestibular aqueduct?
Large vestibular aqueduct syndrome - aka Pendred syndrome
Commonest cause congenital sensorineural hearing loss
Axials - The vestibular aqueduct is never larger than the adjacent posterior semicircular canal
Tinnitus and hearing loss after meningitis in child ?
Labyrinthitis ossificans
ossification of membranous labyrinth
Conductive hearling loss in an adult female?
Otosclerosis
Temporal bone CT: Lucent (otospongiotic) foci involving bony labyrinth
Usually in context of normally aerated middle ear
Difference between pars flaccida and pars tensa cholesteatoma?
.Par flaccida -
-superior part of the tympanic membrane.
-erodes the scutum and filling/extends into Prusak space and Tegman tympani (roof)
-**Medial displacement of the head of the malleus **
- Labyrinth fistula - into the lateral semi-circular canal
- long process of incus erosion is common
Pars Tensa
-Less common
**-Often congenital **
- Inferior tympanic membrane
- erodes ossicles, invades and flattens the tympanic CNVII canal, and is primarily medial to the ossicles
- More common in children.
- -often intact tympanic membrane
Noise induced vertigo?
Dehiscence of the superior semi-circular canal
What segment of the Facial nerve do not normally enhance?
Cisternal, canalicular and labyrinthine segement should NOT enhance.
**The infratemporal course (tympanic and mastoid) does enhance **
abnormal enhancement in bells, lymes, ramsay-hunt and malignancy.
Bells = LABYRINTHE
Damaged in = Transverse Temporal # > longitudinal’
Features of pagets disease of the skull?
- Well defined and sharp margin of radiolucency affecting the frontal and occipital bones = OSTEOLYSIS CIRCUMSRIPTA
- Thickened and expanded sclerotic skull.
OLD person 80s
Pagets skull related complications ?
**Deafness
Cranial nerve paresis
Basilar invagination = hydrocephalus = brainstem compression
Secondary High grade osteosarcoma
Young 20-year-old with lytic skull lesion with ground glass appearance?
Fibrous dysplasia
Spares the optic capsule - no hearing issues
**McCune-Albirght syndrome = **
Multi-focal fibrous dysplasia, cafe-au-lait spots and precocious puberty
Teenage male with nose bleeds. Mass centred in the sphenopalatine foramen and extends into the pterygopalatine fossa?
Juveline nasal angiofibroma
Very vascular.
Blood supply from the ascending pharyngeal artery and or internal maxillary artery.
Not IR. 80% cured by radiation!
Adult 30-40s with nasal obstrictive symptoms. large solitary opacification extending into the nasal cavity from the maxillary sinus with widening of the maxillary antrum?
Antrochoanal polyp
effectively a large solitary sinonasal polyp
**No bone destruction, smooth enlargement of the sinus. ** ‘Dumbell shape’
Peripheral enhancement.
Water signal on CT/MRI
Sinus mass arising from the lateral wall of middle meatus, with extension into the antrum?
Inverting Papilloma
Cerebriform pattern of enhancement on MRI.
Focal hyperostosis on CT suggests tumour origin/stalk,
Destruction of the medial wall of the maxillary sinus
Trapped sectrions
10% harbour a SCC
Soft tissue mass in the maxillary antrum with destruction of the sinus walls?
SCC
Can extend into orbits, brain etc
Decreases T2 signal relative to other sinus pathologies = hypercellular
maxillary antrum is involved in 80% of cases
Note Sinonasal Adenocarcinoma - predilection for ethmoid sinus and enhances more.
Impossible to distinguish from SNUC
20 year old Dumbbell shaped mass with waist at the cribriform plate , with upper portion in the anterior cranial fossa and lower portion in the upper nasal cavity?
Esthesioneuroblastoma
Bimodal -m20s or 60s
Avid homogenous enhancement
Somatostatin positive = uptake on octeride scan
Heterogenous sinonasal mass with bone destruction & rapid growth
Sinonasal undifferenced carcinoma (SNUC)
Very aggressive. at least 4cm at presentation.
Ethmoid origin more common that maxillary
Homogeneous soft tissue mass with predilection for nasal cavity, bone destruction and low signal on T2?
Sinonasal lymphoma
Also low on T2 and bone destruction like SCC but = Nasal cavity
SCC = Maxillary antrum
Very nonspecific imaging features
can mimic variety of neoplasms & aggressive inflammatory disorders
well circumscribed midline mass in the floor of the oral cavity predominantly of flood density with intralesional fat density cysts?
Floor of mouth dermoid
‘sack of marbles’
Epidermoid will ne homogenous fluid signal
Simple well-defined thin walled cyst in the sublingual space?
Rannula
Thin-walled SMS cyst with SLS tail = Diving rannula
Crossed mylohyoid
Which duct/gland sialolithiasis commonly affects?
Whartons duct/submandibular gland
Young adult with new level 2a neck mass?
HPV related SCC
HPV-positive OPSCC can have **small primary tumours but large and often cystic-appearing nodal metastases
**
The US appearances of the nodal involvement in level 2 can mimic 2nd brachial cleft cyst
Most common location for ectopic thyroid tissue?
Tongue base - ‘Lingual thyroid’
Will be hyperdense like thyroid.
Anterior midline suprahyoid or midline/paramidline infrahyoid cystic neck mass?
Thyroglossal cyst
wall enhancement and soft tissue stranding = infected
Nodularity or Ca2+ suggests papillary carcinoma
Which thyroid goitre is at risk of developing primary thyroid lymphoma?
Hashimotos
low on tech-99m
Which thyroid goitre has significant increased radioactive iodine uptake?
Graves disease
50-80%. Visualisation if the pyramidal lobe is accentuated on nuclear medicine.
De Quervain’s/subacute thyroitis uptake is decreased
Acute suppurative thyroidits in a child, what is the mechanism?
Infection starts in the 4th Brachial cleft anomaly and travels/fistula via the pyriform sinus into the thyroid gland (usually left)
Thin-walled thyroid cysts with multiple echogenic foci and comet-tail artifacts?
Colloid cyst
Suspicious features
-Microcalcifications
- increased vascularity
- larger than 1.5cm
Thyroid cancer with macrocalcifications?
Papillary
Most common (P for Popular)
**Mets via lymphatics - Calcification in a node!!!
**
Good prognosis and responds well to iodine therapy
Second most common thyroid cancer?
Follicular
Spread/Mets haematogenously to bone, lung, liver etc
Survival is ok. Responds to iodine therapy
Hurthle cell type = seen in elderly and doesn’t not take up iodine as well as follicular.
Uncommon thyroid cancer associated with MEN 2 syndrome?
Medullary
Local invasion , lymph and haematogenous spread.
CALCIFIED LYMPH NODES
DOESNT respond to iodine
Elevated Calcitonin
Thyroid cancer seen in elderly ?
Anaplastic
Uncommon and undifferentiated
Rapid growth and lymphatic spread
DOESNT respond to iodine
Causes of hyperparathyroidism?
Hyperfunctioning adenoma (90%)
Multi-gland hyperplasia (8-10)
Cancer (1-3)
CT parathyroid adenoma shows early arterial enhancement with delayed washout.
Can’t differentiate from cancer - look for cervical adenopathy
Contents of the parotid gland?
Parotid gland
Facial nerve
Retromandibular vein
Sharply marginated, intraparotid ovoid mass with uniform enhancement. Very bright T2 signal ?
Pleomorphic adenoma/Parotid Benign Mixed Tumor
Small < 2cm - well defined
Large > 2cm - Lobulated
90% arise in superficial lobe.
Nb ‘pear shaped’ when arising from the deep lobe
Most common benign/any major and minor salivary gland tumour.
Can occur in SM and SL glands.
but parotid 90%
differentiate from a partoid warthins
- Pleomorphic adenoma can have CALCIFICATION
Second most common benign tumour in parotid gland?
Warthin
Only occur in parotid gland.
Usually solid/cystic, male and smoker. Bilateral (15%)
Two malignant tumours that favour the minor salivary glands?
Adenoid cystic carcinoma (ACCa)
-Strong propensity for perineural spread
-Tends to hematogenous spread to lungs
-Slow-growing; may metastasize many years later
- Most common malignant tumour of submandibular gland
Mucoepidermoid carcinoma (MECa)
-Tends to spread to lymph nodes
-Most common malignant tumour of parotid gland
What is the relationship between sjorgens and parotid lymphoma?
Sjorgens has a 100X risk of primary NH MALT type lyphoma of the parotid gland.
If bilateral homogenous masses in Sjogren’s = lymphoma
Can be secondary lymphoma to the parotid gland.
Painless diffusely enlarged bilaateral parotid glands, in patient with HIV?
Benign lymphoepithelial disease
Mixed solid and cystic
Can mimic Sjorgens!! - differentiate with no calcification and often cervical adenopathy
Enlarged parotid(s) with surrounding fat stranding/ surrounding cellulites
Acute parotitis
Often secondary to stone blocking stensens duct or mumps
Bilateral enlarged parotids with multiple cystic & solid intraparotid lesions ± smooth, round intraglandular calcifications
Sjorgens
Honeycombed or leopard skin appearance of the gland
Female in 60s/ dry eyes and mouth
what structures are in the carotid space?
Carotid artery
Jugular vein
Cranial nerve 9,10,11
Internal jugular chain lymph nodes - II, III, IV
What are the three classic carotid space tumours?
Paraganglioma
Schwannoma
Neurofibroma (NF-1)
Imaging features of paraganglioma?
‘Salt and pepper’ from flow voids and heterogenous content
Hyper vascular - Intense tumour blush on angio
Octreotide positive
What are the different types of carotid paraganglioma?
- Carotid body - at level of bifurication (splaying the ICA and ECA)
- Glomus vagale - above carotid bifurication but below the jugular foramen
- Glomus Jugulare - Level of jugular foramen **middle ear floor/PA destroyed
- Glomus Tympanicum - Confined to middle ear, pulsatile tinnitus. DOESNT destroy destriy the middle ear
Imaging features of jugular foramen schwannoma
Sharply marginated, enlarged JF on bone CT
Fusiform, enhancing mass enlarging JF on T1WI C+ MR
No flow voids
Can have cystic changes
Not octreotide avid
Not all that vascular on angio
Imaging features of Glomus jugulare?
Mass in JF with permeative-destructive change of adjacent bone on CT
Multiple black dots (“pepper”) in tumor indicate high-velocity flow voids from feeding arterial branches on MR
Contents of the masticator space
Ramus and angle of the mandible
Inferior alveolar nerve
Muscles of mastication
Commonest mass in the masticator space?
Odontogenic infection
In kids can have angry masses like rhabdomyosarcoma
What is Grisels Syndrome ?
Torticollis and atlanto-axial joint inflammation seen in H+N surgery or retropharyngeal abscess
What is Lemierres syndrome?
Neck infection or Recent ENT surgery leads to jugular vein thrombosis and septic emboli
Bacteria is - FUSOBACTERIUM NECROPHORUM
Asian with unilateral mastoid effusion and a pathological retropharyngeal node were should look for ?
Fossa of Rosenmuller for a Nasopharyngeal SCC
Which type of laryngeal SCC has the best outcome?
Glottic
Least lymphatics and symptomatic early
Most common
Subglottic can be silent and presents with lymphadenopathy
What is a radiologically contraindication for laryngeal conservation surgery ?
Invasion of the cricoid cartilage
What additional features make laryngeal SCC at least T3?
Fixation of the cords
Invasion of the paraglottic space (look on coronals)
Thin-walled, fluid- or air-filled lesion communicating with laryngeal ventricle,
Laryngocele
Stenosis at the laryngeal ventricle can be an obstruction from a tumour (15%)
+/- extra laryngeal extension through the thyrohyoid membrane
Where to review if you see a left sided vocal cord paralysis ?
AP window - left recurrent laryngeal nerve
Nb the right arises from the CN X at subclavian artery
Ipsilateral -
Ballooning of laryngeal ventricle - sail sign
Enlarged pyriform sinus
Medially displaced aryepiglottic fold
Focal discontinuity at the posterior globe ?
Coloboma
if bilateral think CHARGE syndrome
Coloboma
Heart defect
Atresia - Chonal atresia
Retraded growth
Gentials - Hypogonadsim
Ears - small
Most common benign tumor of the orbit?
Dermoid
Arises superior and lateral, arissing from the frontozygomatic suture.
Young child
what is tolosa hunt syndrome?
Histologically same as pseudotumor but involves the Orbital apex and adjacent cavenrous sinus
Painful and cranial nerve palsies. Responds with steroids
What is the most common malignant orbital mass in a child?
Retinoblastoma
Chromosome 13 RB suppressor gene - same as osteosarcoma. risk of facial osteosarcoma after radiation therapy
1/3 bilateral.
Calcification in globe of child is classic
What is trilateral and quadrilateral retinoblastoma ?
Tri - Bilateral orbits and pineal gland
Quad - Bilateral orbits, pineal and suprasellar
what is the most common intraocular metastatic lesion in an adult?
Metastatic melanoma
Enhancing soft tissue mass in the posterior aspect of the globe
What orbital lesion is chlamydia psittaci linked iwth?
Orbital MALT Lymphoma
upper outer orbit and classically associated with the lacrimal gland.
will enhance homogenously and restriction diffusion
What are some of the key differences between a orbital lymphangioma and a venus varix?
Lymphangioma
- malformed veins and lymphatics
- Money shot = they do not increase with the valsalva
-Fluid-fluid levels
- mutlilocuted cystic components
- transpatial involvement - pre, posr septal, intra and extra conal
Varix
-Veins only, weak wall and valves
- massive dilatation of orbital veins
- Distend with provocative measures
- imaging can look normal with no Valsalva
- Most common cause of spontaneous orbital haemmorhage
What is the most common vascular orbital lesion in adults?
orbital Cavernous venous malforation/cavernous haemangioma
Weak arterial supply - so slow enhancement with delayed washout - progressive fill in
classic lateral intraconal sparing orbital apex
Low T1 signal pseudocapsule
Where does Per-septal and post-septal cellulitis usually originate?
Preseptal = Teeth and face
Post septal = Paranasal sinusitis
Well circumscribed round rim enhancing lesion centered into the lacrimal fossa?
Dacroyocyctitis
lentiform, rim-enhancing, low-density fluid collection along orbital wall
Adjacent sinusitis, particularly ethmoid with breach of the lamina papyracea?
Orbital subperiosteal abscess
Common causes of raccoon eyes on physical examination of a child?
Metastatic neuroblastoma
Basilar skull #
What type of breast cancer metastases to the orbits?
Invasive lobular carcinoma
Present many years later from index diagnosis with Enophthalmos (posterior displacement of the globe)
Classic imaging appearances of optic neuritis?
Enhancement of optic nerve
increase T2 signal
Unilateral and pain
What is neuromyelitis optica?
bilateral optic neuritis + myelitis
Ocular pain, visual loss, paralysis
relapsing and remitting
Classic imaging appearance of thyroid orbitopathy?
Enlargement of the belly of extraocular muscles sparing tendon
IMSLO - inferior, medial, superior, lateral, oblique
Increased volume of infraorbital fat and exophthalmos
What are orbital findings associated with NF-1?
Orbital pathway glioma
-WHO grade 1 pilocyctic astrocytoma
-Expansion nd enlargement of the entire nerve
Plexiform neurofibroma (PNF)
-Serpentine, unencapsulated, infiltrative masses
- enlarge skull base foramina
sphenoid wing dysplasia - Cause pulsatile exophthalmos
buphthalmos (visible enlargement of the globe)
lisch nodules
What are orbital findings carotid cavernous fistula?
Pulsatile exophthalmos
Proptosis
Enlarged cavernous sinus
Prominence of left superior ophthalmic vein
Cranial nerve palsy - 3,4, V1 and V2 and 6
Small eye (microphthalmia) with increased vitreous density?
Persistent hyperplastic primary vitreous
can cause V shaped retinal detachment
Main causes of Leukocoria (loss of red eye reflex) in a child ?
Retinoblastoma
Coats disease
Persistent hyperplastic primary vitreous
Coats
-Normal-sized globe, hyperdense; no Ca⁺⁺
-Subretinal exudate with retinal detachment
PHPV
-Retrolental tissue & stalk
- small eye
Retinoblastoma
-Calcification present in vast majority
What are classic features if optic nerve sheath meningioma?
Tram track sign
-Enhancing tumor surrounding the non enhancing optic nerve
Possible calcification and hyperostosis of adjacent bone
Bilateral = NF-2
Young boy with painless enlarging orbital mass, proptosis and visual changes?
Rhabdomyosarcoma
Masses in mandible
Odontoma -
- Most common lucent lesion in mandible
-Over time shows calcifications that coalesce to form a dense lesion with a lucent rim.
- 2nd decade of life
**-associated with gardners syndrome **
Ameloblastoma –
-Soap appearance , fluid levels
-classically arise near the angle of the mandible
-locally aggressive so additional features such as tooth
resorption and cortical erosion through the bone into adjacent tissues
Dentigerous cyst -
-Benign, developmental lucent lesion surrounding the crown of unerupted tooth.
-Also know as follicular cyst
-crown of a tooth projecting in to the cystic space is pathognomonic
Periapical cyst
- any tooth
–often the result of a **dental infection **and an associated dental cavity may be seen
Odontogenic keratocysts
-destructive, multilocular lesions centered about the ramus or body of the mandible
-Unlike a dentigerous cyst, an odontogenic keratocyst can erode
through the cortex of the mandible
-multiple odontogenic keratocysts = basal cell nevus syndrome
Benign cyst of jaw with aggressive behavior and high recurrence rate
Odontogenic Keratocyst
If multiple, with midface hypoplasia, calcification of falx, frontal bossing and prognathism = GORLIN basal cell naevus syndrome
Orbital lesions
see picture
Deep spaces neck and displacement of PPS
Masitactor space - Posterior-medial
Parotid space - Antero-medial
Carotid - antero-lateral
Pharyngeal muscosa - Posterio-lateral
Cervical lymph nodes
Level 1 = below mylohyoid and above hyoid anteriorly (1a submental and 1b submandibular) seperated by anterior belly of digastric
Level 2 = Jugulodisgastric (base of skull to hyoid)
Level 3 = Deep cerivical (hyoid to cricoid)
Level 4 = Virchow (cricoid to clavicle )
Level 5 = Posterior triangle (Va and Vb High and low spinal accessory nodes
Level 6 = Pretracheal/pre laryngeal/delphian nodes
Level 7 = Superior mediastinum
Anatomy middle ear
The epitympanum, also known as the attic, is the superior portion above the highest point of the tympanic membrane.
Head of the malleus and short crus of the incus (These give the appearance of an ice-cream cone on an axial CT).
The mesotympanumis the space posterior to the tympanic membrane. Body of the incus, the manubrium of malleus (connected to the tympanic membrane), anterior process of the malleus and the stapes.
stapes =oval window of the cochlea. T
Round window placed more inferiorly which bulges to allow compression waves transmitted from the stapes to the oval window to travel through the cochlea
Large vestibular aqueduct and inherited sensorineural hearing loss?
Pendred syndrome
DDx large vestibular aqueduct?
Chochlear hypoplasia
Mondini syndrome
Nb. Meniere disease = small or absent vestibular aqueduct
Boundaries of Nasopharynx, oropharynx and hypopharynx?
oropharynx divided from hypopharynx by valleculae.
