Head and Neck PATH

Question 1

Inverted papilloma location ? RF ?

Answer 1

Location
- Lateral nasal wall can extend into maxillary antrum

RF
- HPV 6 and 11

Question 2

Inverted papilloma complication ?

Answer 2

• 10% harbors SCC**
• Can also get other cancers like: mucoepidermoid carcinoma, verrucous carcinoma, and adenocarcinoma
• Hence need resection

Question 3

Esthesioneuroblastoma location and age ? What scan to use ?

Answer 3

• This is a neuroblastoma of olfactory cells so it’s gorma start at the cribiform plate (Octreotide scan +)
• Dumbbell shape growth up into the skull and growth down into the sinuses, with a waist at the
  plate (classic)
• Often cysts in the mass (intracral posterior cyst is “diagnostic” look)
• Bi-modal age distribution

Question 4

Ludwig angina imaging

Answer 4

• Gas filled abscess involving Submandibular AND sublingual space* (separated by Mylohyoid)

Question 5

Ranula arise from what location ?

Answer 5

• Sublingual space (typically lateral)
• Plunging ranula: extends into submandibular space

Question 6

OKC (Keratogenic Odontogenic Tumor)
- How is it different to periapical(radicular) and dentigerous cyst
- imaging ?
- location ?
- associated syndrome ?

Answer 6

Unlike the prior two lesions (which were basically fluid collections) this is an actual tumor.

Imaging
- Solitary, unilocular, expansile lesion with smooth, corticated borders* (can have septations, will look like ameloblastoma)
- Ramus or posterior body of mandible*
- When multiple think Gorlin Syndrome (Basal cell naevus syndrome)*

Question 7

OKC (Keratogenic Odontogenic Tumor)
- Epidemiology
- Prognosis ?

Answer 7

• Younger people 10 – 40 years old and more common in males
• Locally aggressive and highly likely to recur (60%) without adequate resection

Question 8

Gorlin Syndrome (Basal cell naevus syndrome) findings ?

Answer 8

• BCCs, calcified falx, medulloblastoma, short 4th metacarpal, PTCH gene**

Question 9

Ameloblastoma
- Imaging ?
- Associated with ?

Answer 9

Also a tumor (Adamantinoma of the jaw)

Imaging
- Multilocular “Soap bubble”
- Extensive tooth root absoprtion* (hallmark)
- Solid component
- Angle of mandible

Associated with
- 20% of ameloblastomas may arise from dentigerous cysts**

Question 10

Odontoma
- Imaging ?

Answer 10

• “Tooth Hamartoma”
• Start lucent, become radio-dense
• eventually Radiodense with a lucent rim
• can be LARGE with “fluffy” calcification

Question 11

PLEOMORPHIC ADENOMA
- complication ?

Answer 11

• Benign
• Degenerate into Carcinoma ex Pleomorphic Adenoma (Malignant Mixed Tumour) – increases with time,
  about 10% at 15 years
• Most aggressive tumor
• High chance of seeding if large G core biopsy.

Question 12

Warthin tumor
- Epi
- Site
- Recurrence ?

Answer 12

Epi
- Benign
- M > F
- Smokers

Site
- Parotid gland (ONLY, c.f. Pleomorphic can occur in all major glands)
- 10% Bilateral and multifocal

Recurrence
- 2% (c.f. Pleomorphic adenoma Likely to recur if only enucleated (25%))

Question 13

Mucoepidermoid Carcinoma
- benign or malignant
- location ?

Answer 13

• Malignant (most common malignant tumor of minor gland)
• Mainly in the parotid glands and minor salivary glands
• Associated with radiation

Question 14

ADENOID CYSTIC
- benign or malignant
- location
- Complication

Answer 14

• Malignant
• Minor gland (most common)
• Perineural spread and can disseminate to distant site decades after removal (Melanoma is the other that perineural spreads)

Question 15

Lymphoma of salivary gland
- Location ?
- Association ?

Answer 15

Location
- Parotid gland (the only salivary gland with lymph nodes)

Association
- Sjogrens
- If you see it and it’s bilateral, you should think
Sjogrens. Sjogrens patients have a big risk (like lOOOx) of parotid lymphoma

Question 16

Sjogrens in salivary gland
- Epi
- Associations

Answer 16

Epi
- Women in 60s

Association
- non-hodgkin MALToma (1000x)

Question 17

Bilateral mixed solid and cystic lesions in parotid with diffusely enlarged parotid glands

Answer 17

Benign Lymphoepithelial Disease
- Seen in HIV
- Painless (unlike parotitis which also enlarges gland)

Question 18

Schwannoma or Neurofibroma more common ?

Answer 18

Schwannoma

Question 19

Neurofibroma vs Schwannoma imaging feature ?

Answer 19

Neurofibroma
- less common than schwannoma
- 10% relates to NF-1, will be bilateral
- more homogeneous with target sign on T2 (c.f. Schwannoma heterogeneous)

Question 20

Laryngeal cancer most common location to least

Answer 20

Glottic (most common)
- best outcome
- slow growing
- rarely mets / mets late
- hoarseness

Supraglottic (next common)
- worst outcome
- early nodal mets
- don’t get hoarseness

Subglottic (least common)
- late presentation due to minimal symptoms
- early nodal mets hence poor prognosis

Question 21

Laryngeal SCC most common location and aetiology

Answer 21

• True vocal cords
• Arises from epithelial changes in the larynx, which occur in response to insult. known as the hyperplasia –
  dysplasia – carcinoma sequence
• Smoking most common cause*

Question 22

Contraindication for laryngeal SCC surgery

Answer 22

• Invasion of Cricoid cartilage (Cricoid cartilage necessary for postoperative stability of vocal cords)

Question 23

Direct vs Indirect CCF

Answer 23

Direct
- ICA communication with Cavernous sinus
- Occurs from Trauma

Indirect
- Dural shunt between ECA meningeal branches and Cavernous sinus
- Occurs randomly in post menopausal woman

Question 24

Varix (orbital vein dilatation) vs Lymphangioma (Venous lymphatic malformation)

Answer 24

Varix (Orbital vein dilatation)
- Distends with valsalva
- Bleeds (most common cause of orbital bleed)

Venous lymphatic malformation
- Does not distend with valsalva
- Fluid-Fluid level
- Bleeds

Question 25

Pre-Septal vs Post-Septal Orbital infection

Answer 25

Pre-septal
- anterior to orbital septum (originates from the periosteum of the orbit and inserts in the palpebral tissue along the tarsal plate)
- infection starts from adjacent structures like teeth and face
- Medical treatment

Post-septal
- Infection starts from paranasal sinusitis
- Surgical treatment

Question 26

Well-circumscribed, round rim enhancing lesion in the lacrimal fossa

Answer 26

Dacryocystitis (Aunt minnie)

Question 27

Spinal cord infarct
- most common cause
- most common involved
- imaging ?

Answer 27

Cause
- Idiopathic (most common cause)
- Atherosclerosis (aortic aneurysm, dissection etc)

Imaging:
- Anterior spinal artery (most common)
- Central cord / anterior horn cell high signal on T2 (because gray matter is more vulnerable to ischemia).
- The “owl’s eye” sign of anterior spinal cord infarct is a buzzword
- Usually long segment*
- However, can be more extensive and look like NMO, TM, MS*

DDx
- POLIO**

Question 28

ADEM vs MS

Answer 28

ADEM
- male (c.f. MS female)
- Monophasic, ANTI-MOG
- affects basal ganglia and basal ganglia (c.f. MS)
- affects grey matter more often
- involvement of callososeptal interface is unusual
- Gets acute haemorrhagic leukoencephalitis (Hurst disease)

Question 29

Inverted V sign in the dorsal column

Answer 29

Subacute Combined Degeneration
- B12 deficiency (Cobalamin)

DDx
*HIV Vacuolar Myelopathy:
- It can only be shown 2 ways
(a) by telling you the patient has AIDS or risk factors
(b) not including B12 as an answer choice

Question 30

Arachnoiditis
- cause
- imaging

Answer 30

Cause
- Post spinal surgery
- Post infectious

Imaging
- Empty sac sign: Nerve roots adherent peripherally
- Central nerve root clumping

Question 31

GBS (Guillain Barre Syndrome)
- Cause
- Imaging

Answer 31

Cause
- Campylobacter
- Others: lymphoma, post surgery, SLE

Imaging
- Enhancement of the nerve roots of the cauda equina*
- Anterior nerve roots involved more
- Facial nerve most common CN involved

DDx
- Chronic inflammatory Demylinating Polyneuropathy (CIDP) if does not improve in 8 weeks: Diffuse “Onion bulb” thickening of nerve roots

Question 32

Astrocytoma vs Ependymoma

Answer 32

Astrocytoma
- most common in Peds
- Upper thoracic
- Eccentric
- May have caudal / rostral syrinx associated
- Heterogeneous enhancement

Ependymoma
- most common in Adults
- Cervical
- Central
- Hemorrhagic (dark T2 cap)
- May have tumoral cysts
- Homogeneous enhancement

Question 33

Locations of Brachial cleft cysts

Answer 33

1st BAC
- Periauricular adjacent to Parotid, Communicates with EAC

2nd BAC
- anterior to SCM
- posterolateral to submandibular gland
- lateral to carotid space

3rd BAC
- Posterior triangle in upper neck
- Anterior triangle in lower neck

4th BAC
- in or adjacent to left thyroid lobe

Question 34

Medullary thyroid cancer arises from what cell ?

Answer 34

• Parafollicular C-cell (the rest arises from Follicular cell)

Question 35

Medullary thyroid cancer secrets what ?

Answer 35

• high calcitonin (however calcium is LOW!)

Question 36

Papillary thyroid cancer
- Microscopic finding ?
- Multifocal or Solitary

Answer 36

Micro
- Orphan Annie eye. Psamomma bodies
- Can be solitary or mutlifocal (c.f. Follicular Solitary)
- Calcifications, Fibrosis, cysts

Question 37

Follicular thyroid cancer
- Can differentiate adenoma to carcinoma on FNA ?
- Solitary or Multifocal
- What’s a variant ?

Answer 37

• Can’t differentiate adenoma from carcinoma on FNA (need hemithyroidectomy)
• Solitary
• Hurthell cell (variant - associated with Hashimotors - like an oncocytoma)

Question 38

Medullary thyroid cancer
- Microscopic

Answer 38

• Amyloid deposits**
• Parafollicular C-cells
• High calcitonin but low calcium