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radiology > Neuro-temporal bone, orbit & skull base/neck > Flashcards

Neuro-temporal bone, orbit & skull base/neck Flashcards

1
Q

Longitudinal vs transverse temporal bones fractures

A
  • Long: long axis, MC, more ossicular dislocation, conductive hearing loss
  • TV: short axis, van injury, sensorineuronal
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2
Q

MC facial fracture

A

nasal bone

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3
Q

MC facial fracture pattern

A

zygomaticomaxillary complex fracture (tripod)-zymgoma, inf orbit, lateral orbit

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4
Q

Le-Fort Fractures

A

involve pterygoid process

1) floating palate-anterolateral margin of nasal loss
2) pyramidal-inferior orbital rim & floor
3) separated face- zygomatic arch, lateral orbital rim wall

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5
Q

MC fracture site to result in CSF leak

A

anterior skull base

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6
Q

“recurrent bacterial meningitis”

A

known association with CSF leak

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7
Q

What is the best predictive factor ISO temporal bone fx?

A

otic capsule violation

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8
Q

Division of middle ear cavity

A
  • epitympanum
  • hypotympanum
  • mesotympanum
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9
Q

hypotympanum-where, what arises from it?

A
  • Below tympanic membrane.

- Eustachian tube arises from here.

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10
Q

epitympanum

A
  • “attic”

- above tip of scutum

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11
Q

mesotympanum

A

-directly behind tympanic membrane

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12
Q

Two parts of tympanic membrane

A

1) pars flaccida (top, weaker)

2) pars tensa (bottom)

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13
Q

cholesteatoma-what, specific sgx, MRI img

A

blob of exfoliated skin in middle ear cavity secondary to hole in pars flaccid.

  • erosion of scutum (v. specific sgx)
  • RD+
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14
Q

Two types cholesteatoma

A

1) pars flaccida

2) pars tensa

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15
Q

Pars flaccida type cholesteatoma

A
  • MC
  • Prussak’s space= MC loc
  • Early erosion scutum
  • long process incus MC segment of ossicular chain to be eroded
  • fistula to SCC MC involve lateral segment
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16
Q

pars tensa type cholesteatoma

A
  • less common

- inner ear involvement occ MC & earlier

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17
Q

prussau’s space

A

btw incus body (medial) and temporal bone process/scutum (lateral)

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18
Q

otic capsule aka

A
  • bony labyrinthine
  • SCC, vestibule, cochlea
  • normally fluid filled
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19
Q

labyrinthine fistula (perilymphatic fistula)

A
  • 2/2 cholesteatoma, iatrogenic, trauma
  • abN conn with MEC (air-filled)
  • Lat SCC MC involved
  • “sudden fluctuating sensorineural hearing loss & vertigo)
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20
Q

imaging labyrinthine fistula 2/2 cholesteatoma

A
  • ST density eating through otic capsule into SCC

- pneumolabyrinth-not often seen

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21
Q

“chronic” OM

A

fluid in MEC >6wks

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22
Q

In whom is OM common?

A

kids & DS (horn Eustachian tube)

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23
Q

complications of OM

A

1) coalescent mastoiditis-erosion mastoid septa w/ or w/o intramastoid abscess
2) facial n palsy-2/2 inflammation tympanic segment
3) dural sinus thrombosis–> venous infarct, otitic hydrocephalus
4) meningitis, labyrinthitis

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24
Q

labyrinthitis ossificants

A

“hx of childhood meningitis”

  • kids, 2-18 mo’s
  • img: ossification of membranous labyrinth
  • sensorineural hearing loss
  • calcification of cochlea CI for cochlear implant
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25
Q

membranous labyrinth

A
  • soft tissue lining bony labyrinth (the series of canals tunneled out of t-bone)
  • further divided into cochlear & vestibular labyrinths
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26
Q

labyrinthitis

A
  • inflammation of membranous labyrinth
  • viral URI (MC), otomastoiditis (UL), bacterial meningitis (BL)
  • img: cochlea & SCC enhancement
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27
Q

6 segments FN. Which normally enhance?

A
  • I Must Learn To Make Expressions
    1) intracranial (cisternal)
    2) meatal (canalicular)-inside IAC
    3) labyrinthine (IAC–> geniculate ganglion) +
    4) tympanic (GG–> pyramidal eminence) +
    5) mastoid (pyramidal eminence–> SMF) +
    6) extratemporal (distal to SMF)
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28
Q

What causes abnormal enh of the FN? When do you think cancer? When do you damage the FN?

A

1) Bell’s palsy (MC), Lymes, Ramsay Hunt, Cancer
2) nodular enhancement
3) T-bone fx (transverse > long)

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29
Q

Bell’s Palsy classic img finding

A

enhancement of canalicular segment (in IAC)

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30
Q

Ramsey hunt

A
  • 2/2 varicella zoster reactivation
  • rash around ear
  • CN 5 & 7 involvement
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31
Q

otosclerosis-what, who, pres, types, mx

A
  • Aka otospongiosis. Bony resorption of bony labyrinth.
  • conductive hearing loss in elderly
  • types: fenestral and retro fenestral (cochlear) types.
  • rx: Flouride dietary supplement. stapedecetomy, cochlear implant.
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32
Q

Fenestral type otosclerosis

A
  • Bony resorption starts at anterior margin of oval window (fissula ante fenestram). No cochlear involvement.
  • If unrx, footplate will fuse to oval window.
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33
Q

retro-fenestral/cochlear type otosclerosis-what, img, bilaterally, pres

A
  • more severe
  • progression to demineralization around cochlea
  • BL, symmetric 100%
  • +sensorineural
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34
Q

superior SCC dehiscence

A
  • aunt minnie
  • 2/2 long standing (+) ICP
  • “noise-induced vertigo”. “Tullio’s phenomenon”
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35
Q

“noise-induced vertigo”. “Tullio’s phenomenon”

A

superior SCC dehiscence

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36
Q

conductive hearing loss in elderly

A

otosclerosis

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37
Q

large vestibular aqueduct syndrome-mo, pres, UL vs BL, findings

A
  • Aunt Minnie.
  • > 1.5 mm, larger than adj PSCC
  • 2/2 failure of endolymphatic sac to resorb endolymph–> endolymphatic hydrops & dilation
  • mcc congenital SN hearing loss
  • often BL
  • cochlear deformity (~100%), abscent bony modulus >90%)
  • “progressive sensorineural hearing loss”-not born with it!
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38
Q

vestibular aqueduct

A
  • bony canal that connects vestibular with endolymphatic sac

- should never be > PSCC

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39
Q

congenital malformations inner ear

A
  • michel’s aplasia-earlier (3rd wk), most severe, rare

- classic mondini’s malformation-latest (7th wk), least severe, common

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40
Q

Mondini Malformation

A

cochlear hypoplasia of middle & apical turns (fuse into cystic apex –> 1.5 turns)

  • ass w/ enlarged vestibule, enlarged vestibular aqueduct
  • SN hearing loss (but high frequency sounds preserved via basal turn!)
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41
Q

Michel’s aplasia/complete labyrinthine aplasia (CLA)-what, when, ass, findings, how to differentiate from a mimic

A
  • Earliest (3rd wk) & most severe of congenital abN of inner ear. V rare
  • absent cochlea, veestibule, vestibular aqueduct
  • completely deaf
  • ass w/ anencephaly, thalidomide exposure
  • some people think it looks like labyrinthitis ossificans (look for absent vestibular aqueduct to help differentiate!)
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42
Q

How to differentiate Michel’s aplasia from labyrinthitis ossificans

A

absent vestibular aqueduct in CLA

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43
Q

endolymphatic sac tumor-ass & imaging.

A
  • sporadic. Ass w/ VHL

- img: int amorphous Ca, T2+, enh+++, FV, tumor blush on angiography

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44
Q

paraganglioma of jugular fossa

A
  • Glomus jugular & jugulotympanic tumors
  • can invade occipital bone and adjacent petrous apex
  • 40% hereditary, multiple
  • MC presenting syx=hoarseness from VN compr
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45
Q

petrous apex anatomic variations

A

1) asymmetric marrow
2) cephalocele
3) aberrant internal carotid

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46
Q

How to avoid misinterpreting asymmetric petrous apex marrow signal

A

STIR/fat suppression

*marrow signal follow that of scalp & orbital fat (T1/T2+)

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47
Q

petrous apex cephalocele-what? BL vs US. Classic img.

A
  • misnomer bc doesn’t contain brain tissue
  • aka “petrous apex arachnoid cyst”
  • acquired or congenital herniation of PL wall of Meckel’s cave into superomedial petrous apex
  • BL > UL
  • “smoothly marginated lobulated cystic expansion of petrous apex.”
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48
Q

“smoothly marginated lobulated cystic expansion of petrous apex.”

A

petrous apex cephalocele

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49
Q

how will examiners try to fool you re: aberrant internal carotid

A

calling it a paraganglioma. look for conn to horz carotid canal.

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50
Q

aberrant internal carotid-MOA, pres, img, mimic?

A

“pulsatile tinnitus”

  • C1/cervical segment involuted/under developed –> middle ear collaterals level (enlarged caroticotympanic a)—> hypertrophied vessels run through tympanic cavity and join carotid canal
  • ENT exam: vascular mass pulsing behind ear drum.
  • vs paraganglioma-connect to horz carotid canal
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51
Q

Apical petrositis

A
  • 1˚ in children. 2˚ in adults from otomastoiditis.

- –> skull base OM, ICA vasospasm, subdural empyema, venous sinus thrombosis, TL stroke, meningitis

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52
Q

gradenigo syndrome

A

complication of apical petrositis when dorellos canal is involved –> lateral rectus palsy
-classic triad: otomastoiditis, face pain, lateral rectus palsy

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53
Q

cholesterol granuloma

A

MC 1˚ petrous apex lesion.

  • obstruction of air cells –> repeated hem/inflamm –>bone expansion/remodeling
  • MC syx=hearing loss
  • T1/T2+
  • rx fast growing ones surgically
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54
Q

petrous cholesteatoma

A
  • congenital (vs MEC)
  • slow growing, ass bony change
  • T1(-), T2 (+), RD+
  • smooth expansile bony change
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55
Q

smooth expansile bony change of petrous apex

A
  • cholesterol granuloma (T1+, RD-)

- cholesteatoma-T1-, RD+

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56
Q

external auditory canal exostosis

A
  • overgrowth tissue in EAC seen in surfers who get repeated bouts of ear inf
  • if chronic=bone
  • BL
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57
Q

external auditory canal osteoma

A

benign bone growth near junction of cartilage and bone in ear canal

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58
Q

external auditory canal atresia-what, findings, what does surgeon want to know?

A

-EAC doesn’t form.
+/- mashed up ossicular chain
-ENT cares about 1) ST or bone covering opening 2) aberrant facial n course?

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59
Q

“osteolysis circumscripta”

A

pagets

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60
Q

MC 1˚malignancy of the globe in children?

A

Retinoblastoma

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61
Q

retinoblastoma-pathology, epidemiology, appearance

A
  • Rb suppressor gene on chromosome 13 (unlucky 13) (same as OS)
  • peds (~3 yo)
  • eyeball size: N/L.
  • Ca+
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62
Q

chromosome 13 pathology

A
  • Rb
  • osteosarcoma
  • Rb patients (+)risk facial osteosarcoma after radiation.)
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63
Q

Rb: bilateral, trilateral, quadrilateral

A
  • Bilateral-both eyes. 30%
  • Trilateral- +pineal gland
  • Quadrilateral- +suprasellar
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64
Q

Coats’ Disease

A

retinal telangiectasia–> leaky blood & sub retinal exudate–> retinal detachment

  • vs RB: no ca, small globe.
  • CT dense, T1/2+
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65
Q

persistent hyper plastic primary vitreous (PHPV)

A

failure of embryonic ocular bs to regress –> retinal detachment
-microphthalmis + vitreous increased density. No Ca

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66
Q

size of globe in toxocariasis

A

normal

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67
Q

Causes of microphthalmia

A
  • persistent hyper plastic primary vitreous (PHPV) (normal before birth)
  • retinopathy of prematurity-BL small
  • coats’
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68
Q

retinal detachment

A
  • causes: PHPV, Coats, trauma, sickle cell, old age

- V or Y shape (listen up retinal leaves & sub retinal fluid)

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69
Q

melanoma

A
  • mc intraoccqular lesion in adult
  • collar but shaped related to Bruch’s membrane
  • stong predilection for liver mets-next step liver MR
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70
Q

optic n glioma

A
  • sporadic <20 yo, GBM
  • BL: NF-1, Who Grade 1 pilocytic astrocytoma
  • enlargement of entire nerve
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71
Q

“tram-track calcification” optic nerve sheath meningioma

A

optic nerve sheath meningioma

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72
Q

“doughnut appearance with circumferential enhancement around optic nerve.”

A

optic nerve sheath meningioma

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73
Q

mc benign congenital orbital mass

A

dermoid

  • classic loc: superolateral, from frontozygomatic suture
  • <10 yo
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74
Q

rhabdomyosarcoma

A
  • mc extra ocular orbital malignancy in children
  • superior-medial orbit
  • bone destruction
  • “bully orbital mass in a 7 yr old”
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75
Q

orbital lymphoma

A

ass with Chlamydia Psittaci (bird fever) & MALT

  • upper outer orbit, closely ass w/ lacrimal gland
  • homogenous enhancement, RD+
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76
Q

metastatic neuroblastoma

A
  • “raccoon eyes” on PE
  • periorbital tumor infiltrate + proptosis
  • BL sphenoid greater wing
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77
Q

bony involvement greater wing of sphenoid

A
  • BL=NB

- UL=EWL

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78
Q

metastatic scirrhous (fibrosing)

A

2/2 breast cancer

-desmoplastic rxn –> enophthalmos (pst displacement globe)

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79
Q

infiltrative retrobulbular mass + exophthalmos=

A

Breast scirrhous carcinoma

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80
Q

what do orbital pseudotumor, tolosa hunt syndrome & lymphocytic hypophysitis all have in common?

A

IgG4 related

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81
Q

orbital pseudotumor

A
  • IgG4 related idiopathic inflamm
  • UL LR
  • myotendinous insertions not spared & pain (vs graves).
  • EOM+, T2-, enh+
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82
Q

tolosa hunt syndrome

A
  • IgG4 related idiopathic inflamm

- cavernous sinus. painful. multiple CN palsies

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83
Q

lymphocytic hypophysitis

A
  • IgG4 related idiopathic inflamm
  • pituitary gland stalk enlarged in post-partum/3rd TM F.
  • Vs pituitary adenoma: T2 dark rim
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84
Q

MCC exophthalmos

A

thyroid orbitopathy

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85
Q

thyroid orbitopathy

A
  • TSH rec ab’s –< orbital fibroblasts & adipocytes
  • confined to EOM m body enlargement
  • risk of compressive optic neuropathy
  • painless
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86
Q

thyroid orbitopathy order of EOM involvement

A

IR > MR> SR > LR >SO/IO

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87
Q

thyroid orbitopathy vs orbital pseudotumor

A

TO m belly only and painless

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88
Q

orbital lymphangioma

A
  • venous and lymphatic malformations
  • ill defined, no capsule
  • multi-spatial-preseptal, post septal, extraconal, intrazonal.
  • F/F levels classic
  • don’t distant with Valsalva maneuvers
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89
Q

orbital varix

A
  • massive dilation of valveless orbital v’s 2/2 weakness in post-capillary venous wall
  • distend with provocative maneuvers
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90
Q

mcc spon’t orbital hemorrhage

A

orbital varix (thrombose + pain)

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91
Q

intraconal space

A

inside rectus muscle pyramid

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92
Q

extraconal space

A

space outside rectus m pyramid

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93
Q

insertions of orbital septum

A

periosteum of orbit –> palpebral tissue along tarsal place

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94
Q

where do pre- and postseptal infections arise from?

A
  • pre: teeth, face

- post: paranasal sinus

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95
Q

mcc periorbital abscess induced thrombosis of opthalmic v or cavity sinus?

A

aspergillosis

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96
Q

dacryocystitis

A

Aunt minnie

  • inflamm & dil lacrimal sac 2/2 obstruction –> bacterial inf (staph, strep)
  • well circumscribed, round enhancing lesion centered in lacrimal fossa
  • CT if peri-orbital cellulitis
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97
Q

MCC orbital subperiosteal abscess

A

Aunt minnie

-ethmoid sinusitis

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98
Q

optic neuritis

A

nerve enh without enlargement

  • UL (70%), painful
  • Devics & MS
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99
Q

optic n enhancement + enlargement

A

glioma…NF-1!

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100
Q

papilledema

A

dilation/swelling optic nerve sheath

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101
Q

drusene

A
  • mineralization at optic disk

- ass w/ age-related maculopathy

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102
Q

intraocular lens implant

A

standard treatment for cataracts

-implant = thin, linear

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103
Q

ectopia lentis

A
  • lens dislocation

- causes: trauma, marfans, homocystinuria

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104
Q

coloboma

A
  • failure of choroid tissue to close –> focal discontinuity of globe
  • posterior.
  • UL = sporadic
  • BL= CHARGE
105
Q

“sudden fluctuating sensorineural hearing loss & vertigo”

A

labyrinthine fistula

106
Q

MCC’s labyrinthitis

A

-URI (MC)
otomastoiditis (UL)
-bacterial meningitis (BL)

107
Q

“hx of childhood meningitis”

A

labyrinthitis ossificans

108
Q

MC presenting symptom of jugular paragangliomas

A

hoarseness from VN compression

109
Q

What percent of jugular paragangliomas are hereditary (and likely multiple)

A

40%

110
Q

clivus chordoma vs chondrosarcoma

A

chordoma=midline, chondrosarcoma off midline

111
Q

McCune Albright Syndrome

A

MF fibrous dysplasia, cafe-au-lait spots, and precocious puberty

112
Q

Pagets of the skull- inner vs outer table

A

favors inner table

113
Q

Paget’s skull related complications-which is MC

A
  • deafness (MC)
  • CN paresis
  • basilar invaginations–> HCP–> BS compression
  • 2˚ OS (high grade)
114
Q

which part of the skull does fibrous dysplasia classically spare?

A

otic capsule

115
Q

which part of the skull does FD favor?

A

outer table

116
Q

When would you use CT in sinus disease?

A
  • sinus & orbital infections (anterior 2/3 orbit)
  • Diff infection from tumor (inf hyperdense)
  • Anatomic variation
117
Q

When would you use MRI in sinus disease?

A
  • Cavernous sinus involvement or pst 1/3 orbit.

- tumor progression/extension (perineurial, marrow)

118
Q

hyperdense sinus

A
  • blood
  • dense (inspissated) secretions
  • fungus
119
Q

fungal sinusitis-types

A

1) allergic

2) acute invasive fungal

120
Q

allergic fungal sinusitis-what is it, location, appearance (CT & MR), immune status

A
  • chronic allergic fungal sinusitis via hypersensitivity run to fungus
  • immunocompetent, hx asthma
  • mult sinuses (usually BL ethmoid & MS)
  • CT: dense centrally or w/ layers/curvilinear. chronic= bony erosion/remodeling.
  • MR: T1/2 (high protein/heavy metals). Can mimic aerated sinus! Mucosa T2+ (inflamed). Fungal blob will not enhance.
121
Q

What’s in it? Infraorbital canal/foramen

A

infraorbital vessels & n

122
Q

acute invasive fungal sinusitis-appearance (CT & MR) immune status.

A
  • mult sinuses. *Periorbital fat extension
  • immunocomromised- neutropenic (aspergillus), DM in DKA (zygomycetes/mucor)
  • ct- not hyperdense. Fat stranding (orbit, masticator far, pre-antral fat, PPF=invasion). No bone change required
  • MR-T1/T2(-) Mucosa +/- enh, ie: (-) in necrosis. extra sinus disease= STIR+, enh.
123
Q

chronic inflammatory sinonasal disease

A

inflammation >12wks.

124
Q

osteomeatal unit (OMU)

A
  • common drainage pathway for maxillary, frontal and anterior ethmoid sinuses
  • maxillary sinus esteem, infundibulum, uncinate process, hiatus semilunaris, ethmoid bulla & middle meatus (some authors include frontal recess)
125
Q

What part of OMU is blocked in isolated maxillary sinus disease?

A

maxillary sinus osteium or infundibulum

126
Q

What part of OMU is blocked in maxillary, frontal & anterior ethmoid sinus disease?

A

-hiatus semilunaris

127
Q

Which is the largest paranasal sinus?

A

maxillary

128
Q

How is ethmoid sinus divided? What divides it? Differences in drainage?

A
  • Ant: frontal recess–> middle meatus (OMU)
  • Pst: drains via tiny ostia under superior turbinate into superior meatus.
  • divided by basal lamella
129
Q

What sep ES from orbit?

A

lamina papyracea

130
Q

What lines the sinuses?

A

ciliary mucosa

131
Q

what does frontal sinus represent at birth?

A

enlarged anterior ethmoid cell, ie: not formed at birth

132
Q

drainage frontal sinus

A

into ethmoid infundibulum via frontal recess

133
Q

drainage sphenoid sinus

A

into ethmoid air cells via sphenoethmoidal recess

134
Q

overview sinus drainage:

A
  • frontal –> frontal recess –> ethmoid infundibulum –> OMU –> middle meatus
  • sphenoid –> sphenoethmoidal recess–> pst ethmoid air cell
  • ant ethmoid –> frontal recess
  • pst ethmoid–> unnamed ostia (under sup turbinate)–> superior meatus
  • maxillary: maxillary sinus ostium –> infundibulum –> hiatus semilunaris –> middle meatus
135
Q

FESS-acronym

A

functional endoscopic sinus surgery

136
Q

Important things to not re: preoperative FESS imaging

A

anatomic variations: dehiscent lamina papyracea, dehiscent cribriform plate

137
Q

dehiscent lamina papyracea- imaging appearance and clinical consequence in FESS

A
  • medial bulge of orbit

- enter orbit

138
Q

dehiscent cribriform plate-imaging appearance and clinical consequence in FESS

A
  • inferior bulge of frontal lobe

- enter FL

139
Q

Agger nasi cell-what is it, clinical consequence?

A

“nasal mound”. Most anterior air cell.

-may cause obstruction of FS if large

140
Q

Haller cell- what is it, clinical consequence?

A

ethmoid cell inferior to orbit

-compromise maxillary osmium if enlarged or inflamed

141
Q

Onodi cell- what is it, clinical consequence?

A
  • most posterosuperior ethmoid air cell
  • directly inferomedial to optic nerve
  • may be mistake for optic nerve endoscopically–> damage
142
Q

concha bullosa-aka, what is it, locations, clinical consequence?

A
  • aka “concha/tubinate pneumatization”
  • extension of sinus into concha –> pneumatization 50%+ vertical heigh of middle concha
  • may cause septal deviation, narrowing of infundibulum when large
143
Q

pott’s puffy tumor

A

subgaleal abscess + ST edema 2/2 OM frontal bone

144
Q

Patterns of chronic inflammatory sinonasal disease

A

1) infundibular
2) ostiomeatal
3) sinonasal polyposis

145
Q

infundibular pattern chronic inflammatory sinonasal disease

A
  • MC

- maxillary sinus via obstruction ostium/infundibulum

146
Q

ostiomeatal unit pattern chronic inflammatory sinonasal disease- pathophys/causes?

A
  • 2nd MC
  • blockage middle meatus –> MS, FS, ES
  • HTr turbinates, anatomic variants (concha bullosa, middle turbinates curling wrong way (paradoxical), septal deviation.
147
Q

sinonasal polyposis pattern- pathophys, imaging, key feature/classic description, class associations

A
  • ST nasal polyps & variable degrees of sinus opacification
  • key feature: bony remodeling, erosion. “widening infundibula”-must distinguish from expansion via mucocele
  • f/f levels 50%
  • ass: ASA sensitivity, CF
148
Q

muocele-pathophys, appearance (change over time), MC sinus

A
  • chronic sinus obstruction (inflamm/tumor) –> circumferential bony expansion
  • FS = MC (via obstruction sinus ostia)
  • CT: homogenous total opacification
  • MR: variable: increasing chronicity, T1+/T2-. In late disease, T2- may be so dark it looks like normally aerated sinus.
  • +/- PERIPHERAL enh via inflamed mucosa
149
Q

complications sinonasal disease

A
  • acute, chronic infection/inflammation
  • orbital: subperiosteal abscess, cellulitis, ophthalmic vein thrombosis
  • intracranial: spread–> cavernous sinus thrombus, meningitis, abscess (ED, SD, intraparenchymal)
  • bony: periostitis, OM –> pott’s puffy tumor
  • mucus retention cyst-obstructed small mucosal serous or mutinous glands
150
Q

antrochoanal polyp-population, syx’s, MC sinus, appearance

A
  • 30-40yo
  • syx’s- nasal congestion/obstruction
  • benign polyp extending from maxillary sinus –> “widening of ostium” –> nasal cavity
  • +/- bone remodeling: smooth enlargement, ie: NO DESTRUCTION
  • Rx-complete resection (prevent recurrence)
151
Q

inverted papilloma-what, classic location, imaging, mx, associated with which cancer?

A
  • rare benign lobulated polypoid epithelial tumor of sinus mucosa
  • classic location: lateral wall nasal cavity (middle turbinate)–> impaired maxillary drainage
  • img: cerebriform, COMPLETE enhancement (vs mucocele or obstructive secretions). Focal hyperostosis at humor org.
  • rx: surgical (recurrent 15%)
  • SCC 15-20%
152
Q

juvenile nasal angiofibroma (JNA)-classic hx

A
  • male teenager w/ nose bleed. obstruction MC in real life
  • loc: sphenopalantine foramen
  • vascular, intratumor FV, +bony remodel
  • presurgical embo internal maxillary, asc pharyngeal artery
153
Q

“widening of maxillary ostium”

A

antrochoanal polyp

154
Q

Enthesioneuroblastoma-pathophys, where, classic look, diagnostic app, who, NM scan?

A
  • malignant NB of olfactory cells. Starts in cribriform plate
  • “dumbbell shape w/ waisting at cribriform plate” +Cysts
    • dumbell shape-sup growth into skull, inf growth into sinus
    • +bone remodeling AND destruction
    • v vascular
  • diagnostic: intracranial pst cyst
  • bimodal age distribution
  • ocreotide+
  • really fills the nasal cavity –> ext to other structures
155
Q

cribriform plate

A
  • Sieve-like structure btw anterior cranial loss & nasal cavity, part of the EB.
  • Supports olfactory bulb.
156
Q

SNUC acronym

A

Sinonasal undifferentiated carcinoma

157
Q

mc cancer of H/N

A

SCC

158
Q

MC location H/N SCC?

A

maxillary antrum

159
Q

Imaging H/N SCC-T2 and enh

A
  • T2 dark (v cellular)

- enhances less than other sinus cancers

160
Q

Sinonasal undifferentiated carcinoma (SNUC)-what, where

A
  • Rare, aggressive, sinonasal nonsquamous cell epithelial or nonepithelial malignant neoplasm of varying histogenesis.
  • MONSTER SCC-aggressive, bone destruction, rapid growth, >4cm at presentation, extension
  • nasal cavity–> sinuses (ethmoid)
161
Q

epistaxis-causes. involved locations & mx

A
  • Idiopathic (MC), HHT
  • ant septum (MC)= kiesselbach plexus. Compression.
  • Pst (5%): sphenopalatine artery (terminal internal maxillary artery). Angiogram, nasal packing, IR
162
Q

what to watch out for when embolizing sphenopalatine artery

A

variant anastomosis btw ECA & ophthalmic artery

163
Q

nasal septal perforation-MC loc & cause

A
  • ant septal cartilaginous area
  • causes: surgery (old school Killian submucousal resection), cocaine (3mo), Wegener granulomatosis, syphilis (affects bony septum)
164
Q

Corresponding ducts: submandicular, parotid, sublingual

A

SM: Wharton
Parotid: Stenson
SL: Rivinus

165
Q

Salivary duct most commonly involved in sialolithiasis

A

Submandibular (Wharton)

166
Q

odontogenic infection causes. MC scenario?

A
  • Dental or periodontal.

- MC in extracted tooth than abscess of intact tooth

167
Q

mylohyoid line-clinical significance?

A
  • mylohyoid m –> mylohyoid ridge
  • above=anterior mandibular teeth/sublignual space.
  • below=2nd & 3rd molars, submandibular space
  • dictates spread of infection to SL and SM spaces
168
Q

MC masticator space mass in adult

A

odontogenic abscess

169
Q

Ludwig’s angina- MC cause

A
  • aggressive cellulitis in floor of mouth (submental, SLS, SMS)
  • odontogenic infection
170
Q

Torus palatinus-what, classic history?

A
  • bony exostosis off hard palate midline (normal variant)

- grandma’s dentures won’t stay in

171
Q

mandibular onsteonecrosis-causes

A
  • prior radiation
  • radium
  • bisphos rx
172
Q

ranula

A
  • mucous retention cyst arising from SL gland/space

- typically lateral

173
Q

“plunging ranula”

A

ranula extends under mylohyoid m (into SMS)

174
Q

young adult with new level II neck mass

A

HPV related SCC w/ necrotic level II LN

175
Q

lesions of the jaw categories

A
  • non-odontogenic-bony lesions that you see in other bones

- odontogenic- related to teeth

176
Q

periapical/radicular cyst-what, were, appearance

A
  • acquired cystic degeneration around periodontal ligament from inflammation (dental caries) & less commonly trauma
  • well corticated
  • <2cm
  • apex of non-vital tooth
177
Q

what is the MC odontogenic cyst

A

periapical/radicular cyst

178
Q

dentigerous/follicular cyst

A
  • developemental odontogenic cyst that forms around crown of un-erupted tooth
  • ass expansion of mandible, thinning of lingual cortex. inferior alveolar canal displaced inferiorly.
  • displaces tooth (typically into condylar regions of mandible or floor of orbit), usually in apical direction.
179
Q

Keratogenic odontogenic tumor/odontogenic keratocyst-appearance (OKC). Ass syndrome when multiple

A
  • Cystic multiloculated tumor at mandibular body/ramus w/o cortical expansion
    • Daughter cysts=multilocular
    • grow along length of bone
    • bone smoothly scalloped/thinned, can dehisce
  • Gorlin Syndrome
180
Q

Gorlin Syndrome

A

rare phakomatosis char by multiple odontogenic keratocysts (OKC) & multiple BCCs

181
Q

Ameloblastoma (adamantinoma of jaw)-what, loc, appearance, hallmark, relation to dentigerous cysts?

A
  • benign but locally aggressive tumor of jaw from odontogenic epithelium
  • expansile multicystic (“bubbly”) + solid comps
  • usually near 3rd molar (if maxillary, 1st molar)
  • usually shown with UNINTERRUPTED tooth
  • HM: extensive tooth root absorption
  • 5% from dentigerous cysts
182
Q

Odontoma-what, 2 forms, app.

A
  • tooth hamartoma. “bag of teeth”
  • immature form (Lucent).
  • mature-sclerotic. radiodense + Lucent rim
  • +/- fluffy Cal
183
Q

“bag of teeth”

A

Odontoma

184
Q

What’s in it: parotid space

A
  • parotid gland
  • CN 7
  • retromandibular vein
185
Q

relationship of retromandibular vein & facial nerve

A

RMV medial to FN

186
Q

What is special about the parotid gland relative to other salivary glands?

A

Only gland that contains lymph tissue

187
Q

parotid space pathology

A
  • pleomorphic adenoma/benign mixed tumor
  • warthins
  • mucoepidermoid carcinoma
  • adenoid cystic carcinoma
  • lymphoma
  • sjogrens
  • benign lymphoepithelial dx
  • acute parotitis
188
Q

major & minor salivary glands

A
  • major: parotid, SM, SL

- minor: >100 unnamed

189
Q

MC major (and minor) salivary gland tumor, MC loc

A

pleomorphic adenoma/BMT

-parotid –> SL/Sm

190
Q

Parotid gland division, rel to FN

A

-line from lateral surf pst belly digastric muscle –> lateral surface mandibular ascending ramus
-superficial lobe-lateral to FN
deep lobe-medial to FN

191
Q

pleomorphic adenoma/BMT-mc loc, img, malignant potential, rx

A
  • PG (superficial 90%)
  • T2+, rim of low signal
  • small mal pot
  • rx=surgery (can recur of spilled)
192
Q

Warthin’s tumor-what, who, BL vs UL, nukes study?

A
  • benign cystic tumor of PG (only), 2nd MC
  • older male smoker
  • BL 15%
  • pertechnetate+ (only other PG tumor to do this is parotid oncocytoma) (P for P)
  • also thallium and FDG-PET
193
Q

mucoepidermoid carcinoma-ass?

A
  • mc minor salivary gland malignant tumor

- radiation

194
Q

MC malignant salivary gland tumor

A

mucoepidermoid carcinoma

195
Q

Is malignancy more common in minor or major SGs?

A

minor

196
Q

adenoid cystic carcinoma-location, what to know

A
  • malignant SG tumor (minor –> PG)

- perineural spread

197
Q

parotid lymphoma-causes, app

A

1˚ or 2˚

  • BL=sjogrens
  • img: variable (like everywhere else in body)
198
Q

What disease is ass with parotid lymphoma

A

Sjogrens (1000x increased risk)

199
Q

Sjogren’s parotid involvement

A
  • H/N inv
  • honeycombed appearance of gland
  • new mass=NH MALT type lymphoma
200
Q

Sjogrens-what, 1˚ vs 2˚, who, img

A
  • AI destruction of SGs & lacrimal glands–> “dry eyes, dry mouth.”
  • middle aged-60s F
  • 1˚-only SG & LG involvement
  • 2˚
201
Q

benign lymphoepithelial disease-ass, img

A
  • HIV
  • BL cystic & solid lesions, diffusely enlarged PGs
  • painless (vs parotitis which also enlarge PG)
202
Q

Causes of parapharyngeal space displacement-ant, medial, pstmedial, lateral

A
  • ant=carotid space
  • medial=parotid
  • pstmedial-masticator
  • lateral-superficial mucosal
203
Q

Parapharyngeal space contents-clinical significance

A
  • triangular space of fat, +pterygoid v’s & branches CN5
  • spread of inf, tumor
  • use displacement to localize org of pathology
204
Q

parapharyngeal space cystic mass

A
  • necrotic LN-mc

- atypical 2nd branchial cleft cyst

205
Q

carotid space aka

A

post-styloid, retro-styloid

206
Q

what’s in it: carotid space

A
  • carotid a
  • jugular v
  • portions of: CN9-11
  • IJ chain LNs
207
Q

3 classic carotid space tumors

A

1) paraganglioma
2) schwannoma
3) neurofibroma

208
Q

Carotid space pathology

A
  • classic tumors- PG, Sch, NF
  • infection-necrotizing otitis external
  • malignant spread-NP SCC
209
Q

carotid paragangliomas-types based on location

A

1) carotid body tumor
2) glomus jugulare
3) glomus vagale
4) glomus tympanicium

210
Q

Paraganglioma imaging app

A
  • hypervascular (intense tumor blush)
  • “Salt & pepper” on MRI from FVs
  • Ocreotide NM scan
211
Q

rule of 10’s in paraganglioma

A
  • ass w/ familiar syndromes

- 10% BL, mal, etc

212
Q

carotid body glomus-classic img

A

splaying ICA, ECA at bifurcation

213
Q

glomus jugular-classic img

A
  • skull base

- destruction middle ear/jugular foramen

214
Q

glomus vagale

A

above carotid bifurcation, below jugular foramen

215
Q

glomus tympanicum

A
  • confined to middle ear
  • “overlying cochlear promontory”
  • middle ear floor intact
216
Q

Schwannoma- types in carotid space, img, ass

A
  • CN10 (if higher near skull base: CN 9, 11, 12)
  • oval, T2+ hetero (cystic + solid), avidly enhancing (via extravascular leakage and poor venous drainage)
  • hypovascular- ie: neg angio
  • NF 2 (if multiple)
217
Q

why do schwannomas have avid enhancement?

A

Not because of vascularity! Hypovascular lesions but have extravascular leakage + poor venous drainage

218
Q

Things to consider in resection of carotid space lesions

A
  • distance from skull base: >1 cm=neck dissection
  • vascularity-may need pre-embo
  • rel to carotid-don’t fuck with big red!
219
Q

carotid space neurofibroma-img, ass

A
  • T1~/T1+, enh+. Mildly hetero (more homog than schwannoma)
  • T2 “target sign”-bright rim, dark middle
  • 10% NF-1
220
Q

paraganglioma vs schwannoma vs neurofibroma

A
  • paraganglioma-peripheral autonomic (SNS, PNS) cells

- neurofibroma-benign peripheral nerve sheath tumor inseparable from normal nerve

221
Q

neck infection syndromes

A
  • Lemierre’s

- Grisel’s syndrome

222
Q

bacteria ass w/ lemierre’s disease

A

fusobacterium necrophorum

223
Q

grisel’s syndrome

A

torticollis w/ atlanto-axial joint inflama seen in H/N surgery or RPA

224
Q

masticator space-m’s, bone, nerve, extent

A
  • muscles of mastication (masseter –> mandible ramus –> temporalis –> pterygoid plate: lateral–> medial pterygoids)
  • mandibular ramus
  • inferior alveolar nerve (branch of V3)
  • extends superior along skull via temporalis m
225
Q

MC masticator space mass. What to look out for.

A
  • infection

- look for spread via pterygopalatine fossa –> orbital apex & cavernous sinus

226
Q

masticator space pathology

A
  • infection (MC)
  • sarcoma (rhabdomyosarcoma in kids, bone (chondrosarcoma of TMJ)).
  • cavernous hemangioma-phleboliths. (venous & lymphatic involve multi compartments/spaces)
  • perineural spread-adenoid cystic Ca, melanoma
  • nerve sheath tumors-schwannoma or NF of V3 (inferior alveolar n)
227
Q

what’s most likely to widen neural foramina: schwannoma or perineural spread?

A

schwannoma

228
Q

retropharyngeal space

A
  • potential space located pst to pharynx sep by pharyngobasilar fascia
  • ant true space- & pst danger space
  • ant: ext from skull base –> upper mediastinum (@level of tracheal bifurcation; C6/C7).
  • directly lateral are CS and PPS
229
Q

alar fascia

A
  • directly pst to RPS

- sep RPS from danger space

230
Q

danger space

A

ext into mediastinum

-alar f ant, prevertebral f pst

231
Q

prevertebral space

A
  • anterior comp of perivertebral space in supra hyoid neck, just ant to VB
  • bounded ant by prevertebral f, pst by longs Colli m’s
232
Q

what infections affect the prevertebral space?

A

spine/disc

233
Q

role of delayed img in neck inf?

A

differentiate phlegmon from abscess

234
Q

mcc retrophargyngeal space infection

A

tonsillar infection

235
Q

nodes of rouviere

A

LNs in lateral retropharyngeal region, regress by age 4

  • peds: infection
  • adults: mets (SCC, papillary thyroid), lymphoma (won’t be necrotic until treated.)
236
Q

What are the cervical LN stations

A 
IA, IIB-submental, submandibular
IIA, IIB- upper IJ nodes
III-middle jugular nodes
-IV-inf jugular nodes
-VA, VB-pst cervical nodes
-VI-pretracheal
-VII-superior mediastinal nodes, described by location
237
Q

Level IA

A

submental

btw medial margin ant digastric

238
Q

divisions cervical node stations

A
  • IA, B: hyoid inferiorly, pst margin SM gland
    • div by medial margin ant digastric m
  • IIA, B: hyoid inferiorly, skull base (pst margin SM gland)
    • div by pst margin internal jugular v
  • III-
    • craniocaudally from hyoid to inferior cricoid cartilage
    • posteriorly: margin SCM
  • IV
    • craniocaudally cc –> clavicle
    • AP: carotid a –> SCM (sup), anterior scalene (inf)
  • VA-
    • CC: skull base –> inf cc
    • AP: SCM–> trap
  • VB-
    • CC: cc–> clav
    • AP: anterior scale–> trap
239
Q

epidemiology of nasopharyngeal SCC

A
  • asian
  • bimodal
    • 15-30, chinese
    • > 40
240
Q

what worsens prognosis in NP SCC?

A

PPH involvement (compared to nasal cavity or oropharynx invasion)

241
Q

Fossa of Rosenmuller

A

most common location NPP

242
Q

earliest sign NP SCC

A

effacement of fat in FOR

243
Q

which nodes are mc in NP SCC

A

retropharyngeal

*generally, nodal mets=90%

244
Q

what percent of patients with NP SCC have skull base invasion?

A

30%

LOOK AT CLIVUS!

245
Q

division of larynx

A

1) supraglottic- epiglottis, valleculae, hypo epiglottic lig preepiglottic fat, false cords, paraglottic space, arytenoid cartilage
2) glottic region- true cords, cricoarytenoid joint, anterior commisure
3) sub glottic region-cricoid ring

246
Q

laryngocele-what, cause

A
  • fluid filled cyst of laryngeal ventricle (via obstruction)

- forceful blowers (trumpet players, glass blower), 15% obstructed via tumor

247
Q

vocal cord paralysis

A

ipsilateral expanded laryngeal ventricle OR laryngeal CA OR chest tumor from recurrent laryngeal n compression

248
Q

laryngeal cancer-MC type, RFs

A

85% SCC

-smoking, EtOH, radiation, laryngeal keratosis, HPV, GERD

249
Q

role of radiologist in laryngeal cancer?

A

staging-supraglottic, glottic, subglottic, transglottic (crosses laryngeal ventricle)

250
Q

when can partial laryngectomy be performed in setting of laryngeal CA?

A

-supraglottic w/o involvement arytenoids or laryngeal Vt

251
Q

supraglottic laryngeal cancer types

A
  • more aggressive, early LN mets, no hoarseness
    1) epiglottic centered: ant, spreads ant across hypo-epiglottic ligament into pre-epiglottic space/fat (which is rich in lymphatics!) and paired vallecula
    2) false cord/fold centered
    a) pstlat. invades paraglottic space/fat (which comm sup with pre-epiglottic space)
    b) aryepiglottic fold mass spreading into paraglottic space & piriform sinus.
    • paraglottic tumor=T3, “transglottic”, best seen in coronal
252
Q

glottic laryngeal cancer

A
  • MC and best outcome. Grows slowly. Late metastatic disease
  • “progressive & con’t hoarseness”
  • ant cord–> spread via ant commissure (typically defined as ST thickening >2mm)
  • fixation of cords=T3, best assessed with scope but suspected w/ disease in cricoarytenoid joint
253
Q

subglottic laryngeal cancer-details, location, surgical

A
  • least common, often small compared to nodal burden (often BL + mediastinal extension)
  • ST thickening btw aw & cricoid ring. only reliable sign of cc invsion=tumor on BOTH sides of cartilage (irregular sclerotic cartilage can be N)
  • invasion of cricoid=CI to laryngeal conservation surgery)-cc necessary for postoperative stability of vc’s.
254
Q

adult orbital Ca

A
  • senile
  • trochlear (superolat)
  • drusen (optic n head, looks like papilledema
  • pthisis bulbi-end stage: small globe + Ca
255
Q

orbital NF

A

middle age
CN 3, 4, 5 CN
expands SOF
well-defined lobular mass

256
Q

lymphoma in the eye

A
  • retinal
  • conal
  • lacrimal
257
Q

vagal schwannoma vs carotid body tumor

A

vagal schwannoma-NF 1. Separates ICA, IJV and displace ICA ant
-Carotid body tumor-splays ICA and ECA

258
Q

mc middle ear tumor

A

gloms tympanum paraganglioma

-arise from jacobson n at cochlear promontory

radiology (31 decks)

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