Pharynx & Larynx Flashcards
- In the staging of supraglottic laryngeal cancer, which indicates stage T3 disease?
A. Tumour confined to the site of origin
B. Cord fixation
C. Involvement of adjacent supraglottic site
D. Involvement of the tongue base
E. Involvement of the thyroid cartilage
B. Cord fixation
Stage T3 disease includes tumour limited to the larynx with cord fixation or extension to post-cricoid area, and medial wall of the pyriform sinus/pre-epiglottc space.
- Concerning carotid body tumours:
A. Usually painful, pulsatile, mass below the angle of the jaw
B. Malignant transformation in 6%
C. Demonstrate poor vascularity on angiography
D. Poor contrast enhancement on MR
E. Usually high T1
B. Malignant transformation in 6%
Carotid body tumours are painless pulsatile vascular masses, hyperintense on T2 and heterogeneously isointense on T1 with avid enhancement. Multiple flow voids are usually seen on MRI.
@# 8 A neck lump is found on clinical examination. Axial MR images of the neck demonstrate a mass displacing the parapharyngeal space posteromedially and the styloid musculature posteriorly. In which fascial space is the mass most likely to be located?
(a) Masticator space
(b) Carotid space
(c) Pharyngeal mucosal space
(d) Parotid space
(e) Retropharyngeal space
(a) Masticator space
The displacement of the parapharyngeal space and styloid musculature can help localise neck lesions:
45 A smoker suffers from a hoarse voice and is found .to have a glottic laryngeal carcinoma. The tumour is seen to have supra-glottic extension and fixes the cords. What is the tumour stage?
(a) T1
(b) T2
(c) T3
(d) T4
(e) T5
(c) T3
Staging is: T1: tumour confined to vocal cord.
T2: supra/ subglottic extension with or without impaired mobility.
T3: fixation of true vocal cord.
T4: destruction of thyroid cartilage/ extension outside Lx. There is no T5.
@# 13. A 20 year old female is under investigation for periodic halitosis. A CT scan reveals a well-defined, hypodense mass located between the longus colli muscles. There is no enhancement post-contrast injection. MRI demonstrates a midline cystic structure in the posterior roof of the nasopharynx. It shows high signal intensity on both T1 and T2 sequences. The most likely diagnosis is:
a. Benign polyp
b. Rathke’s pouch cyst
c. Ranulas
d. Tornwaldt’s cyst
e. Thyroglossal duct cyst
13.d. Tornwaldt’s cyst
Tornwaldt’s cyst is a benign mass typically located in the midline, between the longis colli muscles, in the posterior nasopharynx. They arise as a result of a focal adhesion between the ectoderm and regressing notochord. This causes the creation of a pouch but when the communication with the pouch is lost, a cyst develops. Tornwaldt’s cysts are usually asymptomatic and are picked up as incidental findings. Periodically, the pressure within the cyst increases causing the release of its contents into the nasopharynx. This leads to presentations including halitosis, foul taste in the mouth and persistent nasopharyngeal drainage. Peak age at presentation is 15–30 years. Imaging features can vary depending on the protein content within the cyst but typical features are of a well-delineated, thin-walled, midline cystic lesion measuring 2–10 mm in diameter. They are hypodense on CT, rarely calcify and do not enhance. They can be high or low on T1 (depending on protein content) but are high on T2 imaging. Rathke’s pouch cysts are located anterior and cephalad to Tornwaldt’s cysts.
- A middle-aged gentleman is diagnosed on imaging with suspected laryngeal carcinoma. Which of the following factors would favour a diagnosis of adenoid cystic carcinoma over squamous cell carcinoma?
a. A history of long-term smoking
b. Involvement of regional neck lymph nodes
c. Invasion through laryngeal cartilage
d. Supraglottic extension
e. Propensity for nerve invasion
- e. Propensity for nerve invasion
Laryngeal adenoid cystic carcinoma accounts for approximately 1% of all malignant laryngeal tumours (cc. laryngeal carcinoma – 98%). Typically, there is an absent history of smoking and regional lymph nodes are hardly ever involved. Eighty per cent of them are subglottic (around the junction with the trachea) but they may spread through the entire larynx. Their characteristic feature is their propensity to invade nerves leading to paralysis.
- A seven year old boy presents with pain in his neck. His mother thinks she can feel a lump. Ultrasound shows a thick-walled cyst with internal echoes. It has a paramedian location within the strap muscles. MRI shows a heterogeneous cystic mass measuring 3 cm in diameter. It demonstrates high signal on T1 and contains areas of low signal on T2. There is marked enhancement of the wall after administration of gadolinium. What is the most likely diagnosis?
a. Infected thyroglossal duct cyst
b. Fibroma
c. Branchial cleft cyst
d. Teratoma
e. Lymphangioma
- a. Infected thyroglossal duct cyst
Thyroglossal duct cysts arise from the remnants of the embryonic thyroglossal duct and account for up to 70% of congenital neck masses in children. Typically, children present with a non-tender mass that elevates on swallowing. If infected there may be pain, local tenderness and recent increased growth. Most are midline, although they become more paramedian below the level of the hyoid. Approximately 20% are suprahyoid, 15% occur at the level of the hyoid and 65% are infrahyoid. Generally they are thin-walled cysts and show typical cystic imaging characteristics. If infected or if the cyst has haemorrhaged, high signal may be seen on T1 and low signal may be present on T2-weighted MR images. Haemorrhage and infection may also cause thickening and marked enhancement of the wall.
- A 48 year old female presents with tinnitus. CT shows a soft-tissue mass in the region of the hypotympanum. There is irregular bone demineralisation in the region of the carotid canal and jugular foramen, making their margins irregular and partially indistinct. On proton density MR imaging, the mass has mixed hyper- and hypointensity signal. The tumour shows strong enhancement after gadolinium administration. What is the most likely diagnosis?
a. Glomus tympanicum tumour
b. Glomus jugulare tumour
c. Carotid body tumour
d. Glomus vagale tumour
e. Cholesteatoma
- b. Glomus jugulare tumour
All of the tumours listed in the differential (apart from cholesteatoma) are paragangliomas. They grow slowly and rarely metastasise.
Glomus jugulare tumours originate from the adventitia of the jugular vein.
CT demonstrates a soft-tissue mass in the region of the jugular bulb/hypotympanum/middle ear space.
Local bone destruction is common, particularly of the jugular plate or the lateral portion of the caroticojugular spine.
A unique ‘salt-and-pepper’ pattern of hyper- and hypointensity on T1- and T2-weighted images is also seen. This represents multiple small tumour vessels. They are highly vascular lesions, usually deriving a blood supply from branches of the external carotid artery
QUESTION 14
A 9-year-old girl is referred for a neck ultrasound to investigate a superficial swelling at the angle of her left mandible. The scan reveals a well-defined, anechoic lesion anterior to the left sternocleidomastoid muscle with posterior acoustic enhancement. What is the most likely diagnosis?
A Pseudoaneurysm of the left common carotid artery
B Ranula
C Second branchial cleft cyst
D Third branchial cleft cyst
E Thyroglossal duct cyst
C Second branchial cleft cyst
Ninety-five per cent of branchial cleft anomalies arise from the remnants of the second branchial apparatus. Second branchial cleft cysts lie superficial to the common carotid artery and internal jugular vein, posterior to the submandibular gland and along the medial and anterior margin of the submandibular gland. If uninfected, the majority appear as simple cysts although they may have internal echoes due to proteinaceous content. If complicated by infection or inflammation they are thick-walled, ill-defined and heterogeneous. In this case they are difficult to distinguish from metastatic lymph nodes and fine needle aspiration is indicated.
QUESTION 37
A 55-year-old woman presents with pulsatile tinnitus in her right ear. She also complains of dizziness and on examination she has hearing loss on the right side. MRI shows a mass in the right jugular fossa which is of high signal on T2w images and contains several low signal areas. There is marked enhancement postcontrast. What is the most likely diagnosis?
A Acoustic neuroma
B Glomus jugulare
C Glomus tympanicum
D Meningioma
E Metastasis
B Glomus jugulare
The low signal areas within the mass are due to flow voids as glomus tumours are highly vascular.
@# QUESTION 74
A 48-year-old woman presents to her GP with a midline neck mass which has been growing slowly over many months. On examination, she has a welldefined lump in the suprasternal notch and she is referred for an ultrasound. This shows a predominantly cystic lesion with some internal echoes. There is also a single echogenic focus within the lesion which has dense posterior acoustic shadowing. What is the most likely diagnosis?
A Dermoid cyst
B Epidermoid cyst
C Haemorrhagic thyroid nodule
D Ranula
E Thymic cyst
A Dermoid cyst
Dermoid cysts are the commonest teratoma in the head and neck. This scenario describes a cyst with cellular contents as well as an osseodental structure. CT and MRI may show globules of fat with fat and/or fluid levels.
@# 42. You are reporting a CT scan of neck in a patient with a head and neck cancer. You see an enlarged necrotic jugulo-digastric lymph node on the right side and wish to describe the appropriate level of this lymph node in your report. What is the correct level?
A. I.
B. II.
C. III.
D. IV.
E. V.
F. VI.
G. VII.
- B. II.
Lymph nodes in the neck have been divided into seven levels, generally for the purpose of squamous cell carcinoma staging. This is, however, not all inclusive, as the parotid nodes and retropharyngeal space nodes are not included in this system.
Level I: Below mylohyoid to hyoid bone anteriorly
Level Ia: Submental Level Ib: Submandibular
Level II: Jugulodigastric (base of skull to hyoid)
Level III: Deep cervical (hyoid to cricoid)
Level IV: Virchow (cricoid to clavicle)
Level V: Posterior triangle groups
Level Va: Accessory spinal (posterior triangle), superior half
Level Vb: Accessory spinal (posterior triangle), inferior half
Level VI: Prelaryngeal/pretracheal/Delphian node
Level VII: Superior mediastinal (between common carotid arteries (CCAs), below top of manubrium) Lymph node levels of the neck.
@# 45. A 50-year-old male undergoes an MR carotid angiogram on which an incidental soft-tissue mass is noted in right parapharyngeal soft tissue. The mass displaces the right parapharyngeal space anteromedially. What is the location of the soft-tissue mass?
A. Masticator space.
B. Carotid space.
C. Retropharyngeal space.
D. Mucosal space.
E. Parotid space
- E. Parotid space.
Loss of symmetry and displacement of the parapharyngeal space are useful for lesion identification and localization in the parapharyngeal soft tissues.
A thorough knowledge of the anatomical relationship between the spaces is essential.
The parapharyngeal space is shaped like an inverted pyramid with the apex pointing inferiorly toward the greater cornu of the hyoid bone and the skull base demarcates the base superiorly.
A lesion arising from the parotid space displaces the fat in the parapharyngeal space anteromedially.
A lesion in the masticator space displaces the parapharyngeal fat posteromedially.
Carotid space lesions displace it anteriorly,
mucosal space lesions displace it posterolaterally,
and retropharyngeal space lesions displace it anterolaterally.
Posterior displacement of the carotid space or parapharyngeal fat completely surrounding a lesion localizes it to the parapharyngeal space.
- A 60-year-old woman presents with a painless, slowly growing mass in the lateral aspect of the neck. The patient is referred for imaging with a clinical diagnosis of carotid body paraganglioma. Which of the following is a distinctive feature of carotid body paraganglioma on imaging?
A. Soft-tissue mass in the carotid space.
B. Intense enhancement after IV contrast administration.
C. High signal on T2WI.
D. Splaying of the internal and external carotid arteries.
E. Low signal on T2WI.
- D. Splaying of the internal and external carotid arteries.
Carotid body tumour or paraganglioma is the most common paraganglioma of the head and neck. It arises from the paraganglionic cells located on the medial aspect of the carotid bifurcation. On MRI, they are of low to intermediate signal intensity on T1WI and hyperintense on T2WI. They are hypervascular and demonstrate intense enhancement after contrast administration. Splaying of the internal and external carotid arteries and multiple flow voids producing a ‘salt and pepper’ appearance are distinctive features on imaging.
- A 5-year-old girl with a clinical suspicion of retropharyngeal abscess is referred for MRI of the neck. Which of the following features on MRI is useful in differentiating retropharyngeal abscess from retropharyngeal suppurative lymph node?
A. Enhancing wall.
B. Rounded or ovoid configuration.
C. Mass effect.
D. Filling of retropharyngeal space from side to side.
E. Primary infection source such as otitis media or tonsillitis.
- D. Filling of retropharyngeal space from side to side.
Understanding the retropharyngeal space anatomy is crucial in differentiating retropharyngeal space abscess and retropharyngeal suppurative lymph node. The retropharyngeal space is bounded by visceral fascia covering the pharynx and oesophagus anteriorly, the prevertebral fascia covering the prevertebral muscles posteriorly, and the carotid sheaths laterally. A retropharyngeal suppurative lymph node is unilateral, whereas a retropharyngeal abscess fills the entire retropharyngeal space from side to side. The differentiation is important because many cases of suppurative lymph nodes do not have purulent material at surgery. The treatment for suppurative lymph nodes is a trial of antibiotics if the patient is stable. Surgical drainage is considered if there is progression or if the suppurative lymph node is large at presentation. The volume of central low density is a better predictor of purulence than the mere presence of rim enhancement and low-density centre.
