Samplex Through the Years Flashcards
What is the term for benign thickening of normal cortical and medullary
bone on the oral surface of the hard palate? (Som, p. 14)
a. Torus palatinus
b. Torus maxillaris
c. Torus tubarius
d. Torus mandibularis
a. Torus palatinus
-covered by thin mucosa
-typically aligns along the median intermaxillary–interpalatine suture, protrudes downward from the apex of the palatal arch, and extends to both sides, symmetrically
-palatal rugae and the greater palatine foramina are usually spared, so the tori have a “faceted,” triangular/diamond configuration
-nasal aspect of the hard palate is never affected by simple torus palatinus
Cervical lymph node seen within 2cm of the skull base and lie medial to the internal carotid arteries (Som Head and Neck Imaging, 5th ed, p2297)
a. Level IB
b. Level IIA
c. Level IIB
d. Retropharyngeal
d. Retropharyngeal nodes
ABOVE the HYOID BONE: Levels I-II
Level Ia and Ib are demarcated by anterior belly of the digastric
If medial, level Ia. If lateral, level Ib
Level Ib and II are demarcated by back of the submandibular gland
If anterior, level Ib. If posterior, level II
Level IIa and IIb are demarcated by IJV.
If anterior or posterior with no fat plane, level IIa. If posterior with fat plane, level IIb
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N1A for 2010 AJCC definitions of TNM for thyroid cancer (Som Head and Neck Imaging, 5th ed, p2312)
a. Metastasis to level III
b. Metastasis to level IV
c. Metastasis to level V
d. Metastasis to level VI
d. Metastasis to level VI
N1
The first echelon of metastasis is to the level VI nodes (paralaryngeal, paratracheal, and prelaryngeal [Delphian] nodes adjacent to the thyroid gland). However, involvement of these nodal stations has essentially no prognostic value and therefore is not part of the staging system.
Most common primary neoplasm in the parapharyngeal space (Som Head and Neck Imaging, 5th ed, p2393)
a. Neurofibroma
b. Schwannoma
c. Pleomorphic adenoma
d. Mucoepidermoid carcinoma
c. Pleomorphic adenoma
The vast majority of primary tumors affecting the parapharyngeal space arise from the deep portion of the parotid gland, and almost all of them are pleomorphic adenomas.
Although statistically the most common masses in the parapharyngeal space are hyperplastic or metastatic level II lymph nodes, they are not included in most clinical series of parapharyngeal space masses, as they are not considered to be primary lesions of this space.
(Pleomorphic adenoma, also referred to as benign mixed tumor, is the most common salivary gland tumor and represents 70% to 80% of all benign tumors of the major salivary glands)
The most common malignancies are mucoepidermoid carcinomas, adenoid cystic carcinomas, and acinic cell carcinomas.
Most common type of malignant minor salivary gland tumor (Som Head and Neck Imaging, 5th ed, p2555)
a. Clear cell carcinoma
b. Mucoepidermoid carcinoma
c. Epithelial-Myoepithelial carcinoma
d. Adenoid cystic carcinoma
b. Mucoepidermoid carcinoma
Mucoepidermoid carcinoma (MEC) comprises 2.8% to 15.5% of all salivary gland tumors, 12% to 29% of malignant salivary gland tumors, and 6.5% to 41% of minor salivary gland tumors, representing the most common type of malignant minor salivary gland tumor in most series.
About half of the cases occur in the major salivary glands; more than 80% of these occur in the parotid gland, 8% to 13% in the submandibular gland, and 2% to 4% involve the sublingual gland
In the minor salivary glands, MEC most commonly arises on the palate, but a significant number may also be found in the retromolar area floor of the mouth, buccal mucosa, lip, and tongue. Rarely, MEC can arise as primary jaw or heterotopic intranodal tumors or as laryngeal, lacrimal, nasal, paranasal sinus, tracheal, or pulmonary tumors.
It is the most common malignant salivary gland tumor to arise in children and adolescents under 20 years of age.
MEC has a slight pre- dilection for women.
The most commonly implicated etiologic factor is radiation
Low-grade lesions are benign in appearance, with apparently well-delineated, smooth margins. Cystic areas may be present, with a low attenuation of 10 to 18 HU. Rarely, focal calcification may be seen. The appearance is similar to that of a benign mixed tumor.
On MR imaging, these low-grade tumors also have signal intensities that are indistinguishable from those of pleomorphic adenomas. By comparison, the high-grade lesions have indistinct infiltrating margins and may destroy salivary ducts (Fig. 40-177). On CT they usually have few cystic areas, and they tend to be more homogeneous in appearance than the low-grade tumors. On MR imaging, these cellular tumors tend to have low to intermediate signal intensities on both T1-weighted and T2-weighted images
Most common cause of primary hyperparathyroidism (Som Head and Neck Imaging, 5th ed, p2659)
a. Parathyroid hyperplasia
b. Multiple parathyroid adenoma
c. Single parathyroid adenoma
d. Parathyroid carcinoma
c. Single parathyroid adenoma
The causes of primary hyperparathyroidism include a single parathyroid adenoma (75% to 85% of cases), parathyroid hyperplasia (10% to 15%), multiple parathyroid adeno- mas (2% to 3%), and, rarely, parathyroid carcinomas (less than 1%)
Secondary hyperparathyroidism occurs in patients with chronic renal insufficiency in whom there is not only retained nonprotein nitrogen and creatinine, but there is also retained phosphate, which causes a marked hyperphosphatemia.
Secondary hyperparathyroidism can also be the result of vitamin D deficiency
In tertiary hyperparathyroidism, hypercalcemia occurs as a sequela of secondary hyperparathyroidism as a result of the autonomous secretion of PTH from chronically overstimu- lated parathyroid glands. It occurs most often in patients with chronic secondary hyperparathyroidism and in renal trans- plant patients. These cases are treated by surgery.
Type of thyroid malignancy with the highest incidence of cervical lymph node metastases (Som Head and Neck Imaging, 5th ed, p2639)
a. Follicular carcinoma
b. Papillary carcinoma
c. Medullary carcinoma
d. Hurthle-Cell tumor
b. Papillary carcinoma
Differentiated thyroid carcinomas, including papillary (60% to 80%) and follicular subtypes, are most common and have a favorable prognosis. Carcinomas arise from both follicular and parafollicular C cells
Most benign to most aggressive: Papillary > Follicular > Medullary > Anaplastic
Prognosis is affected by gender, biologic behavior, tumor size, and the tendency for hematogenous or lymphatic metastases
TCVs (tall-cell variant) confined to the thyroid do appear to have a greater tendency to present with lymph node metastasis than classical papillary thyroid carcinoma, suggesting a more aggressive biologic behavior
The most common features of papillary cancer on sonography include a hypoechoic nodule with solid echotex- ture, microcalcifications, and intrinsic vascularity. On CT, the gland may appear normal, there may be a benign-appearing nodule, or there can be a mass with irregular margin
Of thyroid malignancies, papillary carcinoma has the highest incidence of cervical lymph node metastases, seen in up to 50% of cases
The majority of nodal metas- tases from thyroid cancer will occur in the lateral cervical lymph chains and central compartment, and less commonly in the mediastinum. Occasionally, metastases will occur in retropharyngeal lymph nodes, usually in the setting of recurrent disease
The severity of this ultrasound finding tends to parallel the patient’s degree of hyperthyroidism (Som Head and Neck Imaging, 5th ed, p2629)
a. Enlargement of the thyroid gland
b. Increase in thyroid vascularity
c. Heterogeneous echopattern of the thyroid
d. With discrete nodules
b. Increase in thyroid vascularity
Grave’s disease:
On ultrasonography, the gland is diffusely enlarged with a smooth but lobular contour, and may range from isoechoic to diffusely hypoechoic. The echotexture is homogeneous without discrete nodules, but patchy areas of altered echotexture may occur. There is a characteristic marked increase in thyroid vascularity observed on color Doppler called the “thyroid inferno,” the severity of which tends to parallel the patient’s degree of hyperthyroidism.
The CT and MR imaging findings in Graves’ disease are nonspecific. The enlarged thyroid demonstrates avid enhancement. The CT density is actually decreased, reflecting a decrease in iodine concentration even though there is an overall increase in iodine content in the gland.
After treatment, density values may not return to normal
Jugulodigastric and submandibular lymph nodes are considered abnormal if the maximal longitudinal diameter is greater than (Som Head and Neck Imaging, 5th ed, p2353)
a. 8 mm
b. 10 mm
c. 11 mm
d. 15 mm
d. 15 mm
The jugulodigastric (level II) and submandibular (level I) nodes tend to be larger than other cervical nodes because they are the primary drainage nodes for, among other things, the inflammations associated with teething, tonsillitis, pharyngitis, sinusitis, and skin infections of the facial region
On imaging, these nodes are homogeneous, with smooth, noninfiltrating margins, and they enhance slightly.
On CT, such nodes usually have an attenuation similar to or slightly less than that of muscle.
On MR imaging, the nodes typically have homogeneously low to intermediate T1-weighted and fairly high T2-weighted signal intensities.
The two major imaging criteria used are nodal size and the presence of central nodal necrosis or nodal nonhomogeneity (see table above)
Interestingly, regardless of which of these criteria are used, the overall error rates for both false-positive and false-negative diagnoses are between 15% and 20%, reflecting the limitations of imaging and the use of size criteria.
UTZ:
When considering all necks (with and without clinical disease), the minimal axial diameters should be 8 to 9 mm for level II and 7 to 8 mm for the rest of the neck
Central necrosis
On T2-weighted MR images, such nodes have areas of both high and intermediate signal inten- sity. The high signal intensity corresponds to the areas of necrosis, while the intermediate signal intensity corresponds to tumor cells and residual normal lymph node tissues.
Regardless of lymph node size, the most reliable imaging finding of metastatic disease is the presence of central nodal necrosis on contrast-enhanced CT and, as mentioned, when such areas are larger than 3 mm, they are routinely identified on CT
Hyperplastic versus metastatic LN with central necrosis:
On noncontrast MR, as described, the most reliable finding is variable T2-weighted signal intensity. A less reliable criterion is the presence on T1-weighted MR images of low signal intensity areas that do not enhance. Use T1-weighted, contrast-enhanced, fat- suppressed MR image that a central nonenhancing region (akin to the central nodal necrosis appearance on CT).
Subcapsular Nodal Tumor
Because the majority of the tumor load enters a lymph node via the afferent lymphatics, the tumor cells first start to proliferate within the node in the subcapsular regions
CT: low-attenuation focal areas in the subcapsular nodal regions
Type of neck dissection that removes lymph node levels I to V and at least one of the non-nodal structures such as sternocleidomastoid muscle, spinal accessory nerve, internal jugular vein or submandibular gland (Som Head and Neck Imaging, 5th ed, p2778)
a. Radical
b. Modified
c. Selective
d. Extended
b. Modified
Tumors in the oral cavity most frequently metastasize to levels I, II, and III nodes.
Tumors involving the oropharynx, hypopharynx, and supraglottic larynx most commonly metastasize to levels II, III, and IV nodes
The most common fractures of the facial skeleton: (Som & Curtin, Head and Neck Imaging, 5th ed, p. 494)
a. Nasal bone
b. Maxillary bone
c. Zygomatic bone
d. Orbital walls
a. Nasal bone
Nasal injuries are the most common fractures of the facial skeleton.
In summary, the majority of nasal bone fractures involve the thinner, distal third of the nasal bones, and the nasoethmoid margin remains intact. A lateral blow to the nose usually causes a simple cartilage depression or fracture of only the ipsilateral nasal bone
Which of the following is/are matched correctly? (Som & Curtin, Head and Neck Imaging, 5th ed, p. 502)
a. Le Fort I: Pyramid-shaped fracture
b. Le Fort II: Floating palate
c. Le Fort III: Craniofacial dissociation
d. All of the above.
c. Le Fort III: Craniofacial dissociation
Le Fort I: Guérin or “floating palate”:
-The fracture extends through the lower nasal septum, the lower walls of the maxillary sinuses, and the lower pterygoid plates
-Involves the entire palate, maxillary alveolus and teeth, and portions of the pterygoid plates
Le Fort II: Pyramid-shaped fracture:
-Extends through the root of the nose and then runs bilaterally to involve the lacrimal bones and medial orbital walls. On each side the fracture line then turns anteriorly along the floor of the orbit near the infraorbital canal and extends down the zygomatico- maxillary suture and the anterior wall of the maxilla; posteri- orly the fracture goes down across the infratemporal surface of the maxilla and finally extends through the lower pterygoid plates.
-In the Le Fort II fractures (Wassmund I and Wassmund II) the zygomatic bones remain attached to the cranium.
Le Fort III: Craniofacial dissociation:
-The distinguishing feature between the Le Fort III fracture and the Le Fort II fracture is the inclusion in the Le Fort III fractured segment of the zygomas and lateral orbital walls.
A patient who was punched in the face by a known assailant had a facial CT done in another institution. Their impression was a trimalar fracture on the left. The ORL and Ophtha RODs asked for second opinion. What will you expect to see while reviewing the CT to confirm the diagnosis? (Som & Curtin, Head and Neck Imaging, 5th ed, p. 506)
a. Fractures involving the left zygoma, left orbital floor with extension to the medial aspect of the left maxilla, the premolar region and the palate.
b. Fractures involving the left lateral orbital wall, left zygomatic arch, and left anterior maxilla
c. Fractures involving the lateral and inferior wall of the left orbit and left zygomatic arch
d. Fractures involving the lateral and inferior wall of the left orbit, left lamina papyrecea, and left zygomatic arch
b. Fractures involving the left lateral orbital wall, left zygomatic arch, and left anterior maxilla
Zygomatic fractures are the second most common midfacial fractures after nasal bone trauma. Fracture lines extend from the lateral orbital wall (zygomaticofrontal suture and the zygo- maticosphenoid suture) to the inferior orbital fissure, then across the orbital floor near the infraorbital canal, down the anterior maxilla near the zygomaticomaxillary suture, and up the posterior maxillary wall back to the inferior orbital fissure.
That is, fracture lines are seen (1) through the lateral orbital wall and rim, (2) separating the zygoma and maxilla, and (3) through the zygomatic arch
Weakest part of the zygomatic arch: 1.5 cm dorsal to the zygo- maticotemporal suture
Tetrapod or quadramalar fractures:
-Fractures extend through four suture lines (zygomaticofrontal, zygomaticosphenoid, zygomaticotemporal, and zygomaticomaxillary)
What differentiates staphyloma and coloboma? (Som & Curtin, Head and Neck Imaging, 5th ed, p. 594)
a. Staphyloma is congenital and coloboma is degenerative and a result of infection.
b. Staphyloma may be associated with congenital syndromes.
c. Staphyloma has thin but layers are all intact while coloboma has an actual gap extending completely through the involved structures.
d. All are true.
c. Staphyloma has thin but layers are all intact while coloboma has an actual gap extending completely through the involved structures.
On orbital MRI, a V-shaped pattern with the apex pointing toward the optic disc is seen within the globe. What is your diagnosis? (Som & Curtin, Head and Neck Imaging, 5th ed, p. 599)
a. Posterior hyaloid detachment
b. Retinal detachment
c. Choroidal detachment
d. Persistent primary vitreous
b. Retinal detachment
This term refers to the end-stage calcified shrunken globe. (Som & Curtin, Head and Neck Imaging, 5th ed, p. 604)
a. Phthisis bulbi
b. Retinoblastoma
c. Warburg
d. Pseudotumor
a. Phthisis bulbi
Phthisis bulbi is the term used to refer to an end-stage calci- fied shrunken globe, regardless of etiology. Phthisis bulbi may result from a variety of previous insults, but trauma and infection are the most common causes
Warburg’s Syndrome
Complex syndromes with congenital malformations of the central nervous system, microphthalmia, and congenital unilateral or bilateral retinal nonattachment have been described in a number of disorders such as Meckel’s syndrome, a disorder with malformations of the central nervous system, including encephalocele, cleft palate, polydactyly, cysts of the liver and kidneys, genital malformations, and microphthalmia
Warburg’s syndrome, is a congenital oculocerebral disorder caused by a genetic defect that simultaneously affects ocular and cerebral embryogenesis and specifically involves the retina and the brain. The syndrome emphasizes the developmental and morphologic similarities between the cerebral cortex and the retina. The syndrome is characterized by congenital bilateral leukocoria.
The CT and MR imaging findings in the eyes of patients with Warburg’s syndrome include bilateral retinal detachment, subretinal hemorrhage, vitreous hemorrhage, and gravi- tational intravitreal fluid
Idiopathic orbital inflammation is commonly referred to as orbital pseudotumor
-In general, orbital pseudotumor represents a nongranulomatous inflammatory process in the orbit or eye with no known local or systemic cause.
Among orbital disorders, after Graves disease, pseudotumor is the next most common ophthalmologic disease
