Ebook Diagnostic imaging head and neck (2nd edition): Part 1

Diagnostic Imaging Head and Neck

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Diagnostic Imaging Head and Neck

Table of Contents
Authors......................................................................................................................................................................12
Dedication .................................................................................................................................................................14
Case Contributors ......................................................................................................................................................14
Preface ......................................................................................................................................................................15
Acknowledgements....................................................................................................................................................16
Part I - Suprahyoid and Infrahyoid Neck......................................................................................................................16
Section 1 - Introduction and Overview ....................................................................................................................16
Suprahyoid and Infrahyoid Neck Overview ..........................................................................................................16
Section 2 - Parapharyngeal Space ...........................................................................................................................23
Introduction and Overview .................................................................................................................................23
Parapharyngeal Space Overview .....................................................................................................................23
Benign Tumors ...................................................................................................................................................26
Parapharyngeal Space Benign Mixed Tumor....................................................................................................26
Section 3 - Pharyngeal Mucosal Space ....................................................................................................................29
Introduction and Overview .................................................................................................................................29
Pharyngeal Mucosal Space Overview ..............................................................................................................29
Congenital Lesions..............................................................................................................................................34
Tornwaldt Cyst ...............................................................................................................................................34
Infectious and Inflammatory Lesions...................................................................................................................37
Retention Cyst of Pharyngeal Mucosal Space ..................................................................................................37
Tonsillar Inflammation ....................................................................................................................................40
Tonsillar/Peritonsillar Abscess.........................................................................................................................43
Benign and Malignant Tumors ............................................................................................................................46

Benign Mixed Tumor of Pharyngeal Mucosal Space .........................................................................................46
Non-Hodgkin Lymphoma of Pharyngeal Mucosal Space...................................................................................49
Masticator Space Overview.............................................................................................................................55
Section 4 - Masticator Space...................................................................................................................................60
Introduction and Overview .................................................................................................................................60
Pterygoid Venous Plexus Asymmetry ..............................................................................................................60
Pseudolesions ....................................................................................................................................................63
Benign Masticator Muscle Hypertrophy ..........................................................................................................63
CNV3 Motor Denervation ...............................................................................................................................66
Infectious Lesions ...............................................................................................................................................72
Masticator Space Abscess ...............................................................................................................................72
Benign Tumors ...................................................................................................................................................78
Masticator Space CNV3 Schwannoma .............................................................................................................78
Malignant Tumors ..............................................................................................................................................81
Masticator Space CNV3 Perineural Tumor .......................................................................................................81
Masticator Space Chondrosarcoma .................................................................................................................87
Masticator Space Sarcoma ..............................................................................................................................93
Section 5 - Parotid Space ........................................................................................................................................99
Introduction and Overview .................................................................................................................................99
Parotid Space Overview ..................................................................................................................................99
Infectious and Inflammatory Lesions................................................................................................................. 104
Acute Parotitis .............................................................................................................................................. 104
Parotid Sjogren Syndrome ............................................................................................................................ 110
Benign Lymphoepithelial Lesions-HIV............................................................................................................ 116
Benign Tumors ................................................................................................................................................. 122
Parotid Benign Mixed Tumor ........................................................................................................................ 122
Warthin Tumor ............................................................................................................................................. 128
Parotid Schwannoma .................................................................................................................................... 134
Malignant Tumors ............................................................................................................................................ 137
Parotid Mucoepidermoid Carcinoma............................................................................................................. 137

Parotid Adenoid Cystic Carcinoma ................................................................................................................ 143
Parotid Malignant Mixed Tumor ................................................................................................................... 146
Parotid Non-Hodgkin Lymphoma .................................................................................................................. 149
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Diagnostic Imaging Head and Neck
Metastatic Disease of Parotid Nodes ............................................................................................................. 155
Section 6 - Carotid Space ...................................................................................................................................... 161
Introduction and Overview ............................................................................................................................... 161
Carotid Space Overview ................................................................................................................................ 161
Normal Variants ............................................................................................................................................... 166
Tortuous Carotid Artery in Neck .................................................................................................................... 166
Vascular Lesions ............................................................................................................................................... 169
Carotid Artery Dissection in Neck .................................................................................................................. 169
Carotid Artery Pseudoaneurysm in Neck ....................................................................................................... 175
Carotid Artery Fibromuscular Dysplasia in Neck ............................................................................................ 178
Acute Idiopathic Carotidynia ......................................................................................................................... 181
Jugular Vein Thrombosis ............................................................................................................................... 184
Post-Pharyngitis Venous Thrombosis (Lemierre) ........................................................................................... 190
Benign Tumors ................................................................................................................................................. 193
Carotid Body Paraganglioma ......................................................................................................................... 193
Glomus Vagale Paraganglioma ...................................................................................................................... 199
Carotid Space Schwannoma .......................................................................................................................... 206
Sympathetic Schwannoma ............................................................................................................................ 212
Carotid Space Neurofibroma ......................................................................................................................... 215
Carotid Space Meningioma ........................................................................................................................... 218
Section 7 - Retropharyngeal Space........................................................................................................................ 221
Introduction and Overview ............................................................................................................................... 221
Retropharyngeal Space Overview.................................................................................................................. 221

Infectious and Inflammatory Lesions................................................................................................................. 226
Reactive Adenopathy of Retropharyngeal Space ........................................................................................... 226
Suppurative Adenopathy of Retropharyngeal Space ...................................................................................... 229
Retropharyngeal Space Abscess .................................................................................................................... 232
Retropharyngeal Space Edema...................................................................................................................... 238
Metastatic Tumors ........................................................................................................................................... 244
Nodal SCCa of Retropharyngeal Space........................................................................................................... 244
Nodal Non-Hodgkin Lymphoma in Retropharyngeal Space ............................................................................ 247
Non-SCCa Metastatic Nodes in Retropharyngeal Space ................................................................................. 250
Section 8 - Perivertebral Space ............................................................................................................................. 253
Introduction and Overview ............................................................................................................................... 253
Perivertebral Space Overview ....................................................................................................................... 253
Pseudolesions .................................................................................................................................................. 258
Levator Scapulae Muscle Hypertrophy .......................................................................................................... 258
Infectious and Inflammatory Lesions................................................................................................................. 261
Acute Calcific Longus Colli Tendonitis............................................................................................................ 261
Perivertebral Space Infection ........................................................................................................................ 264
Vascular Lesions ............................................................................................................................................... 270
Vertebral Artery Dissection in Neck............................................................................................................... 270
Benign and Malignant Tumors .......................................................................................................................... 273
Brachial Plexus Schwannoma in Perivertebral Space ..................................................................................... 273
Chordoma in Perivertebral Space .................................................................................................................. 276
Vertebral Body Metastasis in Perivertebral Space ......................................................................................... 279
Section 9 - Posterior Cervical Space ...................................................................................................................... 285
Introduction and Overview ............................................................................................................................... 285
Posterior Cervical Space Overview ................................................................................................................ 285
Benign Tumors ................................................................................................................................................. 288
Posterior Cervical Space Schwannoma .......................................................................................................... 288
Metastatic Tumors ........................................................................................................................................... 294
SCCa in Spinal Accessory Node ...................................................................................................................... 294

Non-Hodgkin Lymphoma in Spinal Accessory Node ....................................................................................... 297
Section 10 - Visceral Space ................................................................................................................................... 300
Introduction and Overview ............................................................................................................................... 300
Visceral Space Overview ............................................................................................................................... 300
Inflammatory Lesions ....................................................................................................................................... 305
Chronic Lymphocytic Thyroiditis (Hashimoto)................................................................................................ 305
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Diagnostic Imaging Head and Neck
Metabolic Disease ............................................................................................................................................ 308
Multinodular Goiter ...................................................................................................................................... 308
Benign Tumors ................................................................................................................................................. 314
Thyroid Adenoma ......................................................................................................................................... 314
Parathyroid Adenoma in Visceral Space ........................................................................................................ 320
Malignant Tumors ............................................................................................................................................ 326
Differentiated Thyroid Carcinoma ................................................................................................................. 326
Medullary Thyroid Carcinoma ....................................................................................................................... 332
Anaplastic Thyroid Carcinoma....................................................................................................................... 338
Non-Hodgkin Lymphoma of Thyroid.............................................................................................................. 344
Parathyroid Carcinoma ................................................................................................................................. 347
Cervical Esophageal Carcinoma ..................................................................................................................... 350
Miscellaneous .................................................................................................................................................. 353
Esophagopharyngeal Diverticulum (Zenker) .................................................................................................. 353
Colloid Cyst of Thyroid .................................................................................................................................. 356
Lateral Cervical Esophageal Diverticulum ...................................................................................................... 357
Section 11 - Hypopharynx, Larynx, and Cervical Trachea ....................................................................................... 359
Introduction and Overview ............................................................................................................................... 359
Hypopharynx, Larynx, & Trachea Overview ................................................................................................... 359
Infectious and Inflammatory Lesions................................................................................................................. 366

Croup ........................................................................................................................................................... 366
Epiglottitis in a Child ..................................................................................................................................... 370
Supraglottitis ................................................................................................................................................ 371
Trauma............................................................................................................................................................. 372
Laryngeal Trauma ......................................................................................................................................... 372
Benign and Malignant Tumors .......................................................................................................................... 378
Upper Airway Infantile Hemangioma ............................................................................................................ 378
Laryngeal Chondrosarcoma........................................................................................................................... 382
Treatment-related Lesions................................................................................................................................ 387
Post-Radiation Larynx ................................................................................................................................... 387
Miscellaneous .................................................................................................................................................. 391
Laryngocele .................................................................................................................................................. 391
Vocal Cord Paralysis ...................................................................................................................................... 396
Acquired Subglottic-Tracheal Stenosis........................................................................................................... 402
Section 12 - Lymph Nodes .................................................................................................................................... 408
Introduction and Overview ............................................................................................................................... 408
Lymph Node Overview.................................................................................................................................. 408
Infectious and Inflammatory Lesions................................................................................................................. 414
Reactive Lymph Nodes.................................................................................................................................. 414
Suppurative Lymph Nodes ............................................................................................................................ 420
Tuberculous Lymph Nodes ............................................................................................................................ 426
Non-TB Mycobacterium Nodes ..................................................................................................................... 429
Sarcoidosis Lymph Nodes.............................................................................................................................. 430
Giant Lymph Node Hyperplasia (Castleman).................................................................................................. 432
Histiocytic Necrotizing Lymphadenitis (Kikuchi) ............................................................................................. 438
Kimura Disease ............................................................................................................................................. 441
Malignant Tumors ............................................................................................................................................ 447
Nodal Non-Hodgkin Lymphoma in Neck ........................................................................................................ 447
Nodal Hodgkin Lymphoma in Neck................................................................................................................ 453
Nodal Differentiated Thyroid Carcinoma ....................................................................................................... 459

Systemic Nodal Metastases in Neck .............................................................................................................. 462
Section 13 - Trans-spatial and Multi-spatial .......................................................................................................... 465
Introduction and Overview ............................................................................................................................... 465
Trans-spatial & Multi-spatial Overview.......................................................................................................... 465
Normal Variants ............................................................................................................................................... 468
Prominent Thoracic Duct in Neck .................................................................................................................. 468
Benign Tumors ................................................................................................................................................. 471
Lipoma of H&N ............................................................................................................................................. 471
Hemangiopericytoma of H&N ....................................................................................................................... 477
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Diagnostic Imaging Head and Neck
Plexiform Neurofibroma of H&N ................................................................................................................... 480
Malignant Tumors ............................................................................................................................................ 483
Post-Transplantation Lymphoproliferative Disorder ...................................................................................... 483
Extraosseous Chordoma ............................................................................................................................... 486
Non-Hodgkin Lymphoma of H&N .................................................................................................................. 489
Liposarcoma of H&N ..................................................................................................................................... 495
Synovial Sarcoma of H&N ............................................................................................................................. 498
Malignant Peripheral Nerve Sheath Tumor of H&N ....................................................................................... 501
Miscellaneous .................................................................................................................................................. 504
Lymphocele of Neck ..................................................................................................................................... 504
Sinus Histiocytosis (Rosai-Dorfman) of H&N .................................................................................................. 507
Fibromatosis of H&N .................................................................................................................................... 510
Section 14 - Oral Cavity ........................................................................................................................................ 516
Introduction and Overview ............................................................................................................................... 516
Oral Cavity Overview .................................................................................................................................... 516
Pseudolesions .................................................................................................................................................. 523
Hypoglossal Nerve Motor Denervation ......................................................................................................... 523

Congenital Lesions............................................................................................................................................ 525
Submandibular Space Accessory Salivary Tissue ............................................................................................ 525
Oral Cavity Dermoid and Epidermoid ............................................................................................................ 528
Oral Cavity Lymphatic Malformation ............................................................................................................. 534
Lingual Thyroid ............................................................................................................................................. 538
Infectious and Inflammatory Lesions................................................................................................................. 541
Ranula .......................................................................................................................................................... 541
Oral Cavity Sialocele ..................................................................................................................................... 546
Submandibular Gland Sialadenitis ................................................................................................................. 549
Oral Cavity Abscess ....................................................................................................................................... 552
Benign Tumors ................................................................................................................................................. 558
Submandibular Gland Benign Mixed Tumor .................................................................................................. 558
Palate Benign Mixed Tumor .......................................................................................................................... 561
Malignant Tumors ............................................................................................................................................ 564
Sublingual Gland Carcinoma ......................................................................................................................... 564
Submandibular Gland Carcinoma .................................................................................................................. 567
Oral Cavity Minor Salivary Gland Malignancy ................................................................................................ 570
Submandibular Space Nodal Non-Hodgkin Lymphoma .................................................................................. 573
Submandibular Space Nodal SCCa ................................................................................................................. 576
Section 15 - Mandible-Maxilla and Temporomandibular Joint ............................................................................... 579
Introduction and Overview ............................................................................................................................... 579
Mandible-Maxilla and TMJ Overview ............................................................................................................ 579
Congenital Lesions............................................................................................................................................ 586
Solitary Median Maxillary Central Incisor ...................................................................................................... 586
Nonneoplastic Cysts ......................................................................................................................................... 589
Nasolabial Cyst ............................................................................................................................................. 589
Periapical Cyst (Radicular) ............................................................................................................................. 592
Dentigerous Cyst .......................................................................................................................................... 595
Simple Bone Cyst (Traumatic) ....................................................................................................................... 598
Nasopalatine Duct Cyst ................................................................................................................................. 601

Infectious and Inflammatory Lesions................................................................................................................. 604
TMJ Juvenile Idiopathic Arthritis ................................................................................................................... 604
Mandible-Maxilla Osteomyelitis.................................................................................................................... 607
Tumor-like Lesions............................................................................................................................................ 610
TMJ Calcium Pyrophosphate Dihydrate Deposition Disease ........................................................................... 610
TMJ Pigmented Villonodular Synovitis ........................................................................................................... 611
TMJ Synovial Chondromatosis....................................................................................................................... 613
Mandible-Maxilla Central Giant Cell Granuloma ............................................................................................ 615
Benign and Malignant Tumors .......................................................................................................................... 619
Ameloblastoma ............................................................................................................................................ 619
Keratocystic Odontogenic Tumor (Odontogenic Keratocyst) .......................................................................... 624
Mandible-Maxilla Osteosarcoma................................................................................................................... 630
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Diagnostic Imaging Head and Neck
Treatment-related Lesions................................................................................................................................ 634
Mandible-Maxilla Osteonecrosis ................................................................................................................... 634
Part II - Squamous Cell Carcinoma ............................................................................................................................ 636
Section 1 - Introduction and Overview .................................................................................................................. 636
Squamous Cell Carcinoma Overview ................................................................................................................. 636
Section 2 - Primary Sites, Perineural Tumor and Nodes ......................................................................................... 644
Nasopharyngeal Carcinoma .............................................................................................................................. 644
Nasopharyngeal Carcinoma .......................................................................................................................... 644
Oropharyngeal Carcinoma ................................................................................................................................ 650
Lingual Tonsil SCCa ....................................................................................................................................... 650
Palatine Tonsil SCCa ...................................................................................................................................... 656
Posterior Oropharyngeal Wall SCCa .............................................................................................................. 662
HPV-Related Oropharyngeal SCCa ................................................................................................................. 664
Oral Cavity Carcinoma ...................................................................................................................................... 665

Oral Tongue SCCa ......................................................................................................................................... 665
Floor of Mouth SCCa ..................................................................................................................................... 671
Alveolar Ridge SCCa ...................................................................................................................................... 675
Retromolar Trigone SCCa .............................................................................................................................. 678
Buccal Mucosa SCCa ..................................................................................................................................... 681
Hard Palate SCCa .......................................................................................................................................... 682
Hypopharyngeal Carcinoma .............................................................................................................................. 683
Pyriform Sinus SCCa ...................................................................................................................................... 683
Post-Cricoid Region SCCa .............................................................................................................................. 689
Posterior Hypopharyngeal Wall SCCa ............................................................................................................ 691
Laryngeal Carcinoma ........................................................................................................................................ 692
Supraglottic Laryngeal SCCa .......................................................................................................................... 692
Glottic Laryngeal SCCa .................................................................................................................................. 698
Subglottic Laryngeal SCCa ............................................................................................................................. 701
Perineural Tumor ............................................................................................................................................. 705
Perineural Tumor Spread .............................................................................................................................. 705
Squamous Cell Carcinoma Lymph Nodes ........................................................................................................... 710
Nodal Squamous Cell Carcinoma ................................................................................................................... 710
Section 3 - Post-Treatment Neck .......................................................................................................................... 716
Nodal Dissection in Neck .................................................................................................................................. 716
Reconstruction Flaps in Neck ............................................................................................................................ 719
Expected Changes of Neck Radiation Therapy ................................................................................................... 722
Complications of Neck Radiation Therapy ......................................................................................................... 723
Part III - Pediatric and Syndromic Diseases................................................................................................................ 725
Section 1 - Pediatric Lesions ................................................................................................................................. 725
Introduction and Overview ............................................................................................................................... 725
Congenital Overview..................................................................................................................................... 725
Congenital Lesions............................................................................................................................................ 730
Lymphatic Malformation .............................................................................................................................. 730
Venous Malformation ................................................................................................................................... 736

Congenital Vallecular Cyst ............................................................................................................................. 742
Thyroglossal Duct Cyst .................................................................................................................................. 745
Cervical Thymic Cyst ..................................................................................................................................... 751
1st Branchial Cleft Cyst ................................................................................................................................. 757
2nd Branchial Cleft Cyst ................................................................................................................................ 763
3rd Branchial Cleft Cyst ................................................................................................................................. 769
4th Branchial Cleft Cyst ................................................................................................................................. 775
Dermoid and Epidermoid .............................................................................................................................. 781
Trauma............................................................................................................................................................. 787
Fibromatosis Colli ......................................................................................................................................... 787
Benign Tumors ................................................................................................................................................. 790
Infantile Hemangioma .................................................................................................................................. 790
Malignant Tumors ............................................................................................................................................ 796
Rhabdomyosarcoma ..................................................................................................................................... 796
Primary Cervical Neuroblastoma ................................................................................................................... 802
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Diagnostic Imaging Head and Neck
Metastatic Neuroblastoma ........................................................................................................................... 803
Section 2 - Syndromic Diseases ............................................................................................................................. 805
Neurofibromatosis Type 1 ................................................................................................................................ 805
Neurofibromatosis Type 2 ................................................................................................................................ 810
Basal Cell Nevus Syndrome ............................................................................................................................... 813
PHACES Association .......................................................................................................................................... 816
Branchiootorenal Syndrome ............................................................................................................................. 822
Hemifacial Microsomia ..................................................................................................................................... 828
Treacher Collins Syndrome ............................................................................................................................... 830
Pierre Robin Sequence...................................................................................................................................... 831
McCune-Albright Syndrome .............................................................................................................................. 834

Cherubism ........................................................................................................................................................ 836
Mucopolysaccharidosis..................................................................................................................................... 837
Part IV - Sinonasal Cavities and Orbit ........................................................................................................................ 841
Section 1 - Nose and Sinus.................................................................................................................................... 841
Introduction and Overview ............................................................................................................................... 841
Sinonasal Overview....................................................................................................................................... 841
Congenital Lesions............................................................................................................................................ 848
Nasolacrimal Duct Mucocele......................................................................................................................... 848
Choanal Atresia ............................................................................................................................................ 851
Nasal Glioma ................................................................................................................................................ 857
Nasal Dermal Sinus ....................................................................................................................................... 863
Frontoethmoidal Cephalocele ....................................................................................................................... 869
Congenital Nasal Pyriform Aperture Stenosis ................................................................................................ 875
Infectious and Inflammatory Lesions................................................................................................................. 878
Acute Rhinosinusitis...................................................................................................................................... 878
Chronic Rhinosinusitis................................................................................................................................... 883
Complications of Rhinosinusitis..................................................................................................................... 889
Allergic Fungal Sinusitis ................................................................................................................................. 895
Mycetoma .................................................................................................................................................... 898
Invasive Fungal Sinusitis................................................................................................................................ 901
Sinonasal Polyposis ....................................................................................................................................... 907
Solitary Sinonasal Polyp ................................................................................................................................ 913
Sinonasal Mucocele ...................................................................................................................................... 918
Silent Sinus Syndrome .................................................................................................................................. 924
Sinonasal Wegener Granulomatosis .............................................................................................................. 927
Nasal Cocaine Necrosis ................................................................................................................................. 932
Benign Tumors and Tumor-like Lesions ............................................................................................................. 935
Sinonasal Fibrous Dysplasia........................................................................................................................... 935
Sinonasal Osteoma ....................................................................................................................................... 938
Sinonasal Ossifying Fibroma.......................................................................................................................... 944

Juvenile Angiofibroma .................................................................................................................................. 950
Sinonasal Inverted Papilloma ........................................................................................................................ 956
Sinonasal Hemangioma................................................................................................................................. 961
Sinonasal Nerve Sheath Tumor ..................................................................................................................... 965
Sinonasal Benign Mixed Tumor ..................................................................................................................... 966
Malignant Tumors ............................................................................................................................................ 967
Sinonasal Squamous Cell Carcinoma ............................................................................................................. 967
Esthesioneuroblastoma ................................................................................................................................ 973
Sinonasal Adenocarcinoma ........................................................................................................................... 979
Sinonasal Melanoma .................................................................................................................................... 982
Sinonasal Non-Hodgkin Lymphoma ............................................................................................................... 985
Sinonasal Undifferentiated Carcinoma .......................................................................................................... 991
Sinonasal Adenoid Cystic Carcinoma ............................................................................................................. 993
Sinonasal Chondrosarcoma........................................................................................................................... 994
Sinonasal Osteosarcoma ............................................................................................................................... 996
Section 2 - Orbit ................................................................................................................................................... 997
Introduction and Overview ............................................................................................................................... 997
Orbit Overview ............................................................................................................................................. 997
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Diagnostic Imaging Head and Neck
Congenital Lesions.......................................................................................................................................... 1002
Coloboma ................................................................................................................................................... 1002
Persistent Hyperplastic Primary Vitreous .................................................................................................... 1009
Coats Disease ............................................................................................................................................. 1012
Orbital Dermoid and Epidermoid ................................................................................................................ 1015
Orbital Neurofibromatosis Type 1 ............................................................................................................... 1021
Vascular Lesions ............................................................................................................................................. 1027
Orbital Lymphatic Malformation ................................................................................................................. 1027

Orbital Venous Varix ................................................................................................................................... 1033
Orbital Cavernous Hemangioma ................................................................................................................. 1036
Infectious and Inflammatory Lesions............................................................................................................... 1042
Ocular Toxocariasis ..................................................................................................................................... 1042
Orbital Subperiosteal Abscess ..................................................................................................................... 1045
Orbital Cellulitis .......................................................................................................................................... 1051
Orbital Idiopathic Inflammatory Pseudotumor ............................................................................................ 1055
Orbital Sarcoidosis ...................................................................................................................................... 1060
Thyroid Ophthalmopathy............................................................................................................................ 1064
Optic Neuritis ............................................................................................................................................. 1070
Tumor-like Lesions.......................................................................................................................................... 1076
Orbital Langerhans Cell Histiocytosis ........................................................................................................... 1076
Benign Tumors ............................................................................................................................................... 1080
Orbital Infantile Hemangioma ..................................................................................................................... 1080
Optic Pathway Glioma ................................................................................................................................ 1085
Optic Nerve Sheath Meningioma ................................................................................................................ 1091
Lacrimal Gland Benign Mixed Tumor ........................................................................................................... 1097
Malignant Tumors .......................................................................................................................................... 1101
Retinoblastoma .......................................................................................................................................... 1101
Ocular Melanoma ....................................................................................................................................... 1107
Orbital Lymphoproliferative Lesions............................................................................................................ 1113
Lacrimal Gland Carcinoma .......................................................................................................................... 1119
Part V - Skull Base .................................................................................................................................................. 1122
Section 1 - Skull Base Lesions.............................................................................................................................. 1122
Introduction and Overview ............................................................................................................................. 1122
Skull Base Overview .................................................................................................................................... 1122
Clivus ............................................................................................................................................................. 1128
Ecchordosis Physaliphora ............................................................................................................................ 1128
Invasive Pituitary Macroadenoma ............................................................................................................... 1131
Chordoma .................................................................................................................................................. 1134

Sphenoid Bone ............................................................................................................................................... 1140
Persistent Craniopharyngeal Canal .............................................................................................................. 1140
Sphenoid Benign Fatty Lesion ..................................................................................................................... 1143
Central Skull Base Trigeminal Schwannoma................................................................................................. 1145
Occipital Bone ................................................................................................................................................ 1146
Hypoglossal Nerve Schwannoma................................................................................................................. 1146
Jugular Foramen ............................................................................................................................................. 1149
Jugular Bulb Pseudolesion........................................................................................................................... 1149
High Jugular Bulb ........................................................................................................................................ 1152
Dehiscent Jugular Bulb................................................................................................................................ 1155
Jugular Bulb Diverticulum ........................................................................................................................... 1158
Glomus Jugulare Paraganglioma ................................................................................................................. 1161
Jugular Foramen Schwannoma ................................................................................................................... 1167
Jugular Foramen Meningioma..................................................................................................................... 1173
Dural Sinuses .................................................................................................................................................. 1176
Dural Sinus & Aberrant Arachnoid Granulations .......................................................................................... 1176
Skull Base Dural Sinus Thrombosis .............................................................................................................. 1181
Cavernous Sinus Thrombosis....................................................................................................................... 1187
Dural AV Fistula .......................................................................................................................................... 1191
Diffuse or Multifocal Skull Base Disease .......................................................................................................... 1196
Skull Base Cephalocele................................................................................................................................ 1196
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Diagnostic Imaging Head and Neck
Skull Base CSF Leak ..................................................................................................................................... 1202
Skull Base Fibrous Dysplasia ........................................................................................................................ 1205
Skull Base Paget Disease ............................................................................................................................. 1210
Skull Base Langerhans Cell Histiocytosis ...................................................................................................... 1213
Skull Base Osteopetrosis ............................................................................................................................. 1219

Skull Base Idiopathic Inflammatory Pseudotumor ....................................................................................... 1222
Skull Base Giant Cell Tumor......................................................................................................................... 1228
Skull Base Meningioma ............................................................................................................................... 1231
Skull Base Plasmacytoma ............................................................................................................................ 1237
Skull Base Multiple Myeloma ...................................................................................................................... 1243
Skull Base Metastasis .................................................................................................................................. 1246
Skull Base Chondrosarcoma ........................................................................................................................ 1249
Skull Base Osteosarcoma ............................................................................................................................ 1255
Section 2 - Skull Base and Facial Trauma ............................................................................................................. 1258
Introduction and Overview ............................................................................................................................. 1258
Skull Base and Facial Trauma Overview ....................................................................................................... 1258
Introduction and Overview ............................................................................................................................. 1263
Temporal Bone Trauma .............................................................................................................................. 1263
Skull Base Trauma....................................................................................................................................... 1268
Introduction and Overview ............................................................................................................................. 1274
Orbital Foreign Body ................................................................................................................................... 1274
Orbital Blowout Fracture ............................................................................................................................ 1277
Trans-facial Fracture (Le Fort) ..................................................................................................................... 1280
Zygomaticomaxillary Complex Fracture ....................................................................................................... 1285
Complex Facial Fracture .............................................................................................................................. 1288
Naso-orbital-ethmoidal Fracture ................................................................................................................. 1290
Mandible Fracture ...................................................................................................................................... 1291
TMJ Meniscal Dislocation ............................................................................................................................ 1294
Part VI - Temporal Bone and CPA-IAC ..................................................................................................................... 1297
Section 1 - Introduction and Overview ................................................................................................................ 1297
Temporal Bone Overview ............................................................................................................................... 1297
Section 2 - External Auditory Canal ..................................................................................................................... 1304
Congenital Lesions.......................................................................................................................................... 1304
Congenital External Ear Dysplasia................................................................................................................ 1304
Infectious and Inflammatory Lesions............................................................................................................... 1310

Necrotizing External Otitis .......................................................................................................................... 1310
Keratosis Obturans ..................................................................................................................................... 1314
Medial Canal Fibrosis .................................................................................................................................. 1316
EAC Cholesteatoma .................................................................................................................................... 1322
Benign and Malignant Tumors ........................................................................................................................ 1325
EAC Osteoma.............................................................................................................................................. 1325
EAC Exostoses............................................................................................................................................. 1328
EAC Skin SCCa ............................................................................................................................................. 1331
Section 3 - Middle Ear-Mastoid........................................................................................................................... 1334
Congenital Lesions.......................................................................................................................................... 1334
Congenital Middle Ear Cholesteatoma ........................................................................................................ 1334
Congenital Mastoid Cholesteatoma ............................................................................................................ 1340
Congenital Ossicular Fixation ...................................................................................................................... 1341
Oval Window Atresia .................................................................................................................................. 1343
Lateralized Internal Carotid Artery .............................................................................................................. 1346
Aberrant Internal Carotid Artery ................................................................................................................. 1348
Persistent Stapedial Artery ......................................................................................................................... 1354
Infectious and Inflammatory Lesions............................................................................................................... 1358
Acute Otomastoiditis with Abscess ............................................................................................................. 1358
Coalescent Otomastoiditis .......................................................................................................................... 1363
Chronic Otomastoiditis with Ossicular Erosions ........................................................................................... 1367
Chronic Otomastoiditis with Tympanosclerosis ........................................................................................... 1369
Pars Flaccida Cholesteatoma....................................................................................................................... 1373
Pars Tensa Cholesteatoma .......................................................................................................................... 1378
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Diagnostic Imaging Head and Neck
Mural Cholesteatoma ................................................................................................................................. 1384
Middle Ear Cholesterol Granuloma ............................................................................................................. 1387

Benign and Malignant Tumors ........................................................................................................................ 1393
Glomus Tympanicum Paraganglioma .......................................................................................................... 1393
Temporal Bone Meningioma ....................................................................................................................... 1399
Middle Ear Schwannoma ............................................................................................................................ 1405
Middle Ear Adenoma .................................................................................................................................. 1409
Temporal Bone Rhabdomyosarcoma........................................................................................................... 1412
Miscellaneous ................................................................................................................................................ 1417
Temporal Bone Cephalocele ....................................................................................................................... 1417
Ossicular Prosthesis .................................................................................................................................... 1420
Section 4 - Inner Ear ........................................................................................................................................... 1426
Pseudolesions ................................................................................................................................................ 1426
Subarcuate Canaliculus ............................................................................................................................... 1426
Cochlear Cleft ............................................................................................................................................. 1429
Congenital Lesions.......................................................................................................................................... 1433
Labyrinthine Aplasia ................................................................................................................................... 1433
Common Cavity Malformation .................................................................................................................... 1435
Cystic Cochleovestibular Malformation (IP-I) ............................................................................................... 1438
Cochlear Incomplete Partition Type I (IP-I) .................................................................................................. 1441
Large Vestibular Aqueduct (IP-II) ................................................................................................................. 1444
X-Linked Stapes Gusher (DFNX2) ................................................................................................................. 1450
Cochlear Aplasia ......................................................................................................................................... 1453
Cochlear Hypoplasia ................................................................................................................................... 1456
Cochlear Nerve & Cochlear Nerve Canal Aplasia-Hypoplasia........................................................................ 1459
Globular Vestibule-Semicircular Canal......................................................................................................... 1462
Semicircular Canal Hypoplasia-Aplasia ........................................................................................................ 1463
CHARGE Syndrome ..................................................................................................................................... 1465
Infectious and Inflammatory Lesions............................................................................................................... 1470
Labyrinthitis................................................................................................................................................ 1470
Otosyphilis.................................................................................................................................................. 1474
Labyrinthine Ossificans ............................................................................................................................... 1477

Otosclerosis ................................................................................................................................................ 1482
Benign and Malignant Tumors ........................................................................................................................ 1487
Intralabyrinthine Schwannoma ................................................................................................................... 1487
Endolymphatic Sac Tumor........................................................................................................................... 1493
Miscellaneous ................................................................................................................................................ 1496
Intralabyrinthine Hemorrhage .................................................................................................................... 1496
Semicircular Canal Dehiscence .................................................................................................................... 1499
Cochlear Implants ....................................................................................................................................... 1502
Section 5 - Petrous Apex..................................................................................................................................... 1508
Pseudolesions ................................................................................................................................................ 1508
Petrous Apex Asymmetric Marrow.............................................................................................................. 1508
Petrous Apex Cephalocele .......................................................................................................................... 1511
Congenital Lesions.......................................................................................................................................... 1514
Congenital Petrous Apex Cholesteatoma..................................................................................................... 1514
Infectious and Inflammatory Lesions............................................................................................................... 1520
Petrous Apex Trapped Fluid ........................................................................................................................ 1520
Petrous Apex Mucocele .............................................................................................................................. 1523
Petrous Apex Cholesterol Granuloma.......................................................................................................... 1526
Apical Petrositis .......................................................................................................................................... 1532
Vascular Lesions ............................................................................................................................................. 1538
Petrous Apex ICA Aneurysm........................................................................................................................ 1538
Section 6 - Intratemporal Facial Nerve ................................................................................................................ 1541
Pseudolesions ................................................................................................................................................ 1541
Intratemporal Facial Nerve Enhancement ................................................................................................... 1541
Middle Ear Prolapsing Facial Nerve ............................................................................................................. 1544
Infectious and Inflammatory Lesions............................................................................................................... 1547
Bell Palsy .................................................................................................................................................... 1547
10

Diagnostic Imaging Head and Neck
Benign and Malignant Tumors ........................................................................................................................ 1553
T-Bone Facial Nerve Venous Malformation (Hemangioma).......................................................................... 1553
T-Bone Facial Nerve Schwannoma .............................................................................................................. 1559
T-Bone Perineural Parotid Malignancy ........................................................................................................ 1565
Section 7 - Temporal Bone, No Specific Anatomic Location ................................................................................. 1570
T-Bone CSF Leak ............................................................................................................................................. 1570
T-Bone Arachnoid Granulations ...................................................................................................................... 1573
T-Bone Fibrous Dysplasia ................................................................................................................................ 1576
T-Bone Paget Disease ..................................................................................................................................... 1580
T-Bone Langerhans Cell Histiocytosis .............................................................................................................. 1583
T-Bone Metastasis .......................................................................................................................................... 1586
T-Bone Osteoradionecrosis ............................................................................................................................. 1589
Section 8 - CPA-IAC............................................................................................................................................. 1592
Introduction and Overview ............................................................................................................................. 1592
CPA-IAC Overview....................................................................................................................................... 1592
Congenital Lesions.......................................................................................................................................... 1597
CPA Epidermoid Cyst .................................................................................................................................. 1597
CPA Arachnoid Cyst .................................................................................................................................... 1603
CPA-IAC Congenital Lipoma......................................................................................................................... 1609
IAC Venous Malformation ........................................................................................................................... 1615
Infectious and Inflammatory Lesions............................................................................................................... 1618
CPA-IAC Meningitis ..................................................................................................................................... 1618
Ramsay Hunt Syndrome.............................................................................................................................. 1621
CPA-IAC Sarcoidosis .................................................................................................................................... 1624
Benign and Malignant Tumors ........................................................................................................................ 1627
Vestibular Schwannoma ............................................................................................................................. 1627
CPA-IAC Meningioma.................................................................................................................................. 1633
CPA-IAC Facial Nerve Schwannoma ............................................................................................................. 1639
CPA-IAC Metastases.................................................................................................................................... 1642

Vascular Lesions ............................................................................................................................................. 1648
Trigeminal Neuralgia................................................................................................................................... 1648
Hemifacial Spasm ....................................................................................................................................... 1651
CPA-IAC Aneurysm...................................................................................................................................... 1654
CPA-IAC Superficial Siderosis....................................................................................................................... 1657
Index ..................................................................................................................................................................... 1664
A ........................................................................................................................................................................ 1664
B ........................................................................................................................................................................ 1665
C ........................................................................................................................................................................ 1666
D ........................................................................................................................................................................ 1671
E ........................................................................................................................................................................ 1672
F ........................................................................................................................................................................ 1673
G ........................................................................................................................................................................ 1674
H ........................................................................................................................................................................ 1675
I ......................................................................................................................................................................... 1676
J ......................................................................................................................................................................... 1677
K ........................................................................................................................................................................ 1678
L ........................................................................................................................................................................ 1678
M ....................................................................................................................................................................... 1681
N........................................................................................................................................................................ 1684
O........................................................................................................................................................................ 1686
P ........................................................................................................................................................................ 1689
R ........................................................................................................................................................................ 1693
S ........................................................................................................................................................................ 1695
T ........................................................................................................................................................................ 1701
U........................................................................................................................................................................ 1704
V ........................................................................................................................................................................ 1704
W ....................................................................................................................................................................... 1705
X ........................................................................................................................................................................ 1706
Z ........................................................................................................................................................................ 1706

11


Diagnostic Imaging Head and Neck

Authors
Authors
H. Ric Harnsberger MD
Professor of Radiology and Otolaryngology
R.C. Willey Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, UT
Christine M. Glastonbury MBBS
Associate Professor
Radiology and Biomedical Imaging, Otolaryngology - Head
and Neck Surgery, and Radiation Oncology
University of California, San Francisco
San Francisco, CA
Michelle A. Michel MD
Professor of Radiology and Otolaryngology
Chief, Head and Neck Neuroradiology
Medical College of Milwaukee
Milwaukee, WI
Bernadette L. Koch MD
Associate Professor of Radiology and Pediatrics
University of Cincinnati College of Medicine
Associate Director of Physician Services and Education
Cincinnati Children's Hospital Medical Center
Cincinnati, OH
Barton F. Branstetter IV MD

Associate Professor of Radiology, Otolaryngology, and Biomedical Informatics
University of Pittsburgh School of Medicine
Director of Head and Neck Imaging
University of Pittsburgh Medical Center
Pittsburgh, PA
H. Christian Davidson MD
Associate Professor of Radiology
University of Utah School of Medicine
Salt Lake City, UT
Deborah R. Shatzkes MD
Director of Head and Neck Imaging
St. Lukes - Roosevelt Hospital Center
Associate Professor of Radiology
Columbia University College of Physicians and Surgeons
New York, NY
Rebecca S. Cornelius MD
Professor of Radiology and Otolaryngology - Head and Neck Surgery
University of Cincinnati College of Medicine
University Hospital - UC Health
Cincinnati, OH
P.iii

Troy Hutchins MD
Assistant Professor of Radiology and Neurosurgery
University of California, Irvine
Orange, CA
C. Douglas Phillips MD, FACR
Professor of Radiology
Director of Head and Neck Imaging
Weill Medical College of Cornell University

12


Diagnostic Imaging Head and Neck
New York Presbyterian Hospital
New York, NY
Patricia A. Hudgins MD, FACR
Professor of Radiology and Otolaryngology
Director of Head and Neck Radiology
Department of Radiology
Emory University School of Medicine
Atlanta, GA
Kristine M. Mosier DMD, PhD
Associate Professor of Radiology
Chief, Head and Neck Radiology
Indiana University
Department of Radiology & Imaging Sciences
Indianapolis, IN
Caroline D. Robson MBChB
Associate Professor of Radiology
Harvard Medical School
Operations Vice Chair, Radiology
Director of Head and Neck Imaging
Children's Hospital, Boston
Boston, MA
Hilda E. Stambuk MD
Associate Attending of Radiology
Clinical Head of Head and Neck Imaging
Memorial Sloan - Kettering Cancer Center

New York, NY
Associate Professor of Radiology
Weill Medical College of Cornell University
New York, NY
Karen L. Salzman MD
Associate Professor of Radiology
Leslie W. Davis Endowed Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, UT
Richard H. Wiggins III MD
Associate Professor
Department of Radiology, Otolaryngology Head and Neck Surgery, and BioMedical Informatics
University of Utah School of Medicine
Salt Lake City, UT
Contributing Authors
Philip R. Chapman, MD
Assistant Professor of Neuroradiology
University of Alabama, Birmingham
Birmingham, AL
Yolanda Y.P. Lee, MBChB, FRCR
Honorary Associate Professor
Department of Imaging and Interventional Radiology
The Chinese University of Hong Kong
Hong Kong SAR
Bronwyn E. Hamilton, MD
Associate Professor of Radiology
Director MRI Department of Radiology
Neuroradiology Division
Oregon Health & Science University
Portland, OR

Lawrence E. Ginsberg, MD

13


Diagnostic Imaging Head and Neck
Professor of Radiology and Head and Neck Surgery
The University of Texas M.D. Anderson Cancer Center
Houston, TX
Laurie A. Loevner, MD
Professor of Radiology, Otolaryngology, Head and Neck Surgery
Neuroradiology Division
University of Pennsylvania School of Medicine
Philadelphia, PA

Dedication
This 2nd edition of Diagnostic Imaging: Head & Neck is the physical manifestation of a village of talented people with
common purpose driving to completion together. To my co-editors, Drs. Glastonbury, Michel, and Koch, without your
excellence in editing and intrepid spirits, I would not have survived this last crazy year. The passage was painful but
bearable because of you three. To the rest of the author team, you guys are amazing. I know that you each gave a
piece of yourself, thank you.
Also thanks to the “home team” at Amirsys central who performed miracles in creating this dynamite work.
Specifically thanks to Ashley, Kellie, Arthur, Kate, Dave, and Jeff (our awesome editorial team), Rich (our superb
medical illustrator), and Mike (our Production Director). Paula, my sister separated at birth and my partner in the
Amirsys dream, the whole thing is impossible without you. Paul and Julia, thanks for your friendship and amazing
ability to see the big picture.
Finally thanks to my family, Jungle J (74?) and Dave, Dan, and Dylan. I know that every time I start talking about the
next book, you all cringe. Take heart, I think this is the last big book that was stuck inside yearning to come into the
light. To Doris and Hutch, you gave me more than enough love to get me through. Wish you could have seen this day.
HRH

A book like this only happens with dedication and hard work from every level in the production team at Amirsys and
from a true team of authors. Together we've “placed oars in the water,” “gone over the falls in a barrel,” “circled our
wagons,” “pushed our noses across the tape,” and counted “bottles of beer on the wall” to “the end of the
marathon.” It's been a long, extraordinary, and fun trip. Thank you all! Every day I am honored to work with, learn
from, and be inspired by amazing radiologists, ENT surgeons, and radiation oncologists. I especially thank Bill and Jim
and all my Neuro colleagues at UCSF. And of course I thank Ric for taking a chance on a registrar from Adelaide and
opening up this world of H&N to me! Thanks, Boss.
CMG
I dedicate my work on this fabulous piece to the MCW radiology residents and Neuroradiology fellows who put up
with my absence in the reading room during the year leading up to its completion. It was an honor to work with such
an amazing team of individuals at Amirsys, from the technical and production staff, to the illustrators, to my coauthors, and of course, my mentor and dearest friend, Dr. Harnsberger. I thank my supportive friends, family, dogs,
and of course my Harley, “Sweetness,” for helping me maintain my sanity throughout this process. It was an honor,
Ric, and thanks for having me on board!
MAM
To Ric, for giving me the opportunity to be involved in such an incredible project, to all of the coauthors and editors
for all of their help and dedication, and to the production team at Amirsys who magically create beautiful works of art.
To my family, Peter, Jay and Katherine, my mother and siblings, I could not have accomplished this without their love,
support, and understanding. To Bill, for his encouragement to enter the world of Head and Neck imaging many years
ago, his neverending inspiration and teaching.
BLK

Case Contributors
Below are listed the important group of radiologists who took the time to help find the case material necessary to fill
the extensive image galleries of Diagnostic Imaging: Head and Neck, 2nd edition. Without their willingness to “share
the wealth,” this book would have been far less rich an offering.
Thank you all so much for your generous natures and avid interest in this project. No book of this nature could have
been done alone!
Ric, Christine, Michelle, and Bernadette
Anil T. Ahuja; Hong Kong, China
Hank Baskin; Salt Lake City, UT

Susan I. Blaser; Toronto, Canada
Philip Chapman; Huntsville, AL
Joel K. Curé; Birmingham, AL
14


Diagnostic Imaging Head and Neck
Nancy Fischbein; Palo Alto, CA
Lindell Gentry; Madison, WI
Lawrence E. Ginsberg; Houston, TX
Julian Goh; Singapore
Gary L. Hedlund; Salt Lake City, UT
Peter Hildenbrand; Burlington, MA
Tim Larsen; Seattle, WA
Laurie Loevner; Philadelphia, PA
Yolanda Lee; Hong Kong, China
Lisa Lowe; Kansas City, MO
André Macdonald, MBChB; Salt Lake City, UT
Karen Moeller; Louisville, KY
Kevin Moore; Salt Lake City, UT
Brian Psooy; Halifax, Canada
Jeff Ross; Phoenix, AZ
Marlin Sandlin; Houston, TX
Charles Schatz; Los Angeles, CA
Anthony J. Scuderi; Johnstown, PA
Lubdha Shah; Salt Lake City, UT
Brian Steele; Denver, CO
Robert Wallace; Phoenix, AZ

Preface

This stunning (if we do say so ourselves) 2nd edition of Diagnostic Imaging: Head and Neck represents the most
comprehensive single volume textbook in the field of Head and Neck Imaging today. As you might expect there are
many new and exciting features in the second edition. We've improved but kept the basic layout so that the same
information is in the same place—every time, in every chapter. We've added 120 new diagnoses, 2500 new images,
and 300 of our signature color graphics. The references have all been updated to within a few weeks of publication.
What else makes the second edition significantly different? The most important new feature are the 23 new prose
introductions at the front of each of the book's sections. The goal of these introductions is to guide the reader
through the relevant anatomy and approaches to imaging issues in each area of the head and neck. Another key
update comes from the fact that in each of the diagnosis chapters virtually all of the gallery images have been
replaced with newer, more advanced imaging examples of each diagnosis. As there were no eBook images in the first
edition, the 1700 images in the eBook galleries give a rich additional perspective for each diagnosis chapter.
On a global content level, the 2nd edition of Diagnostic Imaging: Head and Neck now contains an all new 24-chapter
“Squamous Cell Carcinoma” section that follows the same primary site organization (pharynx, oral cavity, and larynx)
of the American Joint Committee on Cancer. A second brand new area in the book is the 27-chapter “Pediatric &
Syndromic Diseases” section.
Our reason for writing this book in the simplest terms was to contribute to the process of demystifying the field of
Head & Neck Imaging. We want Diagnostic Imaging: Head and Neck, second edition to be your favorite Head & Neck
Imaging text—used, worn, dog-eared, and loved. To this end, we welcome any ideas, comments or suggestions. If you
email them to , we will respond to your ideas and implement them as possible.
Thanks for making the books in our Diagnostic Imaging series the bestsellers they so quickly became. We hope you
enjoy this sequel!
H. Ric Harnsberger, MD
Professor of Radiology & Otolaryngology
R. C. Willey Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, UT
Summary of “What's New in DI: H&N Two”
 Two all new book sections
o “Squamous Cell Carcinoma” section
o “Pediatric & Syndromic Diseases” section

 Comparisons of first vs. second editions Diagnostic Imaging: Head and Neck:
o New pages = 200
o New diagnoses = 120
o New color graphics = 300
o eBook images = 1700
15


Diagnostic Imaging Head and Neck
o
o

New prose introductions = 23
All new images in chapter galleries (2800 total book images)

Acknowledgements
Acknowledgements
Text Editing
Arthur G. Gelsinger, MA
Katherine Riser, MA
Dave L. Chance, MA
Matthew R. Connelly, MA
Image Editing
Jeffrey J. Marmorstone
Medical Editing
Sirisha Komakula, MBBS
Logan A. McLean, MD
Illustrations
Lane R. Bennion, MS
Richard Coombs, MS

James A. Cooper, MD
Laura C. Sesto, MA
Associate Editor
Ashley R. Renlund, MA
Production Lead
Kellie J. Heap

Part I - Suprahyoid and Infrahyoid Neck
Section 1 - Introduction and Overview
Suprahyoid and Infrahyoid Neck Overview
> Table of Contents > Part I - Suprahyoid and Infrahyoid Neck > Section 1 - Introduction and Overview > Suprahyoid
and Infrahyoid Neck Overview
Suprahyoid and Infrahyoid Neck Overview
H. Ric Harnsberger, MD
Imaging Approaches & Indications
Neither CT nor MR is a perfect modality in imaging the extracranial H&N. MR is most useful in the SHN because it is
less affected by oral cavity dental amalgam artifact. Since the SHN tissue is less affected by motion compared to the
IHN, MR image quality is not degraded by movement seen in the IHN. Axial & coronal T1 fat-saturated enhanced MR is
superior to CECT in defining soft tissue extent of tumor, perineural tumor spread, & dural/intracranial spread. When
MR is combined with bone CT of the facial bones & skull base, precise preoperative lesion mapping results.
CECT is the modality of choice when IHN & mediastinum are imaged. Swallowing, coughing, & breathing makes this
area a “moving target” for the imager. MR image quality is often degraded as a result. Multislice CT with multiplanar
reformations now permit exquisite images of the IHN unaffected by movement.
High-resolution ultrasound also has a role. Superficial lesions, thyroid disease, & nodal evaluation with biopsy are best
done by skilled ultrasonographers.
Many indications exist for imaging the extracranial H&N. “Exploratory” imaging, tumor staging, & abscess search
comprise 3 common reasons imaging is ordered in this area. “Exploratory” imaging, an imaging search for any lesion
that may be causing the patient's symptoms, is best completed with CECT from skull base to the clavicles.
Squamous cell carcinoma (SCCa) staging is best started with CECT as both the primary tumor & nodes must be imaged,
requiring imaging from the skull base to clavicles. MR imaging times and susceptibility to motion artifact make it a less

desirable exam in this setting. Instead, MR is best used when specific delineation of exact tumor extent, perineural
tumor, or intracranial invasion is needed.
When the type & cause of H&N infection are sought, CECT is the best exam. CECT can readily differentiate cellulitis,
phlegmon, & abscess. CT can also identify salivary gland ductal calculi, teeth infection, mandible osteomyelitis, &
intratonsillar abscess as infection causes.
Imaging Anatomy

16


Diagnostic Imaging Head and Neck
In discussing the extracranial H&N soft tissues, a few definitions are needed. The SHN is defined as deep facial spaces
above hyoid bone, including parapharyngeal space (PPS), pharyngeal mucosal space (PMS), masticator space (MS),
parotid space (PS), carotid space (CS), retropharyngeal space (RPS), danger space (DS), & perivertebral (PVS) space.
The IHN soft tissue spaces are predominantly below hyoid bone, with some continuing inferiorly into the mediastinum
or superiorly into the SHN, including the visceral space (VS), posterior cervical space (PCS), CS, RPS, & PVS.
Important SHN space anatomic relationships include their interactions with the skull base, oral cavity, & infrahyoid
neck. When thinking about the SHN spaces and their relationships with the skull base, perhaps the most important
consideration is to examine each space alone to see what critical structures (cranial nerves, arteries, veins) are at the
point of contact between the space & the skull base. Space by space, the skull base interactions above & IHN
extension below are apparent.
 The PPS has a bland triangular skull base abutment without critical foramen involved; it empties inferiorly
into submandibular space (SMS)
 The PMS touches the posterior basisphenoid & anterior basiocciput, including foramen lacerum; the PMS
includes nasopharyngeal, oropharyngeal, & hypopharyngeal mucosal surfaces
 The MS cephalad skull base interaction includes the zygomatic arch, condylar fossa, & roof of infratemporal
fossa, including foramen ovale (CNV3) & foramen spinosum; the MS ends at inferior surface of body of
mandible
 The PS abuts the floor of EAC, mastoid tip including stylomastoid foramen (CN7); the parotid tail extends
inferiorly into posterior SMS

 The CS meets the jugular foramen (CN9-11) floor, hypoglossal canal (CN12), & petrous ICA canal; CS can be
followed inferiorly to the aortic arch
 The RPS contacts the skull base along the lower clivus without involvement of critical structures; it continues
inferiorly to empty into DS at T3 level
 The PVS touches the low clivus, encircles occipital condyles & foramen magnum; the PVS continues inferiorly
to level into the thorax
In addition to skull base interactions, the relationships of the SHN spaces to the fat-filled PPSs are key to analyzing
SHN masses. The PPSs are a pair of fat-filled spaces in the lateral SHN surrounded by the PMS, MS, PS, CS, & RPS.
When a mass enlarges in one of these spaces, it displaces the PPS fat. Larger masses define their space of origin based
on this displacement pattern.
 The medial PMS mass displaces the PPS laterally
 The more anterior MS mass displaces PPS posteriorly
 The lateral PS mass displaces the PPS medially
 The posterolateral CS mass displaces styloid process & PPS anteriorly
 The more posteromedial lateral RPS nodal mass displaces PPS anterolaterally
The IHN spaces anatomic relationships are defined by their superior & inferior projections. The VS has no SHN
component, instead projecting only inferiorly into the superior mediastinum. The PCS extends superiorly to the
mastoid tip & ends inferiorly at the clavicle. It is predominantly an IHN space however. The CS begins at the floor of
jugular foramen & carotid canal & extends inferiorly to the aortic arch. The RPS begins at clivus superiorly and
traverses SHN-IHN to T3 level. The DS is immediately posterior to the RPS but continues beyond T3 level into
mediastinum. For imaging purposes, RPS & DS can be considered a single entity. The PVS can be defined from skull
base above to clavicle below. The PVS is divided by fascial slip into prevertebral & paraspinal components.
Nobody likes to study the deep cervical fasciae of the neck. However, it is these fasciae that define the very spaces we
use to subdivide neck diseases & construct space-specific differential diagnosis lists. It is imperative that a clear
understanding of these fasciae be grasped by any imager involved in evaluating this area.
Many nomenclatures have been used to describe the neck fascia. The following is a practical distillate meant to
simplify this challenging subject. There are 3 main deep cervical fascia in the neck. The same names are used in the
SHN & IHN. The superficial layer (SL-DCF), the middle layer (ML-DCF), & deep layer of deep cervical fascia (DL-DCF) are
the 3 important fascia in the neck.
In the SHN, the SL-DCF circumscribes MS & PS and contributes to carotid sheath. In the IHN, it “invests” neck

P.I(1):3
by surrounding the infrahyoid strap, sternocleidomastoid, & trapezius muscles. It also contributes to carotid sheath of
the CS in the IHN.
The ML-DCF in the SHN defines the deep margin of the PMS. It contributes to carotid sheath in both the SHN & IHN. In
the IHN, it also circumscribes the VS.
In both the SHN & IHN, the DL-DCF surrounds PVS. A slip of DL-DCF dives medially to the transverse process, dividing
PVS into prevertebral & paraspinal components. Another slip of DL-DCF, the alar fascia, provides the lateral wall to
RPS & DS as well as the posterior wall to RPS separating RPS from DS. The DL-DCF contributes to carotid sheath as
does the SL & ML-DCF.
17


Diagnostic Imaging Head and Neck
The internal structures of the spaces of the neck are for the most part responsible for the diseases there. Let's begin
by defining the critical contents of the SHN spaces:
 The PPS contains fat only
 The PMS contains mucosa, lymphatic ring, & minor salivary glands. The nasopharyngeal mucosal space, the
opening of eustachian tube, torus tubarius, adenoids, superior constrictor, & levator palatini muscles can be
found. The oropharyngeal mucosal space contains the anterior & posterior tonsillar pillars, palatine, & lingual
tonsils
 The MS includes the mandible body & ramus, TMJ, CNV3, masseter, medial & lateral pterygoid & temporalis
muscles, & pterygoid venous plexus
 The PS houses the parotid, extracranial CN7 nodes, retromandibular vein, & external carotid artery
 The CS contains the CN9-12, internal jugular vein, and internal carotid artery
 The RPS has fat, medial & lateral RPS nodes inside
 The prevertebral PVS contains vertebral body, veins & arteries, & prevertebral muscles (longus colli &
capitis); in the paraspinal PVS resides the posterior elements of vertebra & the paraspinal muscles
The critical contents of IHN spaces are defined next.
 The VS contains the thyroid & parathyroid glands, trachea, esophagus, recurrent laryngeal nerves, and
pretracheal & paratracheal nodes

 The PCS has fat, CN11, & level V nodes inside
 The CS houses the common carotid artery, internal jugular vein, and CN10
 The IHN RPS has no nodes & contains only fat
 The prevertebral PVS has the brachial plexus & phrenic nerve, vertebral body, veins & arteries, prevertebral
& scalene muscles within. The paraspinal PVS contains only the posterior vertebra elements & paraspinal
muscles
Approaches to Imaging Issues in SHN & IHN
It is important that the imager has a method of analysis when a mass is found in the neck. In the SHN, mass evaluation
methodology begins with defining mass space of origin (PMS, MS, PS, CS, lateral RPS). When small, this is simple as
the mass is seen within the confines of 1 space. In larger masses, ask the question, “How does the mass displace the
PPS?” Next, utilize a space-specific differential diagnosis list. Match the imaging findings to the diagnoses within this
list to narrow your differential.
With IHN masses, a similar evaluation methodology can be employed. First, determine what space the mass originates
in (VS, CS, PCS, ACS). Then, review space-specific differential diagnosis list. Match radiologic findings of your case to
this DDx list. In all neck masses, knowing the clinical findings can be very helpful.
Lesions of the posterior midline spaces (RPS & PVS) of the neck require a different image evaluation approach. When
a lesion is defined here, first ask the question, “How does mass displace prevertebral muscles (PVM)?” In the case of a
RPS mass, the PVMs are flattened posteriorly or invaded from anterior to posterior. Contrast this imaging appearance
to that of the PVS mass where the PVMs are lifted anteriorly or invaded from posterior to anterior. Since most PVS
lesions arise from vertebral body, vertebral body destruction & epidural disease will be associated. The DL-DCF
“forces” PVS disease into the epidural space.
There are many pseudolesions of extracranial H&N. Always begin your image analysis by considering if the “lesion”
you see is a normal structure, normal variant, or a “leave me alone” lesion. A common pitfall is to mistake a motor
denervation for an intrinsic disease. In acute-subacute muscle denervation, swelling with contrast enhancement is
seen. In chronic denervation, muscle volume loss & fatty infiltration is the rule. Five motor atrophy patterns can be
seen in the H&N. They are CNV3, CN7, CN10, CN11, and CN12.
Selected References
1. Harnsberger HR et al: Differential diagnosis of head and neck lesions based on their space of origin. 1. The
suprahyoid part of the neck. AJR Am J Roentgenol. 157(1):147-54, 1991
2. Smoker WR et al: Differential diagnosis of head and neck lesions based on their space of origin. 2. The infrahyoid

portion of the neck. AJR Am J Roentgenol. 157(1):155-9, 1991
Tables

Common Tumors in the Spaces of the Neck
Warthin tumor
Pharyngeal mucosal
space
Pharyngeal SCCa
Carotid space
Tonsillar NHL
Glomus vagale paraganglioma
Carotid body paraganglioma
Masticator space
Sarcoma

Schwannoma of CN9-12
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Posterior cervical space
Pharyngeal SCCa nodal metastasis
NHL nodal disease
Differentiated thyroid carcinoma
nodes
Visceral space


Diagnostic Imaging Head and Neck

Perineural CNV3 SCCa
Parotid space

Mucoepidermoid
carcinoma
Adenoid cystic carcinoma
Malignant nodal
metastases
Benign mixed tumor

Retropharyngeal space
SCCa nodal metastasis
NHL nodal disease

Differentiated thyroid carcinoma
Anaplastic thyroid carcinoma
Thyroid NHL

Perivertebral space
Vertebral body systemic
metastasis
Brachial plexus schwannoma

Cervical esophageal carcinoma
Parathyroid adenoma

P.I(1):4

Image Gallery

(Top) Axial graphic depicts the spaces of the suprahyoid neck. Surrounding the paired fat-filled parapharyngeal spaces
are the 4 critical paired spaces of this region, the pharyngeal mucosal, masticator, parotid, and carotid spaces. The
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Diagnostic Imaging Head and Neck
retropharyngeal and perivertebral spaces are the midline nonpaired spaces. A PMS mass pushes the PPS laterally, an
MS mass pushes the PPS posteriorly, a PS mass pushes the PPS medially, and a CS mass pushes the PPS anteriorly.
Lateral RPS mass will push the PPS anteriorly without lifting the styloid process. The superficial (yellow line), middle
(pink line), & deep (turquoise line) layers of deep cervical fascia outline the spaces. (Bottom) Axial contrast-enhanced
CT image at the level of the nasopharyngeal suprahyoid neck shows the 4 key spaces surrounding the parapharyngeal
space: The pharyngeal mucosal, masticator, parotid, and carotid spaces. Notice the retropharyngeal fat stripe is not
seen in the high nasopharynx between the prevertebral muscles and the pharyngeal mucosal surface.
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(Top) Axial graphic shows the suprahyoid neck spaces at the level of the oropharynx. The superficial (yellow line),
middle (pink line), and deep (turquoise line) layers of deep cervical fascia outline the suprahyoid neck spaces. Notice
the lateral borders of the retropharyngeal & danger spaces are called the alar fascia, which represents a slip of the
deep layer of deep cervical fascia. The carotid space has a tricolored fascial representation for the carotid sheath. This
is because all 3 layers of deep cervical fascia contribute to the carotid sheath. (Bottom) In this image, through the low
oropharynx, the pharyngeal mucosal & the perivertebral spaces have been outlined. The space between them is the
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Diagnostic Imaging Head and Neck
retropharyngeal space. The alar fascia that makes up the lateral borders of the retropharyngeal space are not shown.
P.I(1):6

(Top) Axial graphic depicts the fascia and spaces of the infrahyoid neck. The 3 layers of deep cervical fascia are present
in the suprahyoid and infrahyoid neck. The carotid sheath is made up of all 3 layers of deep cervical fascia (tricolor line
around carotid space). Notice the deep layer (turquoise line) completely circles the perivertebral space, diving in
laterally to divide it into prevertebral and paraspinal components. The middle layer (pink line) circumscribes the
visceral space while the superficial layer (yellow line) “invests” the neck deep tissues. (Bottom) In this axial CECT

image, the middle layer of deep cervical fascia is drawn to delineate the margins of the visceral space. The visceral
space contains the high-density thyroid gland, the upper cervical esophagus, and the cricoid cartilage. The carotid
spaces are lateral to the visceral space, while the retropharyngeal and perivertebral spaces are posterior.
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Diagnostic Imaging Head and Neck

(Top) Coronal graphic shows suprahyoid neck spaces as they interact with the skull base. The masticator space has the
largest area of abutment with the skull base, including CNV3. The pharyngeal mucosal space abuts the basisphenoid
and foramen lacerum. The foramen lacerum is the cartilage-covered floor of the anteromedial petrous internal carotid
artery canal. (Bottom) Sagittal graphic depicts longitudinal spatial relationships of the infrahyoid neck. Anteriorly, the
visceral space is seen surrounded by middle layer of deep cervical fascia (pink line). Just anterior to the vertebral
column, the retropharyngeal and danger spaces run inferiorly toward the mediastinum. Notice the fascial “trap door”
found at the approximate level of T3 vertebral body that serves as a conduit from the retropharyngeal to the danger
space. Retropharyngeal space infection or tumor may access the mediastinum via this route of spread.

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Diagnostic Imaging Head and Neck

Section 2 - Parapharyngeal Space
Introduction and Overview
Parapharyngeal Space Overview
> Table of Contents > Part I - Suprahyoid and Infrahyoid Neck > Section 2 - Parapharyngeal Space > Introduction and
Overview > Parapharyngeal Space Overview
Parapharyngeal Space Overview

H. Ric Harnsberger, MD
Summary Thoughts: Parapharyngeal Space
The four key spaces of the suprahyoid neck surround the parapharyngeal space (PPS), which is a central fatfilled
lateral suprahyoid neck (SHN) space. When large lesions of the SHN become hard to localize to a space of origin, the
direction of the PPS displacement may be used in combination with the space where most of the tumor is located to
make a definite determination as to where the lesion originated. Once a space of origin is assigned, the space-specific
differential diagnosis can be applied to narrow the diagnostic possibilities.
Imaging Anatomy
The parapharyngeal spaces are central, fat-filled spaces in lateral suprahyoid neck around which most of the
important spaces are located. These surrounding important spaces are the pharyngeal mucosal space (PMS),
masticator space (MS), parotid space (PS), carotid space (CS), and the lateral retropharyngeal space (RPS). The PPS
contents are limited; therefore, few lesions actually occur in this space. Diseases (tumor and infection) of PPS usually
arise in adjacent spaces (PMS, MS, PS, CS), spreading secondarily into PPS.
The importance of the fat-filed PPS is its conspicuity on CT and MR. Even when large lesions are present in the SHN, it
is still usually possible to find the PPS. Identifying the direction of displacement of the PPS by a mass lesion from a
surrounding space can be a key finding in determining its space of origin. The PPS displacement direction defines the
space of the primary lesion.
 PMS mass lesion pushes PPS laterally
 MS mass lesion pushes PPS posteriorly
 PS mass lesion pushes PPS medially
 CS mass lesion pushes PPS anteriorly
 Lateral retropharyngeal space mass (nodal) pushes PPS anterolaterally
The PPS is a crescent-shaped fat-filled space in craniocaudal dimension extending from the skull base superiorly to the
superior cornu of hyoid bone inferiorly. As paired fatty tubes separating other SHN spaces from one another, the PPS
functions as an “elevator shaft” through which infection and tumor from these adjacent spaces may travel from the
skull base to the hyoid bone.
The PPS has multiple important anatomic relationships with surrounding spaces. As there is no fascia separating the
inferior PPS from the submandibular space (SMS), open communication between the PPS and posterior SMS exists.
Superiorly PPS interacts with the skull base in bland triangular area on the inferior surface of the petrous apex. No
exiting skull base foramina are found in this area of attachment. In the axial plane the PMS is medial, the MS anterior,

the PS lateral, the CS posterior, and the lateral RPS posteromedial to the parapharyngeal space.
PPS internal structures are few. There is no mucosa, muscle, bone, nodes, or major salivary gland tissue within the PPS
boundaries. The PPS principal content is fat. Minor salivary glands can be found there but are ectopic and rare.
Although most of the pterygoid venous plexus is in the deep portion of the masticator space, a part of the plexus spills
into the PPS.
The fascia surrounding the PPS is complex. Different layers of the deep cervical fascia combine to circumscribe the
PPS. The medial fascial margin of PPS is made up of the middle layer of deep cervical fascia as it curves around lateral
margin of PMS. The lateral fascial margin of the PPS is comprised of the medial slip of superficial layer of deep cervical
fascia along the deep border of the MS and PS. The posterior fascial margin of the PPS is formed by the deep layer of
deep cervical fascia on the anterolateral margin of the retropharyngeal space and the anterior part of the carotid
sheath (made up of components of all three layers of deep cervical fascia).
Clinical Implications
Since the PPS empties inferiorly into the SMS, PPS infection or malignancy spread inferiorly from the upper SHN to
present as “angle of mandible” mass.
Approaches to Imaging Issues of the Parapharyngeal Space
When you discover a lesion in the PPS on CT or MR, answer the following question first: “Is this lesion really primary to
the PPS?” This question needs to be answered because there are so few things that occur initially in the PPS. In fact,
the vast majority of lesions of the PPS arise in adjacent spaces and spread from there into the PPS. To conclude that a

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Diagnostic Imaging Head and Neck
lesion is primary to the PPS, it must be completely surrounded by PPS fat. In most cases where a lesion is thought to
be primary to PPS, careful observation will find a connection to one of the surrounding spaces.
Lesions that are primary to the PPS itself include atypical 2nd branchial cleft cyst, benign mixed tumor, and lipoma. All
are rare. Far more common lesions can be seen spreading into the PPS, such as intratonsillar abscess becoming
peritonsillar and squamous cell carcinoma of the nasopharynx and oropharyngeal palatine tonsil. When a large,
parotid deep lobe benign mixed tumor pedunculates into the PPS, it may at first glance appear to be primary to the
PPS. Careful inspection will reveal a connection to the deep lobe of the parotid in the vast majority of cases.

Differential Diagnosis
DDx of parapharyngeal space lesion
 Congenital: Atypical 2nd branchial cleft cyst, lymphatic malformation, venous malformation
 Inflammatory: Large diving ranula spreading from submandibular space into PPS
 Infection: Peritonsillar abscess spreading from palatine tonsil into PPS
 Benign tumor: Lipoma, benign mixed tumor
 Malignant tumor: SCCa spreading from naso- or oropharynx into PPS
Selected References
1. Mendelsohn AH et al: Parapharyngeal space pleomorphic adenoma: a 30-year review. Laryngoscope. 119(11):21704, 2009
2. Piccin O et al: Branchial cyst of the parapharyngeal space: report of a case and surgical approach considerations.
Oral Maxillofac Surg. 12(4):215-7, 2008
3. Stambuk HE et al: Imaging of the parapharyngeal space. Otolaryngol Clin North Am. 41(1):77-101, vi, 2008
4. Monobe H et al: Peritonsillar abscess with parapharyngeal and retropharyngeal involvement: incidence and
intraoral approach. Acta Otolaryngol Suppl. (559):91-4, 2007
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Image Gallery

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Diagnostic Imaging Head and Neck

(Top) Axial graphic of the normal parapharyngeal space at the level of the nasopharynx demonstrates the complex
fascial margins and the fat-only contents. Mass lesions originating in the surrounding pharyngeal mucosal, masticator,
parotid, and carotid spaces can extend into the parapharyngeal space. The resulting displacement pattern of the
parapharyngeal space may be helpful in defining the space of origin of a mass in the suprahyoid neck. (Bottom)
Coronal graphic shows suprahyoid neck spaces as they interact with the skull base superiorly and submandibular
space inferiorly. The parapharyngeal space interacts with no critical structures as it abuts the skull base. Inferiorly it
“empties” into the posterior submandibular space along the posterior margin of the mylohyoid muscle. As a

consequence of this anatomic arrangement, it is possible for an infection or a malignant tumor that breaks into the
parapharyngeal space to present inferiorly as an “angle of mandible” mass.

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