Head and Neck #6

– 66-year-old female:
– Feels a lump in the neck when swallowing

In what space houses this lesion?

Mass in the right parapharyngeal space or deep part of parotid space. No parapharyngeal fat is visible, so either the lesion displaces the fat or it arises from it. It is certainly not from the carotid space, since the carotid arteries are displaced posteriorly. It is also not from the mucosal space since it compresses the lateral oropharyngeal wall, instead of arising from it.

Do you want further imaging to make a diagnosis and what?

MRI will provide you more details in head and neck lesions where the lesion arises from exactly, and what the origin is. MRI is made with T1, T2, and T1 with Gad and fat suppression.

What is your differential diagnosis?

Origin from deep parotid lobe, so DD benign or malignant salivary gland tumor, such as pleiomorphic adenoma, adenoid cystic of mucoepidermoid cell carcinoma. Radiologists are not good in differentiating benign from malignant lesions on MRI. Histopathology has to be done. DWI will help you a little, in that, malignant lesions have often lower ADC values, but also Wharthin tumors do so. DD rare schwannoma arises from V3 (mandibular nerve) in the true parapharyngeal space.

Solution

We performed ultrasound and cytologic punction. This turned out to be a fairly rare acinic cell carcinoma.

Teaching point: Malignant tumors of the salivary glands are well delineated and do not have to present as ill-defined lesions, nor have to have lymph node metastasis or perineural spread.

Head and Neck #5

66-year-old female:
– Feels a lump in the neck when swallowing

In what space houses this lesion?

Mass in the right parapharyngeal space or deep part of parotid space. No parapharyngeal fat is visible, so either the lesion displaces the fat or it arises from it. It is certainly not from the carotid space, since the carotid arteries are displaced posteriorly. It is also not from the mucosal space since it compresses the lateral oropharyngeal wall, instead of arising from it.

Do you want further imaging to make a diagnosis and what?

MRI will provide you more details in head and neck lesions where the lesion arises from exactly, and what the origin is. MRI is made with T1, T2, and T1 with Gad and fat suppression.

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What is your differential diagnosis?

Origin from deep parotid lobe, so DD benign or malignant salivary gland tumor, such as pleiomorphic adenoma, adenoid cystic of mucoepidermoid cell carcinoma. Radiologists are not good in differentiating benign from malignant lesions on MRI. Histopathology has to be done. DWI will help you a little, in that, malignant lesions have often lower ADC values, but also Wharthin tumors do so. DD rare schwannoma arises from V3 (mandibular nerve) in the true parapharyngeal space.

We performed ultrasound and cytologic punction. This turned out to be a fairly rare acinic cell carcinoma.

Teaching point:

Malignant tumors of the salivary glands are well delineated and do not have to present as ill-defined lesions, nor have to have lymph node metastasis or perineural spread

Head and Neck #4 – Flashcard

CT – Coronal + C
CT – Axial + C
Where is the abnormality?​

Left side of the neck.

How can the abnormality be described?​

Multiple enlarged neck clustered lymph nodes, with some of them showing necrosis.

What is the differential diagnosis?

Infectious lymphadenitis: such as TB or pyogenic lymphadenitis.
Metastasis: particularly from head and neck malignancies.
Treated lymphoma or lymphoma in immune compromised patient.

What is the final diagnosis

TB lymphadenitis

Head and Neck #3 – Long Case

Axial STIR

Axial T1

Where is the lesion?

Situated at the left common carotid artery bifurcation.

What is the lesion like?

Enhancing soft tissue tumor splaying the internal and external carotid arteries.

Click here to see more images
Axial STIR

Axial T1

What MRI signal characteristics shows the lesion?

Hyperintense on the STIR with dark foci giving salt and pepper appearance. Hypointense on T1.

What is the differential diagnosis?

Carotid body tumor: glomus tumor or paraganglioma of the carotid body. It characteristically splays the internal and external carotid arteries.
Vagal schwannoma: tends to displace both arteries together to one side.
Glomus vagale: paraganglioma with the same signal characteristics as the carotid body paraganglioma but is located more superiorly at the skull base and may extend into the jugular foramen.

What is the most likely diagnosis?

Diagnosis: Carotid body tumor.

Head and Neck – Flashcard #2

What do you see on the following images?

Click here to see the answer

Dehiscent jugular bulb

The jugular bulb bulges into the left middle ear cavity with absence of the sigmoid plate separating the jugular bulb from the middle ear in keeping with dehiscent jugular bulb.

It is one of the causes of pulsatile tinnitus, patients can also present with conductive hearing loss if the jugular vein contacts the tympanic membrane.

Head and Neck – Flashcard #1

Axial CT bone window

What do you see on this image?

Click here to see the answer

Otosclerosis

There is a small lucency anterior to the vestibule, just lateral to the basal turn of the cochlea. Consistent with fenestral otosclerosis.

There are two types of otosclerosis:

1- Fenestral: is the most common type. It involves the bone anterior to the oval window and causes conductive hearing loss.
2- Retro-fenestral: involves the cochlear capsule and causes sensorineural hearing loss.
The two types can occur simultaneously.