Category: Head and Neck cases

Head and Neck #15

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What do you see in the following images?

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Scalp haemangioma
Right parietal subcutaneous well-defined soft tissue oval lesion. It demonstrates low signal on T1W image, Intermediate signal on T2W image with prominent vascular flow voids, and avid enhancement on the post contrast image. No adjacent osseous or soft tissue abnormality. No intracranial extension.

More information

Infantile hemangiomas are benign vascular tumours, most of these tumours arise in the craniofacial region. Most of them are not present at birth but they increase in size during the first year of life, with a subsequent progressive involution during early childhood.

Differential diagnosis includes: epidermoid cyst, lymphatic malformation,  and sinus pericranii.

Head and Neck #14

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What do you see in the following images?

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Nasolabial cyst
Right nasolabial lesion with remodeling of the maxillary alveolus bone. On MRI it shows high signal intensity on both T1- and T2-weighted images with no signal suppression on the T2 FLAIR with Fat saturation sequence.
Differential Diagnosis:
Nasolabial cyst with hemorrhage
Epidermal inclusion cyst
Dermoid cyst
Dentigerous cyst

Head and Neck #13

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What do you see?

Labyrinthitis Ossificans

Ossification of the membranous labyrinth, high-density bone deposition involving all the cochlear turns.

This usually occurs as a complication of suppurative labyrinthitis, either due to otomastoiditis or meningitis. Other causes include trauma, autoimmune diseases, and surgery.

Head and Neck #12

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24-year-old male:
– Feels a lump in the upper lateral corner of right eye.
– MRI was made.

What do you see?

Preseptal lesion right supero-lateral corner, lateral to lacrimal gland.
T2 and T1 hyperintense, low signal after fat suppression.
No enhancement (right upper picture).
Slight remodeling of bone.
No invasive growth no post-septal component.

What is the most likely diagnosis?

Diagnosis: dermoid cyst, also fits with age and location of lesion.

Head and Neck #9

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47-year-old male:
– Headache since 2 months, nausea, and vomiting.
– Papilledema but no loss of vision.
– MRI is made.

What is the most likely diagnosis?

Expansive mass in the midline centered in the clivus (basiocciput and basisphenoid) with high signal on FLAIR (upper left), intermediate to low T1 signal, high T2 signal, and moderate heterogeneous enhancement after contrast administration.

No diffusion restriction.
ADC value is around 1350. No dural tail.
No encasement of basilar artery.
Compression on pons but no invasive growth.
Upward displacement of chaism, anterior displacement of pituitary gland and stalk.

Diagnosis: chordoma.

Does not fit with meningioma, pituitary macroadenoma, chondrosarcoma, lymphoma, or plasmacytoma.This
was histologically proven.

Head and neck #8

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Where is the lesion?

Left carotid sheath posterior to the carotid bulb, internal, and external carotid arteries.

How does it look like?

Large oval avidly enhancing lesion displacing the carotid bifurcation anteriorly.

What is the differential diagnosis?

– Carotid bulb paraganglioma: avidly enhancing lesion with characteristic splaying of the internal and external carotid arteries (lyre sign).
– Glomus vagale: paragangliomas but of the vagus nerve, located posterior to the carotid arteries displacing them anteriorly.
– Vagal schwannoma: those that arises within the carotid sheath posteriorly but usually shows moderate enhancement compared with the avid enhancement of the paragangliomas.

What is the most likely diagnosis

Glomus vagale

Head and neck #7

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60-year-old female:
– Since a few weeks eye movement disorder and diplopia of the left eye, tinnitus, and sinusitis.
– Non-enhanced CT of the orbits is performed (due to contrast allergy).

What are your findings?

Widened infraorbital canal left eye with thickening of the infraorbital nerve.

What is your differential diagnosis and do you want more imaging?

Yes, we want MRI to sort things out more.

Findings: Smoothly thickened T2 hyperintense, enhancing infraorbital nerve in its canal. No continuation posteriorly to the vidian canal or anteriorly to the pre-antral region. No pathologic paranasal sinus mass or pharyngeal mucosal mass indicating perineural tumor spread.

Differential diagnosis:
Schwannoma.
Less likely malignant cause like perineural tumour spread.

Biopsy is performed of right lacrimal gland, since clinically this was found to be prominent (radiologically slight asymmetry, slightly higher T2 signal).

Histopathology: IgG4 disease or dacryoadenitis.

After this, whole body scanning showed evidence of IgG4 disease in the pancreas also. Patient was treated with steroids.

Follow-up MRI: Decrease in size of the infraorbital nerve from 11 to 5 mm. Still high T2 signal, however, the decrease in size on steroids suggests other diagnosis than schwannoma, in this case probably involved in orbital IgG4 disease. Rare!

Head and Neck #6

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– 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

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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