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28.10.2015
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next speaker:Bernhard Schuknecht
ESHNR Sept 24-26 2015 Krakow
Swelling in the head and neck
Bernhard SchuknechtMRI Medical Radiological Institute
Zurich Switzerland
Choice of diagnostic technique
• the condition of the patient
• history /clinical findingstime course, duration, location of swelling,
• suspected anatomic location
of a lesion
• should be related to subsequent tx!!
Dental source
Depends on
1. Periorbital/ midface swelling
• Infections
Supra– infrahyoid
related complications
Developmental lesion related
Glandular
• Inflammation: IgG4, IMFT
• Vascular lesions
• Neoplasms: SCC, lymphoma
Order of business
… categorize lesionsaccording to etiology
Etiology
• infectious
• developmental
• vascular
• neoplastic
• .......
Morphologic findings
in conjunction with advanced imaging
• the condition/age of the patient
• history /clinical findingstime course, duration, location of swelling,
⇒ guide subsequent txor add. diagnostic procedures !!
Infectious:abscess: Imaging depictsdeepextension !
Imaging requires a stabilized clinical condition2. Submandibular swelling
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Suprahyoid neck spaces:parapharyngeal space
Parapharyngeal space abscess⇒ marked airway compromize
assess retropharnygeal + carotid space!
Suprahyoid neck: parapharyngealspace
• parapharyngeal space
Parapharyngeal space abscess w submandibular extension
Suprahyoid neck spaces:pharyngeal mucosal space
3. Tonsillar + pharyngeal mucosal space swelling
Retrotonsillar abscess
For tx : Septations ?Retropharyngealextension?Vessels?
4. Perimandibular/ temporal swelling
Suprahyoidneck: masticator space
Deep masticator space abscess +phlegmonous infiltration
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Submandibular abscess
In submandibular abscess imaging is rarely required for therapeutic reasons!Imaging to identify the source: dental , osseous, salivary gland origin ?
Secondary chronic osteomyelitis
Acute orphyrnygeal infection
Suppurative lymphadenitis
• intranodal abscess + cellulitis• most common: I, IIA, RPN • pharyngitis, tonsillitis, dental sources, rarely sialadenitis
• 2ndary septic thrombophlebitis IJV• acute oropharyngeal infection
+ postanginal septicamia• fusobacterium necropharum
Complications:Lemierre syndrome: Jugular vein thrombosis
Tender swollen neck
Radiographics 2010Becker M et al. Radiology 1997
Complications:Descending necrotising fasciitis
Infection from oral cavity /oropharynx
infiltration and diffuse thickening• cutis / subcutaneous ⇒ cellulitis• superficial deep fascia ⇒ fascitis• platysma, scm, strap m. ⇒ myositisuncommon:• gas collections, mediastinitis, effusion
Developmental:Thyroglossal duct cyst
foramen cecum↔ thyroid bed
90% of nonodontogenic congenital cysts
hyoid level 50%; supra-, infrahyoid 25% each
infrahyoid in paramedian location
+ infection
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2nd branchial apparatus cyst
+ infection
Sinus of His remnant: (manifestation < 25y!)palatine tonsil - angle of mandible - supracl.• anterior cervical space• antero-medial beak towards carotid bif.• thicker wall + cellulitis ⇒ infection
1st BCA 8%osteocartilagenousjunction of EAC⇒ I periauricular
⇒ II periparotid- angle of mandible
1st branchial cleft lesion
CT guided biopsy
⇒ chronic abscess
1st branchial cleft
3 rd BCA 3%along sternocleido m.
lateral to carotid in
ant/post cervical space
- supraclavicular
3rd branchial apparatus lesion
4th branchial apparatus lesion
• apex of piriform sinus to upperaspect of left thyroid lobe ⇒cyst or abscess w thick walled track
• inflammation of – left- thyroid gland
Glandular: submandibular sialadenitis
usually obstructive
STIR and DWI b 1000 more sensitive than T1Gd
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Sialadenitisofsubmandibular gland
usually obstructive
acute sialadenitis contraindication to sialography
Star vibe 0.5mm
Sialadenitis of parotid gland
Obstructive: dilated duct, calculus ?
Bacterial: localized, from LN
Viral : 75% bilateral (clinical d)
Autoimmune: bilateral; Sm, Sl ?
Inflammation : New entity1. IgG4-related disease
chronic fibroinflammatory systemic condition w tumefactivelesions
• may affect every organ in H&N: salivary- lacrimal glands, orbits, thyroid, lymph nodes, sinonasal tract, larynx
• originally in the pancreas as systemic disease in 2003
• Histo: lymphoplasmocytic infiltration, fibrosis, obl. phlebitis /arteritis
• Immunostaining: increased numbers of IgG4+ cells• often elevated serum IgG4 concentrations (>280 mg/dL)
• Encompasses conditions: like Mikulicz, inflammatroy pseudo-tumor retroperitoneal fibrosis, eosinophlic angiocentric fibrosis, periarteritis
A. Ghazale A et al. “Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer,” Am J Gastroenterol 2007; 102: 1646–1653
IgG4 related manifestationssialadenitis - trigeminal nerve involvement
Mikulicz disease= lymphoplasmocytic fibrosis withbilateral swelling of lacrimal and salivary glands
Fujita A et al. IgG4-related Disease of the Head and Neck: CT and MR Imaging Manifestations Radiographics 2012;32
Katsura M et al. IgG4-Related Inflammatory Pseudotumor of the Trigeminal Nerve: Another Component of IgG4-Related Sclerosing Disease? AJNR 20111; 32: E150-152
IgG4 related perarteritis
• thickening of carotid wall centered at carotid bifurcation
• T2 ↓ , enhancement of vessel wall on MR ± lumen narrowing
DD carotidynia
mesenchymal tumor usually affects lungs, separate entity 1994extrapulmonary: abdomen, retroperitoneum, extremities
• H & N (14-18%): orbit > meninges > paranasal sinuses > infratemporal fossa > parotid gland,
• histo: proliferating spindle cells: myofibroblastic + inflammatory, plasma cells + lymphocytes,
• intermediate dignity, tendency for recurrence , <5% meta
• more aggressive at skull base
Synonyms: inflammatory pseudotumor, plasma cell granuloma, histiocytoma, lymphoid or myxoid hamartoma, fibrohistiocytoma…., Gao F et al. Computed tomography and magnetic resonance imaging findings of inflammatory myofibroblastic tumors of the head and neck. Acta Radiol 2014; 55 : 434-440
Inflammation: New entityInflammatory myofibroblastic tumour
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IMFT of temporal bone → a more aggressive and unpredictable course
Inflammatory myofibroblastic tumour DD to IMFTFibromatosis
connective tissue tumouraponeurosis, fascia, muscle
Nodular fascitis
benign reactive processsuperficial and deep fascia
benign myofibroblastictumor like conditions
Proliferative myositis
• lymphatic m.
• venousmalformations
• arterio-venous
composed of primitive lymphatic sacs
nonunion lymphatic + venous system
⇒ sequestration
enlarge in conjunction with infection
29/30y m
Vascular:Lymphatic vascular malformation
F-up
Venousvascularmalformation
Congenital venous vascular arrest with endothelial lined vascular sinusoids, Lobulated± phleboliths
Palatine tonsil carcinoma Piriform sinuscarcinomaN3 nodal metastases extracapsular spread
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Carcinomatous lymphangitis
high grade salivary adeno-ca
Nodal Non-Hodgkin Lymphoma5% of H&N neoplasms
Lymphoreticular system malignancy (> 30% DLBCL)
multiple bilateral solid round/oval nodes
level II-IV most common
slight enhancement
cannot be differentiated from nodal HL
M 53
Extranodal Non-Hodgkin Lymphoma
30% have extranodal manifestations
• non nodal lymphatic :palatine, lingual tonsil
• non nodal extralymphatic:
salivary –lacrimal glands, palate, thyroid
Pats mean age 55 years
L
M 43
Hodgkin Lymphoma
• at presentation mediastinal LN frequently involved
• T2 hyperintens to muscle
• rarely extranodal in H&N
• HL more rare than NHL
• Pats mean age 27 years
Presentation: neck adenopathy→ single or contiguous nodes,
19y f tonsillar swelling
star vibe 0.5mm
quantitative asessementby advanced MRBurkitt lymphoma
Kar-ho Lee F et al. Eur J Radiol 2012;81 784-88
ktrans, Ve and AUC �
CBF
CBV
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Take home: swelling in the neck
Acquire clinical information⇒ have a look at the patient !
Describe lesion location Neck space, fascia, neurovascular structures
Put lesion into a ″category″
Optimize diagnostic assessmentbased on modality specific,″ know how“combine morphology, DWI, DCE, DSC perf.
Focus !! aspects of diagnostic/therapeutic relevance Anything [email protected]