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RADIOLOGY: HEAD AND NECK DR VIBHAY PAREEK RADIATION ONCOLOGY JUPITER HOSPITAL
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CONVENTIONAL RADIOLOGY Temporal Bone: Law’s View, Schullars View, Stenver’s View, Transorbital View, Submentovertical View. Nose And Paranasal Sinuses: Water’s View, Caldwell View, Lateral View, Right And Left Oblique Views, Lateral And Occlusal Views Of Nasal Bone. Neck: Lateral View And Anteroposterior Views Of Neck, Soft Tissue Lateral View Nasopharynx, Submandibular Salivary Gland
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LAW’S VIEW (LATERAL VIEW OF MASTOID) In 1913, Dr Frederik Law Described Lateral View Of Mastoid Bone. Sagittal Plane Of The Skull Is Parallel To The Flim X Ray Beam Is Projected 15 Degree Cephalocaudal.
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STRUCTURES SEEN: External Auditory Canal (EAC) (Superimposed On Internal Auditory Canal (IAC)), Mastoid Air Cells, Tegmen, Lateral Sinus Plate Temporomandibular Joint.
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SCHULLAR’S VIEW 1906, Dr Arthur Schuller, An Austrian Neuroradiologist, Described An Oblique View Of Mastoid Bone. X-ray Beam Is Projected 30° Cephalocaudal And Prevents Superimposition Of Two Sides Of Mastoid Bones. Structures Seen: Eac Superimposed On Iac, Mastoid Air Cells, Tegmen, Lateral Sinus Plate, Condyle Of Mandible, Sinodural Angle And Atticoantral Region (Key Areas For Cholesteatoma And Its Erosion).
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SCHULLER S VIEW
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CLINICAL APPLICATIONS: of intercellular septa Extent of pneumatization, sclerotic mastoid, destruction (mastoiditis), location of sinus plate (position of sigmoid sinus) and tegmen (roof of middle ear and floor of middle cranial fossa), cholesteatoma and longitudinal fracture of petrous pyramid.
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STENVER’S VIEW: In 1917, Dr H. W. Stenver Described Stenvers View Of Temporal Bone Long Axis Of The Petrous Bone Lies Parallel To The Film.
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STRUCTURES SEEN • • • • • • Entire Petrous Pyramid, Arcuate Eminence, Internal Auditory Meatus, Labyrinth With Its Vestibule, Cochlea And Mastoid Antrum
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STENVER’S VIEW:
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TOWNE’S VIEW: In 1926, Dr E. B. Town Of England Described Towns View. This Is An Anteroposterior View Of Skull With 30° Tilt From Above And In Front. It Shows Both Petrous Pyramids, Which Can Be Compared.
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TOWNE’S VIEW Structures Seen: Both Side Temporal Bones, Arcuate Eminence And Superior Semicircular Canal, Mastoid Antrum, IAC, Tympanic Cavity, Cochlea And EAC Clinical Applications: Acoustic Neuroma And Apical Petrositis.
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TRANSORBITAL VIEW: • • • • • • This is an anteroposterior view of skull. Orbitomeatal line is at right angles to the film. X-ray beam passes through the orbit. Structures seen: IAC, cochlea, labyrinth and both petrous pyramids projected through the orbits. Clinical applications: Acoustic neuroma and petrous pyramid.
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TRANSEORBITAL PROJECTION:
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SUBMENTOVERTICAL VIEW: VERTEX REMAINS NEAR THE FILM AND X-RAY BEAM IS PROJECTED FROM THE SUBMENTAL AREA.
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STRUCTURES SEEN: EXTERNAL AUDITORY CANNAL, MIDDLE AIR CLEFT. IE. MASTOID CELLS, MIDDLE EAR & EUSTACHIAN TUBE INTERNAL AUDITORY CANAL SPHENOID SINUSES
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NOSE AND PARANASAL SINUSES • • • • • Water’s view (occipitomental view): In 1914, Dr C. A. Waters and C. W. Waldron, two British radiologists, introduced the Waters view. Nose and chin touch the film and X-ray beam is projected from occipital side. Open mouth view shows sphenoid sinus. Petrous bones are projected below the maxillary sinuses. Fractures of right and left nasal bones and their lateral displacement can be seen.
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STRUCTURES SEEN MAXILLARY (SEEN BEST) FRONTAL AND SPHENOID SINUSES • ZYGOMA, ZYGOMATIC ARCH NASAL BONES, FRONTAL PROCESS OF MAXILLA, SUPERIOR ORBITAL FISSURE AND INFRATEMPORAL FOSSA.
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CALDWELL VIEW (OCCIPITOFRONTAL VIEW): Eugene W. Caldwell, In 1903, Described A View Of The Paranasal Sinuses That Still Bears His Name, “The Caldwell View” Nose And Forehead Touch The Film And X-ray Beam Is Projected 15–20° Caudally. Frontal And Ethmoidal Sinuses Are Seen Well In This View.
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STRUCTURES SEEN Frontal, Ethmoid And Maxillary Sinuses, Frontal Process Of Zygoma, Zygomatic Process Of Frontal Bone Lamina Superior Margins Of Orbits, Papyracea, Superior Orbital Fissures.
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LATERAL VIEW Lateral side of the skull lies against the flim and X ray beam is projected perpendicular from other side.
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STRUCTURES SEEN : Anterior and posterior extents of sphenoid, frontal and maxillary sinuses, sella turcica, Ethmoid sinuses, alveolar process, condyle and neck of mandible.
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NECK, LARYNX AND PHARYNX Lateral View Of Neck Structure Seen: Outline Of Base Of Tongue, Vallecula, Hyoid Bone, Epiglottis And Aryepiglottic Folds, Arytenoids, False And True Cords With Ventricle In Between Them, Thyroid And Cricoid Cartilages, Subglottic Space And Trachea, Prevertebral Soft Tissues, Cervical Spines And Pretracheal Soft Tissues And Thyroid.
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BARIUM SWALLOW Procedure Used To Examine Upper Gastrointestinal Tract,which Include The Pharynx, Esophagus, Cardia Of Stomach. The Contrast Used Is Barium Sulfate. Types Of Contrast Study Single Contrast Study (Ii) DOUBLE CONTRAST STUDY
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CONTRAINDICATION Suspected Esophageal Perforation. Tracheo-esophageal Fistula If Strong Clincal Suspicion Of Aspiration Or Tef,then Omnipaque Swallow (Iohexol) Advised. Xray View Soft Tissue Neck,chest – Ap & Lat
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NORMAL-AP /LAT VIEW - SCOUT
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AP/LAT VIEW WITH BARIUM
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EFT: LATERAL VIEW: EPIGLOTTIS (RED ARROW). POST CRICOID IMPRESSION (YELLOW ARROWS). CRICOPHARYNGEOUS IMPRESSION (WHITE ARROW).RIGHT: AP-VIEW: SMALL LATERAL PHARYNGEAL POUCHES (ARROWS)
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CA ESOPHAGUS THE STENOTIC SEGMENT IS LONG GIVING A “RAT-TAIL” APPEARANCE BARIUM SWALLOW SHOWS MILD DILATATION OF THE ESOPHAGUS WITH IRREGULAR STENOTIC LESION IN THE LOWER END OF THE ESOPHAGUS “MOTH EATEN APPEARANCE
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SIALOGRAPHY • • • Radiologic examination of the salivary glands The submandibular and parotid glands are investigated by this method The sublingual gland is usually not evaluated this way because of difficulty in cannulation
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PROCEDURE Obtain Preliminary Radiographs Any Condition That Is Visibe W/O Contrast Optimum Technique Obtained 2-3 Min Before Procedure Give Lemon Contrast Media (Iohexol) Injected Into Main Duct After Procedure Suck On Lemon To Clear Contrast 10 Min After Procedure Take Radiograph
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PAROTID RADIOGRAPHS SET-UP
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ORTHOPANTOMOGRAPHY (TOMOGRAPHY OF THE MANDIBLE) A Pantomograph Is A Panoramic Radiograph Machine. It Permits Visualization Of Entire Maxillary And Mandibular Dentition, Alveolar Arches And Contiguous Structures On A Single Extraoral Film
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ULTRASOUND Ultrasound Is Sound Within A Frequency Above The Upper Limit Of Normal Hearing. Ultrasound Images Are Formed From Reflected Sound Waves. Sound Waves Are Generated In Short Bursts By The Transducer (Or Probe) And The Sound Energy That Is Reflected Back Is Collected At The Point Of Origin (The Transducer)
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TRANSDUCER (PROBE) Piezoelectric Material Is Used To Produce Sound Wave Usually Lead Zirconate Titanate The Higher The Frequency Of The Probe The Lesser The Depth Of Penetration But Gives Better Spatial Resolution. In Neck Most Of The Structures Of Interest Are Superficial And Required A Higher Frequency Probe Of Greater Than 7.5 Mhz
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ADVANTAGES No Known Harmful Effects And No Contraindications. High-resolution Ultrasound Is Quick And Accurate; Further, It Is Relatively Inexpensive Compared To CT Or MRI. In Addition To Using Echoes To Generate Images, We Can Analyze The Returning Echo Frequencies. This Doppler Analysis Allows Identification Of Moving Blood As Well As Its Direction And Magnitude
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ULTRASOUND APPEARANCE OF COMMON ABNORMALITIES. Lymph Nodes Normal Lymphnode May Be Visualized By Usg In Healthy Subject, They Are Often Not Seen Due To Their Small Size And Similar Echo-texture With Surrounding Structure. When Apparent, Lymph Nodes Are Reactive, Inflammatory Or Neoplastic. Retropharyngeal Lymph Nodes Cannot Be Seen With Ultrasound.
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REACTIVE LYMPH NODE. (A) AN OVAL- SHAPED, LOW-REFLECTIVE LYMPH NODE WITH AN ECHOGENIC HILUM (ARROW) (B) FLORID COLOUR DOPPLER FLOW TO THE CENTRAL HILUM CONSISTENT WITH A BENIGN REACTIVE LYMPH NODE
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SQUAMOUS CELL CARCINOMA LYMPH NODE METASTASIS. AN ENLARGED LOW REFLECTIVE MASS WITH AN IRREGULAR BORDER (LONG ARROW) CAROTID ARTERY (SHORT ARROW)
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THYROID For Ultrasound Imaging Thyroid Disorder May Be Considered Into Two Groups Nodular Diffuse Major Role Of Usg In The Assessment Of Disease 1.Detection Of Focal Masses Differentiation Of Multinodular Goiter/Hyperplasia From Other Nodular Disease To Document The Extent Of A Known Thyroid Malignancy; Follow Up To Look For Residual, Recurrent Or Metastatic Carcinoma; 5.Guidance For FNAC Or Fine Needle Aspiration For Biopsy.
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SALIVARY GLAND DISEASE Both The Parotid And Submandibular Glands Are Superficial And Well Sited For Ultrasound Examination Ultrasound Accurately Differentiates Salivary Gland Tumors From Other Lesions Outside Gland Calculi Larger Than 2mm Are Detected By Usg And Useful In Defining Location Of Calculi In Relation To The Gland Parenchyma It Detects The Presence And Extends Of Any Abscess Formation.
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DOPPLER ULTRASOUND MEASURES BLOOD FLOW OF VESSELS. IN COLORDOPPLERFLOWING BLOOD APPEARS EITHER RED OR BLUE, WHICH DEPENDS UPON THE BLOOD DIRECTION, TOWARDS OR AWAY FROM THE TRANSDUCER. „ POWER DOPPLER: IT CAN DEMONSTRATE TISSUE PERFUSION.
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APPLICATIONS OF ULTRASOUND Differentiating Cystic From Solid Masses „Metastatic Lymph Nodes „Tumor Invasion Of Carotid Vessels And Internal Jugular Vein. „Tumors Of Parotid And Submandibular Salivary Glands „Salivary Duct Stones Even Less Than 2 Mm „Detection And Drainage Of Salivary Gland Abscess Under US Guidance „Masses Of Thyroid And Parathyroid Glands And US Guided Fine Needle Biopsy „ Neck Lymphoma.
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COMPUTED TOMOGRAPHY In 1972 Godfrey Hounsfield Of Great Britain Invent CT. Computed Tomography (Ct) Is Accomplished By Passing A Rotating Fan Beam Of X- rays Through The Patient And Measuring The Transmission At Thousands Of Points. The Data Are Handled By A Computer That Calculates Exactly What The X-ray Absorption Was At Any Given Spot In The Patient. Compared With Plain X-rays, Ct Uses About 10 To 100 Times More Radiation
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COMPUTED TOMOGRAPHY IMAGING Imaging Can Be Obtained In Several Planes. In Most Cases The Axial (Transaxial) Plane, Usually Parallel To The Orbitomeatal Or Infraorbitomeatal Plane, Is Used With The Patient Lying Supine In Addition, Direct Coronal Imaging And Even Direct Sagittal Imaging Can Be Performed. In Fact Images Can Be Reformatted In Any Plane Or Any Angle
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DIFFERENT VIE• WCORSONOALFIMCAGTE PNS AXIAL IMAGE SAGITTAL IMAGE
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COMPUTED TOMOGRAPHY Conventional CT Scanners Have Traditionally Operated In A Step-and- shoot Mode, Defined By Data Acquisition And Patient Positioning Phases Helical CT Is Characterized By Continuous Patient Transport Through The Gantry While A Series Of X-ray Tube Rotations Simultaneously Acquires Volumetric Data. The Evolution Of Multidetector Ct Scanners (Mdcts) Has Resulted From The Combination Of Helical Scanning With Multislice Data Acquisition.
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COMPUTED TOMOGRAPHY In General, The Basic Four Densities On CT Images Are The Same As Those In Plain X- rays: Air Is Black, Fat Is Dark Gray, Soft Tissue Is Light Gray, Bone Or Calcium And Contrast Agents Are White
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CT IMAGE DISPLAY Hounsfield Unit: Value Of CT Number Defined By The Relationship Between The Linear Attenuation Value Of The Material Being Scanned And That Of Water. Gas = -1000 Hu Water = 0 (Zero) HU Bone = +1000 HU Fat = - 80 To -100 HU
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CT IMAGE DISPLAY The Window Level Is Simply The Midpoint Of The Densities Chosen For Display For Imaging Of The Soft Tissues Of The Head And Neck, A Window Level Of Approximately 40 To 70 HU Is Usually Chosen, At A Midpoint Approximately Equal To The Density Of Muscle For Imaging Bony Structures Such As Paranasal Sinuses And Temporal Bone, Window Levels From 0 To +400 HU And A Very Wide Window Width Of 2000 To 4000 HU May Be Chosen
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THE TERMINOLOGY COMMONLY USED TO DESCRIBE THE ABOVE MENTIONED WINDOWS INCLUDES SOFT TISSUE WINDOWS (WINDOW WIDTH OF 250 TO 400 HU) AND BONE WINDOWS (2000 TO 4000 HU). SOFT TISSUE WINDOW CT IMAGE BONE WINDOW CT IMAGE
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CONTRAST CT: Intravenous Contrast Agents Allow Identification Of Rim Enhancement In Pathological Lymph Nodes And Increase The Definition Of Primary Tumors.
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SPIRAL CT Helical Or Spiral CT Scans A Volume Of Tissue And Provides Better Quality Images Than The Conventional CT. It Covers More Than 300 Cm Tissue During A Single Breathhold Of 30 Seconds
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MULTIDETECTOR CT SCANNERS (MDCTS) MDCT Can Reduce Scan Time, Permit Imaging With Thinner Collimation, Or Both Multidetector CT Offers The Additional Advantages Of Decreased Contrast Load, Reduced Respiratory And Cardiac Motion Artifacts, And Enhanced Multiplanar Reconstruction Capabilities.
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CT ANGIOGRAPHY: With Intravenous Bolus Administration Of Iodinated Contrast Material. Permitted Successful Imaging Of Entire Vascular Distributions CT Angiography Has Become An Important Tool For Assessment Of The Abdominal And Iliac Arteries And Their Branches, The Thoracic Aorta, The Pulmonary Arteries, And The Extra- And Intracranial Carotid Circulation.
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PROCESSING OF VOLUMETRIC DATA: The Volumetric Data Can Be Processed To Produce Multiplanar Images: Sagittal And Coronal Three-dimensional (3D) Images Virtual Endoscopy: Such As Laryngoscopy, Bronchoscopy And Sinuscopy
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3-D IMAGE REFORMATTING To Evaluate Bony Structure Like Fracture, Tumour, Exostosis, Destructive Lesions Etc. Helps Immensely In Planning Reconstruction Operation
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3-D RECONSTRUCTION OF CT-ANGIOGRAPHY 3- D Reconstruction Of Cervical Vessels From CT Volumetric Data Set Obtained After Administration Of Contrast Material Gives Better Result Than MR Angiography
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OPTIMAL SLICE THICKNESS 3 Mm Or 5mm = Neck Structure 2 Mm = Facial Bone, Sinunasal Cavities And Orbit, Laryngohypopharyngeal Region 0.8 – 1 Mm = Temporal Bone
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APPLICATIONS OF CT, Extension Of Mucosal Tumors Of Suprahyoid Neck And Metastatic Neck Lymph Nodes (Ring Enhancement) „Postoperative Neck „Salivary Gland Tumors And Metastatic Neck Lymph Nodes „Computed Tomography Sialography Cervical Lymphadenopathy „Trauma, Inflammation And Cancer Of Larynx And Laryngopharynx With Metastatic Neck Nodes „Large Or Fixed Thyroid Tumors Invading And Compressing Larynx, Laryngopharynx, Trachea And Mediastinum „Paranasal Sinuses Prior To Endoscopic Sinus Surgery, Severe Nasal Polyposis, Tumors „ Facial Trauma „Temporal Bone And Skull Base Tumors, Semicircular Canal Fistulas, Cochlear Implants.
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MRI IMAGING PROTOCOLS The Rate Of Energy Loss Is Designated As The Longitudinal (T1) And Transverse (T2) Relaxation Times. T1 Represents The Restoration Of The Longitudinal Magnetization Along The Axis Of The Main Magnetic Field T2 Represents The Decay Time Of The Magnetization In The Transverse Plane. Substances (eg.,Fluid) That Have A Long T1 Will Appear Dark On T1-weighted Images, Whereas Those With Short T1 (Fat) Will Display High Signal Intensity.
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IMAGING PROTOCOLS On T2-weighted Images, A Long T2 Substance (Fluid) Will Appear Bright. The Commonly Used Pulse Sequences Are T1-weighted (T1w), T2- weighted (T2w), Gadolinium-enhanced T1w, Spin (Proton) Density, Fat-suppressed And Gradient Echo Imaging.
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T1W: Because Of High Soft Tissue Discrimination, T1W Images Show Exquisite Anatomical Details. „T2w: The Pathological Lesions Increase T2 De-phase Times, Which Produce Higher Signal Than Surrounding Normal Tissue In T2w Images. The Combination Of T1w And T2w Images Is Good For Characterizing Fluid Containing Structures, Solid Components And Hemorrhage.
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MRI HEAD SAGITTAL SECTION T1-WEIGHTED MRI HEAD AXIAL SECTION T2- WEIGHTED
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GADOLINIUM-ENHANCED T1W: Intravenous Gadolinium (Used In T1W) Reduces T1 Relaxation Time And Enhances Lesions, Which Appear As High Signal Intensity Areas Improved Delineation Of Tumor Margins Relative To The Lower Signal Of Muscle, Bone, Vessel And Globe. Gadolinium Enhancement Is Optimally Used With Specific Fat Suppression Techniques.
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SHORT-TAU INVERSION RECOVERY: The STIR Sequence Suppresses High Signal Intensity From Fat (That Turn Fat Black) And Fluid Containing Structures Remain High Signal Intensity. In Stir, Decreased Signal-to-noise Ratio Degrades The Image. Magnetic Resonance Angiography: It Uses Specific Sequences And Demonstrates Flowing Blood.
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DIFFERENT CHARACTERISTICS (To Quickly Identify A T1WI: Fat Is White, CSF And Vitreous Are Black, And Nasal Mucosa Is Low Signal.) (To Quickly Identify A T2wi: Csf, Vitreous, And Nasal Mucosa Are White. Fat Is Low To Intermediate In Signal.)
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DIFFERENT CHARACTERISTICS To Quickly Identify A Gadolinium-enhanced T1WI: Nasal Mucosa Is White, Fat Is White, And CSF And Vitreous Are Black To Quickly Identify A Stir Image(fat Suppresion): Fat Is Almost Completely Black; Csf, Vitreous, And Mucosa Are White
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ADVANTAGES Superior Soft Tissue Contrast Resolution Than CT No Radiation Exposure Less Image Quality Gets Hampered By The Presence Of Dental Fillings
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DISADVANTAGES Long Image Acquisition Time More Chance Of Motion Artifacts Difficult To Stage Both Primary Tumour And Neck Nodal Disease Higher Cost And Less Availability Absolute Contraindications To MRI Include Patients With Cardiac Pacemakers, Cochlear Implants, And Ferromagnetic Intracranial Aneurysm Clips. Those Patients At Risk For Metallic Orbital Foreign Bodies Should Be Screened With Plain Films Or Ct Before Mri.
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APPLICATIONS OF MRI Tumors Of Nasopharynx, Oropharynx, Oral Cavity And Tongue „Extracapsular Spread Of Tumor From Nodes „Perineural Spread And Extension Beyond Gland Of Salivary Gland Tumors „Tumors Of Nose And Paranasal Sinuses: Distinguish Between Tumor And Obstructed Sinus Secretions (Hydrated Fluid,viscous, Desiccated); Perineural Spread To Anterior Cranial Fossa, Orbit, Parapharyngeal Space And Pterygopalatine Fossa And Cribriform Plate Extension „Lesions Of IAC, Facial Nerve Canal, And Jugular Foramen; Acoustic Schwannoma „Skull Base Tumors
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TECHNETIUM-99M (99MTC)- PERTECHNETATE SCAN: • In Salivary Gland Imaging 99mtc Pertechnetate Imaging May Be Useful For Assessing Salivary Gland Function In Autoimmune And Inflammatory Disease Of The Salivary Glands. If Obstructed, The Degree Of Obstruction As Well As The Follow-up Of Obstruction After Treatment Can Be Assessed. In Evaluating Neoplasms Of The Salivary Glands The Findings Of The 99mtcpertechnetate Scan Are Almost Pathognomonic Of Warthin's Tumor And Oncocytoma.
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THYROID IMAGING Most Nuclear Medicine Imaging Uses Various Isotopes Of Iodine (131I And 123I), Technitium-99m Pertechnetate To Determine Thyroid Function, Identify Hot Or Cold Nodules, Or Access Extent Of Thyroid Masses And Tumors. 1- 4 % Of Hot Nodules – Malignant Upto 25 % Of Cold Nodule – Malignant
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POSITRON EMISSION TOMOGRAPHY Used For Staging And Evaluation Of Recurrence For Primary Head And Neck Tumors, Detecting Distant Lymph Node, Soft-tissue And Skeletal Metastases More Accurate Than CT Or MRI In Detecting Residual Or Recurrent Nodes Highly Reliable After 3 – 4 Months Of End Of Treatment.
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INDICATIONS OF FDG WITH INTEGRATED PET/CT SCC Patients With  Equivocal Nodal Disease Following Conventional Assessment; -Suspicion Of Recurrent/Residual Disease. Patients With Occult Primary Tumors. Post-treatment Papillary And Follicular Thyroid Cancer Patients With Elevated Thyroglobulin And Negative 131-i Scan. Patients With Clinical Suspicion Of More Disease Than Conventional Assessment Demonstrates. Patients Where Resectability Is In Doubt.
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NECK SPACES
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DEEP NECK SPACE ANATOMY Space Involving Entire Length Of Neck Space Limited To Above The Hyoid Bone Space Limited To Below The Hyoid Bone
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CERVICAL FASCIAL PLANES
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SPACE INVOLVING ENTIRE LENGTH OF NECK Retropharyngeal Space Prevertebral Space Carotid Sheath Space
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RETROPHARYNGEAL SPACE Between Visceral Division Of Middle Layer And Alar Division Of Deep Layer From Skull Base To T2 Extend Level More Common In Children Due To Presence Of Retropharyngeal Node
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RETROPHARYNGEAL SPACE Lateral Soft Tissue X-ray (Extension, Inspiration) Abnormal Findings: 1. C2-post Pharyngeal Soft Tissue >7mm 2. C6–adults >22mm, Peads >14mm 3. STS Of Post Pharyngeal Region >50% Width Of Vertebral Body
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PREVERTEBRAL SPACE Prevertebral Division Potential Space Posterior To And Anterior To Vertebral Bodies Extends From Skull Base To The Coccyx
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CAROTID SHEATH SPACE Made Up From All Deep Cervical Fascia Infection From Any Deep Fascia Can Spread To This Space.
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SPACE LIMIT TO ABOVE THE HYOID BONE PARAPHARYNGEAL SPACE SUBMANDIBULAR SPACE MASTICATOR SPACE TEMPORAL SPACE PAROTID SPACE
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PARAPHARYNGEAL SPACE (LATERAL PHARYNGEAL SPACE) Boundary Superiorly : Skull Base Inferiorly Laterally Medially Anteriorly : Hyoid Bone : Medial Pterygoid M. : Buccopharyngeal Fascia : Submandibular Space Posteromedialy : Prevertebral Fascia And Retrophryngeal Space
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SUBMANDIBULAR SPACE Divided Into 2 Spaces By Mylohyoid M. Sublingual Space (Above Mylohyoid M.) Submaxillaly Space (Below Mylohyiod M.) • These 2 Spaces Can Communicate Each Other By Mylohyoid Cleft
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MASTICATOR SPACE Between Masticator M. And Superficial Layer Of Deep Cervical Fascia (Masticator M. = Massestor M.,Medial And Lateral Pterygoid M. And Temporalis Muscle) Locate Anterior And Lateral To Parapharyngeal Space
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PAROTID SPACE Between Parotid Gl. And Superficial Layer Of Deep Cervical Fascia Infection Can Spread Easily To Parapharyngeal Space Due To Uncompleted Encircle At Upper Inner Surface Of Parotid Gland.
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SPACE LIMIT TO BELOW THE HYOID BONE Anterior Viseral Space (Pretracheal Space) Between Trachea, Esophagus And Layer Of Deep Cervical Middle Fascia Extend From Hyoid Bone To Superior Mediastinum
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LEVELS OF CERVICAL LYMPH NODES
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Deep Lymph Nodes Submental Submandibular (Submaxillary) Anterior Cervical Lymph Nodes (Deep) Prelaryngeal Thyroid Pretracheal Paratracheal Deep Cervical Lymph Nodes Lateral Jugular Anterior Jugular Jugulodigastric Inferior Deep Cervical Lymph Nodes Juguloomohyoid Supraclavicular (Scalene
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Level I A Submental Nodes, Between The Medial Margins Of The Anterior Bellies Of The Digastric Muscles.
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Level I B Submandibular Nodes, Lateral To Level I A Nodes And Anterior To The Back Of The Submandibular Salivary Gland.
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Level II Upper Internal Jugular Nodes, Posterior To The Back Of The Submandibular Salivary Gland, Anterior To The Back Of The Sternocleidomastoid Muscle And Above The Level Of The Bottom Of The Body Of The Hyoid Bone.
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Level III Middle Jugular Nodes, Between The Level Of The Bottom Of The Body Of The Hyoid Bone And The Level Of The Bottom Of The Cricoid Arch, Anterior To The Back Of The Sternocleidomastoid Muscle.
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Level IV Low Jugular Nodes, Between The Level Of The Bottom Of The Cricoid Arch And The Level Of The Clavicle, Anterior To A Line Connecting The Back Of The Sternocleidomastoid Muscle And The Posterolateral Margin Of The Anterior Scalene Muscles; They Are Lateral To The Carotid Arteries.
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Level V Posterior Triangle Nodes, Posterior To The Back Of The Sternocleidomastoid Muscle, And Posterior To The Line Described In Level IV.
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Level V A Above The Level Of The Bottom Of The Cricoid Arch. Level V B Between The Level Of The Bottom Of The Cricoid Arch And The Level Of The Clavicle
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Level VI Upper Visceral Nodes, Between The Carotid Arteries From The Level Of The Bottom Of The Body Of The Hyoid Bone To The Level Of The Top Of Manubrium. Level Vii Superior Mediastinal Nodes, Between The Carotid Arteries Below The Level Of The Top Of The Manubrium And Above The Innominate Vein.
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DEEP NECK SPACES
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isceral Space : carotid Space : retropharyngeal Space : posterior Cervical Space : 5-perivertebral Space :
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1-ANTERIORVISCERAL SPACE : A) EXTENSION : FROM THE HYOID TO THE ANTERIOR MEDIASTINUM & DOESN’T EXTEND INTO THE SUPRAHYOID SPACE
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B) Contents : larynx (Laryngocele, SCC & Chondrosarcoma) hypopharynx / Esophagus (Zenker’s Diverticulum & SCC) 3-trachea (Carcinoma & Benign Stenosis) 4-thyroid Gland 5-parathyroid 6-embryonal Remnants (Thyroglossal Cyst , 3rd Branchial Cyst) 7-paratracheal Lymph Nodes (Mets, Lymphoma) 8-recurrent Laryngeal Nerve Paralysis
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Glottic Scc, Axial Contrast Ct Image Shows A Glottis Mass In The Left True Cord Reaching The Anterior Commissure (Black Asterisk), Mild Thickening Of Posterior Commissure Is Noted (Thick Black Arrow) With Sclerosis Of Left Arytenoid And Left Lamina Of Thyroid Cartilage
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ADVANCED SCC, AXIAL CT+C SHOWS A LEFT CORD MASS (THIN WHITE ARROWS) REACHING ANTERIOR COMMISSURE (ASTERISK), NOTE THE SCLEROSIS OF THE LEFT THYROID LAMINA AND LEFT CRICOARYTENOID JOINT (THIN BLACK ARROWS)
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Medullary Thyroid Carcinoma In A 32-year-old Man, (A) Transverse Sonogram Of The Right Lobe Of The Thyroid Shows A Large Nodule With Coarse Calcification And Posterior Acoustic Shadowing (Arrows), (B) Axial Ct Shows The Nodule With An Internal Focus Of Coarse Calcification (Arrows)
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Anaplastic Thyroid Carcinoma In An 84-year-old Woman, (A) Transverse Sonogram Of The Left Lobe Of The Thyroid Shows An Advanced Tumor With Infiltrative Posterior Margins (Arrows) And Invasion Of Prevertebral Muscle, (B) Axial Ct+c Shows A Large Tumor That Has Invaded The Prevertebral Muscle (Arrows)
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PARAMEDIAN THYROGLOSSAL DUCT CYST
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2-Carotid Space: Extension : -From Skull Base To The Aortic Arch -It Traverses The Suprahyoid & Infrahyoid Contents : 1-carotid Artery (Aneurysm, Thrombosis, Dissection) 2-IJV (Thrombosis) cranial Nerves (9-12), Schwannoma & Neurofibroma lymph Nodes (IJV Chain Of Nodes), Mets & Lymphoma 5-embryologic Remnants : 2nd Branchial Cleft Cyst 6-sympathetic Plexus : Paraganglioma (Carotid Body Tumor)
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Carotid Aneurysm, (A) Non-contrast-enhanced Axial Ct Shows A Round Soft Tissue Density Mass In The Right Carotid Space Is Seen, (B) Ct+c Shows A Round Mass Showing Homogeneous Enhancement Is Seen In The Right Carotid Space, (C) Ct+c, Coronal Multiplanar Reformation (Mpr) Shows The Right Internal Carotid Fusiform Aneurysm And Its Top And Bottom Continuity With The Internal Carotid Artery Are Shown
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THROMBOSIS OF IJV
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THROMBOSIS OF JUGULAR VEIN
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PARAGANGLIOMA : T1+C AT THE LEVEL OF THE SUPRAGLOTTIC LARYNX
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PARAGANGLIOMA, (A) T1-WEIGHTED NON-CONTRAST MR, (B) CT+C
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CAROTID BODY TUMOR
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3-Retropharyngeal Space: Extension : -Posterior Potential Midline Space Extends Superiorly To The Base Of The Skull & Inferiorly To The Posterior Mediastinum At The Level Of The Tracheal Bifurcation (T3 Level) Contents : retropharyngeal Abscess fat (Lipoma & Liposarcoma) lymph Nodes (Mets ,Infection & Lymphoma)
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Axial Ct+c Of The Skull Base At The Level Of The Hard Palate Shows An Enhancing Right Lateral Retropharyngeal Lymph Node (Asterisk) And 2 Enhancing Left Superficial Parotid Masses
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4-Posterior Cervical Space : Contents : fat cranial Nerve XI (Schwannoma, Neurofibroma) 3-brachial Plexus : -Schwannoma, Neurofibroma -Direct Invasion Of Apical Lung (Pancoast Tumor), Breast Carcinoma & Lymphoma 4-primitive Embryonic Lymph Sacs (Cystic Hygroma) 5-lymph Nodes (Lymphoma, Metastases, TB)
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Lipoma, The Mass Has The Signal Intensity Of Fat On A T1 (A) And The Signal Is Completely Suppressed With Fat Suppression (B)
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Lymphoma, Ct Image At The Level Of The Hyoid Bone Shows Multiple Rounded Lesions Medial To The Sternocleidomastoid Muscles And Dorsal To The Internal Jugular Veins, These Bilateral Multiple Lesions Are Located In The Posterior Cervical Space
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5-Perivertebral Space : Contents : spine (OM, Tumors) paraspinous Muscles (Myositis, Abscess , Sarcoma, Fibromatosis) 3-brachial Plexus 4-vertebral Artery
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Sarcoma, Large Soft Tissue Mass Adjacent To The Vertebral Body Centered In The Perivertebral Space
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