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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 new?bschuknecht@mri-roentgen.ch