ESHNR Krakau Swelling [Schreibgeschützt] .Perimandibular/ temporal swelling Suprahyoid neck: masticator

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Text of ESHNR Krakau Swelling [Schreibgeschützt] .Perimandibular/ temporal swelling Suprahyoid neck:...



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


Supra infrahyoid

related complications

Developmental lesion related


Inflammation: IgG4, IMFT

Vascular lesions

Neoplasms: SCC, lymphoma

Order of business

categorize lesionsaccording to etiology







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



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



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



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



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 (>280mg/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: 16461653

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 ,



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.



composed of primitive lymphatic sacs

nonunion lymphatic + venous system


enlarge in conjunction with infection

29/30y m

Vascular:Lymphatic vascular malformation



Congenital venous vascular arrest with endothelial lined vascular sinusoids, Lobulated phleboliths

Palatine tonsil carcinoma Piriform sinuscarcinomaN3 nodal metastases extracapsular spread



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


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





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 howcombine morphology, DWI, DCE, DSC perf.

Focus !! aspects of diagnostic/therapeutic relevance Anything new?