Head and Neck Image 頭頸部放射影像學

Transcription

1 Head and Neck Image 頭頸部放射影像學 陳家媛 台北醫學大學 - 市立萬芳醫院 cychen@wanfang.gov.tw

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4 Normal Suprahyoid neck: the old way Nasopharynx Oropharynx Oral cavity Staging of SCC

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7 Spaces of Suprahyoid Neck: a New Way Deep cervical fascia Superficial layer (investing fascia) Middle layer (buccopharyngeal fascia) Deep layer (prevertebral fascia)

8 Approach to Suprahyoid Mass What space is mass in? What important neurovascular structures are in the vicinity of mass? What is the likely pathological diagnosis?

9 Spaces of Suprahyoid Neck Parapharyngeal space not fascia-enclosed Pharyngeal mucosal space not fascia-enclosed Masticator space Parotid space Carotid space Retropharyngeal space Perivertebral space

10 Parapharyngeal Space Central space Fatty tube from skull base to hyoid bone level as elevator shaft Few lesions primarily arise in this space

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12 Contents of Parapharyngeal Space Fat Branch of CNV3 Internal maxillary artery Ascending pharyngeal artery Pharyngeal venous plexus

13 Primary Mass of PPS Fat surrounding the entire circumference of lesion No point of attachment to adjacent space, especially the deep lobe of parotid

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15 DDx of Parapharyngeal Space Lesion Abscess from adjacent space Direct spread of malignant tumor Salivary gland rest lesion Lipoma

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17 Pharyngeal Mucosal Space Area of nasopharynx and oropharynx Airway side of middle layer of deep cervical fascia SCC is the most common and important lesions

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19 Contents of Pharyngeal Mucosal Space Lymphoid tissue Superior and middle constrictor muscle Salpingopharyngeal muscle Pharyngobasilar fascia Levator palatini muscle Torus tubarius aspect of E tube

20 Primary Mass of PMS Medial to parapharyngeal fat Invading PPS medially to laterally, displacing PPS fat laterally Disrupting normal mucosal and submucosal architecture of PMS

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22 DDx of Pharyngeal Mucosal Space Lesion Inflammation Tonsillitis, pharyngitis Benign tumor Mixed tumor Malignant tumor SCC, lymphoma, minor salivary gland malignacy Tornwaldt s cyst

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25 Masticator Space Enclosed by superficial layer of deep cervical fascia Mandible to skull base and temporal fossa Foramen ovale and CN 5th

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27 Contents of Mastictor Space Lateral pterygoid muscle Medial pterygoid muscle Masseter muscle Temporalis muscle Inferior alveolar nerve, artery and vein Ramus and body of mandible

28 Primary Mass of MS Center of mass anterior to PPS fat within the muscle of mastication or the mandible Mass invading PPS fat from anterior to posterior, displacing PPS fat posteriorly

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30 DDx of Masticator Space Lesion Odontogenic abscess Most common Sarcoma Soft tissue sa, chondrosa, osteosa Lymphoma SCC from oropharynx Rhabdomyosarcoma Pediatric population

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32 Perineural Spreading of Tumor along Cranial Nerve V3 Along masticator or inferior alveolar nerves to CN V3 Mental foramen- mandibular foramen- foramen ovale- Meckel s cave MRI is more sensitive to perineural spreading

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35 Parotid Space Enclosed by superficial layer of deep cervical fascia Facial nerve A plane between stylomastoid foramen and lateral wall of retromandibular vein Late encapsulation with LNs within space

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37 Contents of Parotid Space Parotid gland Facial nerve Retromandibular vein External carotid artery Internal maxillary arteries Intraparotid LNs

38 Primary Mass of PS Center of mass lateral to PPS fat Mass invading PPS fat laterally to medially, displacing PPS fat medially Widening the distance between mandibular angle and styloid process

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40 DDx of Parotid Space Lesion Benign mixed tumor (pleomorphic adenoma) 80% of benign tumor Warthin s tumor Mucoepidermoid ca Adenoid cystic ca Skin SCC with parotid LAP Melanoma with parotid LAP

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42 62 y/o Female, mixed tumor

43 39y/o male, abscess 76y/o female, Undifferentiated ca

44 Carotid Space Carotid sheath All three layers of deep cervical fascia Nasopharyngeal, oropharyngeal, cervical and mediastinal segments Highest deep cervical chain as jugulodigastric nodes Jugular foramen and basal cistern

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47 Contents of Carotid Space Common and internal carotid arteries Internal jugular vein Cranial nerves 9th, 10th, 11th, 12th Sympathetic plexus Deep cervical LNs

48 Primary Mass of CS Center of mass within the area of ICA or internal jugular vein Mass invading PPS fat from posterior to anterior, displacing PPS fat anteriorly Styloid process anteriolateral displacement ICA draped over anterior margin of mass

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50 DDx of Carotid Space Lesion Vein thrombosis, thrombophlebitis ICA thrombosis, mural thrombus, aneurysm, pseudoaneurysm Paraganglioma Neurogenic tumor Neurilemmoma, neurofibroma SCC with LN metastasis

51 26y/0 male, paraganglioma

52 Retropharyngeal Space Between deep and middle layers of deep cervical fascias and alar fascia No LN below hyoid level Skull base to T4 vertebral body level

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55 Contents of Suprahyoid Retropharyngeal Space Fat Lateral retropharyngeal LNs Medial retropharyngeal LNs

56 Primary Mass of Suprahyoid RPS Center of mass posteromedial to PPS fat and directly medial to carotid space Mass invading PPS fat posteromedially to anterolaterally Mass anterior to prevertebral muscle Styloid process is usually not displaced

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58 Primary Mass to Infrahyoid RPS Bow-tie or oval shape in the posterior midline Anterior to prevertebral muscle

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60 DDx of Retropharyngeal Space Lesion Inflammation of retropharyngeal nodes and absces Child: Waldeyer s ring infection Adult: Vertebral osteomyelitis, spine Sx Malignancy SCC of head and neck (NPC) Lymphoma Direct invasion of SCC Edema fluid or lymph

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63 Perivertebral Space Enclosed by deep layer of deep cervical fascia Separate into prevertebral and paraspinal portions Skull base to T4 level Tenacious fascia resisting violation by infection or tumor

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65 Contents of Perivertebral Space Prevertebral component: Prevertebral muscle, vertebral a. and V. Scalene muscle, branchial plexus Phrenic nerve, vertebral body Paraspinal component: Paraspinal muscle Posterior elements of vertebral body

66 Primary Mass in Prevertebral PVS Center of mass within prevertebral muscle or vertebral body Mass lifting prevertebral muscle anteriorly

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68 Primary Mass of Paraspinal PVS Center of mass within paraspinal muscles Mass bowing posterior cervical space fat away from posterior elements of spine

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70 DDx of Perivertebral Space Lesion Vertebral body osteophyte Vertebral body osteomyelitis Chordoma Vertebral body or epidural metastasis from lung, breast, prostate or lymphoma

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74 Infrahyoid Neck Hyoid bone to clavicle Triangle: surgical and gross anatomy Space: imaging approach to anatomy

75 Infrahyoid Neck: Five Spaces Visceral space: unique to infrahyoid space Posterior cervical space Carotid space Retropharyngeal space Perivertebral space

76 Visceral Space

77 Contents of Visceral Space Thyroid gland/ parathyroid gland Larynx Trachea Hypopharynx Esophagus Recurrent laryngeal nerve Paratracheal LNs

78 DDx of Visceral Space Lesion Congenital: thyroglossal duct cyst Larynx: SCC, laryngocele, chondroma Thyroid: colloid cyst, goiter, adenoma, ca, lymphoma, meta, thyroiditis Parathyroid: adenoma, cyst Esophagus: Zenker diverticulum, ca LAP Inflammation/abscess

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81 Posterior Cervical Space Between superficial and deep layers of deep cervical fascia Posterior cervical triangle

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83 Centents of Posterior Cervical Space Fat Spinal accessory nerve Spinal accessory chains Pre-axillary brachial plexus

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85 DDx of Posterior Cervical Space Lesion Congenital: cystic hygroma/lymphangioma, hemangioma Inflammatory: abscess, lymphadenitis Benign tumor: lipoma, neurogenic tumor Malignant tumor: metastatic LAP, lymphoma, liposa

86 lymphangioma

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89 Summary Normal Suprahyoid neck Spaces of Suprahyoid Neck Approach to Suprahyoid Mass Parapharyngeal Space Pharyngeal Mucosal Space Masticator Space Parotid Space Carotid Space Retropharyngeal Space Perivertebral Space Infrahyoid Neck Posterior Cervical Space