Head&Neck Imaging. ssregypt.com. Parapharyngeal Spaces. Mamdouh mahfouz MD

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1 Head&Neck Imaging Parapharyngeal Spaces ssregypt.com Mamdouh mahfouz MD

2 Definitio n Fat filled triangular space lateral the pharynx Extends from the skull base to the oropharynx

3 Parapharyngeal Space

4 Content s Fat Arteries [ascending pharyngeal, internal maxillary] Veins [ pharyngeal veins] Nerves [ branches of the mandibular nerve]

5 Imaging An anatomic landmark for the adjacent spaces Imaging plane is directed for the site pathology CT and MRI 5 mm slices Axial and coronal planes Contrast injection TEST HAYTHAM

6 Scanning techniques AXIAL CORONAL

7 C T AXIAL Calcification Bone erosions Hyperostosis CORONAL

8 Closed magnet M RI Superior contrast resolution Direct multiplanar imaging Vascular imaging without contrast injection No bone artifacts

9 Dynamic magnet

10 Anatomic relations Antrolateral Postrolateral Medial ANTRO- LATERAL ASPECT POSTRO- LATERAL ASPECT

11 Clinical aspects Is difficult to be evaluated clinically Presenting symptoms Sore throat Dysphagia Change of voice Nasal obstruction Cranial nerves IX XII A mass bulges posterior to the angle of mandible

12 Antrolateral aspect [ Infratemporal fossa ] Masticator space Parotid space MASTICATOR SPACE PAROTID SPACE

13 Antrolateral aspect [Infratemporal fossa] Masticator Space Muscles of masticatio [ masseter, temporalis, pterygoid muscles] Mandibular ramus Mandibular nerve branches Fat behind the antral wall

14 Postro -lateral aspect space ] Stylo mandibular tunnel [ Parotid Parotid gland (deep lobe) External carotid artery Retromandibular vein Facial nerve Lymph nodes

15 [ extends from the skull base to aortic arch ] Postro -lateral aspect styloid space] Carotid canal Contents Internal carotid artery Internal jugular vein [ Post Cranial nerves 9 to 12, sympathetic plexus Lymph nodes [Internal jugular + lateral retropharyngeal nodes]

16 Medial aspect mucosal space] [ Pharyngeal The pharyngeal mucosal space is separated from the PPS by the pharyngo- basilar fascia (PBF) The PBF is a tough membrane Maintains patent airway Crossed only by aggressive lesions

17 Medial Patholo aspect gy mucosal space] Displacement of the PPS fat laterally 98% of masses are carcinomas 80% squamous cell type [ Pharyngeal Other carcinomas [ adenoid cystic & mucoepidermoid] Lymphomas and sarcomas (children) Angiofibroma, plasmacytoma, melanoma (rare)

18 Nasopharyngeal anatomy Eustachian tube fossa Fossa of Rosenmuller

19 Nasopharyngeal carcinoma F 55Y

20 Nasopharyngeal carcinoma

21 Nasopharyngeal Carcinoma Early diagnosis Best on MRI Obliteration of the fat strip between the tensor and levator veli palatini muscles on T1 WIs Extension into the PPS fat Obliteration of the fat plane between the nasopharynx and prevertebral muscles

22 Nasopharyngeal carcinoma with nodes

23 Nasopharyngeal carcinoma [ Staging ] T1 T2 T3 T4 Confined to the nasopharynx Extension to Oropharynx or nasal fossa (axial) Invasion of bones or sinuses (axial) Intracranial extension or hypo pharynx or orbit

24 Nasopharyngeal Carcinoma Effacement of the FR and ET Heterogeneously enhancing mass in the lateral wall of the nasopharynx Extensions Anteriorly nasal fossa, maxillary sinus, infratemporal fossa Posteriorly prevertebral muscles, carotid sheath Laterally parapharyngeal space, mastecator space

25 Nasopharyngeal Carcinoma Medially nasopharyngeal air space, retropharyngeal to the contra lateral side Inferiorly Oropharynx, tongue Superiorly skull base, intracranial extension

26 Nasopharyngeal Carcinoma F 37Y

27 Nasopharyngeal Carcinoma

28 Nasopharyngeal Carcinoma, otitis

29 M 60Y Nasopharyngeal Carcinoma T4

30 Nasopharyngeal Carcinoma T2 55Y M

31 Other malignancies Lymphomas 20% Others 10% Rhabdomyosarcoma Adenoid cystic carcinoma Melanoma, plasmacytoma,.. F 16 Y

32 Nasopharyngeal NHL M 66Y

33 Rhabdomyosarco ma The most common sarcoma of the head and neck Arise from the primitive mesenchymal cells 70% arise before the age of 12 years Orbit > nasopharynx >temporal bone > sinuses > neck Presents by pain and cranial nerve palsies Soft tissue mass with bone destruction Deposits to the lung and bones DD nasopharyngeal carcinoma, angiofibroma,nhl M 11Y

34 Rhabdomyosarcoma F 6Y

35 Adenoid Cystic Carcinoma

36 Nasopharyngeal benign lesions Tornwaldt s cyst A mucous retention cyst Occurs in the midline nasopharynx Low signal in T1 and high signal in T2 WIs

37 Nasopharyngeal angiofibroma Arises near the sphenopalatine foramen Almost exclusively in adolescent boys Epistaxis

38 Nasopharyngeal angiofibroma Hyper vascular lesion with intense enhancement Supplied by the ascending pharyngeal & ascending palatine branches of the internal maxillary artery M 19Y Forward displacement of the posterior wall of the maxillary sinus [Holman- Miller sign]- classical

39 Grading of nasopharyngeal Angiofibroma I II III Confined to the nasopharynx Extension into pterygopalatine fossa or Intracranial or intraorbital extension masticator space M 17Y

40 Nasopharyngeal angiofibroma M 18Y

41 Nasopharyngeal angiofibroma M 18Y

42 Oro -pharyngeal anatomy

43 Tonsillit is F 21Y

44 Lymphoid hyperplasia

45 Oro -pharyngeal carcinoma

46 NHL tonsils, oropharynx, supraglottic region

47 Oro -pharyngeal carcinoma

48 Lateral Patholo aspect gy [ Parotid space]

49 Adenoid cystic carcinoma

50 Mucoepidermoid carcinoma M 41Y

51 Deep lobe parotid tumor

52 Lymphoma of the nasopharynx and parotid gland M 21Y

53 Antro Patholo -lateral aspect [ gy Masticator space]

54 Adamantinoma of the mandible F 45Y

55 Chondrosarcoma of the hard palate M 45Y

56 Recurrent fibrosarcoma of the maxilla M 50Y

57 Mandibular osteosarcoma M 27Y

58 NHL 10Y M 10Y

59 Rhabdomyosarco ma F 8Y

60 Metastatic renal cell carcinoma in the masticator space

61 Deposit of bronchogenic Carcinoma

62 [ extends from the skull base to aortic arch ] Postro -lateral aspect styloid space] Carotid canal Contents Internal carotid artery Internal jugular vein [ Post Cranial nerves 9 to 12, sympathetic plexus Lymph nodes [Internal jugular + lateral retropharyngeal nodes]

63 Glomus Nodes Neurofibrom a

64 LATERAL RETROPHARYNGEAL NODES INTERNAL JUGULAR NODES MEDIAL RETROPHARYNGEAL NODES

65 F 54Y

66 Cystic neurofibroma M 44Y

67 Glomus tumor Rare, slowly growing hypervasculer tumor Incidence 1: 1,300,000 Male : female 1: Y Arise from the glomus bodies in and around the jugular bulb Benign hyper vascular lesion supplied by Ascending pharyngeal Carotico -tympanic [ICA] Anterior tympanic [ECA] Stylomastoid [ECA] Meningeal branches [ vertebral]

68 Glomus tumor Mass in the jugular fossa with bone destruction Large at presentation 2-6 cm, intense enhancement Intracranial and extra cranial extension Metastases in 4%, Lung, nodes, liver, bones Salt and pepper appearance on MRI

69 Carotid body tumor

70 Glomus tumor Common presenting symptoms Palsatile tinnitus, cranial nerve palsies,vascular retro-tympanic mass M 41Y

71 Glomus tumor Common jugular fossa masses Meningioma, neurofibroma, deposits, congenitally wide or dehiscent M 55Y

72 Lymphadenopat hy Reactive homogenous,young patient less than 1cc Lymphoma bulky homogenous Direct invasion from near by malignancy Inflammatory septic focus abscess formation

73 Metastatic nodes The most common nodal disease Any malignancy can spread to the retro-pharyngeal nodes Enlarged nodes> 0.8 cm with central necrosis and stranding of the perinodal fat 75% of nasopharyngeal carcinoma,20% of oropharyngeal, 5% of thyroid carcinoma have metastatic nodes at presentation

74 Metastatic nodes from thyroid carcinoma F 21 Y

75 PPS LESIONS Antro-lateral aspect Maxilla Mandible Muscles Medial aspect Nasopharynx Oropharynx Tonsil Lateral aspect Deep lobe parotid Posterior aspect Glomus Nodes Neurofibroma

76 Quiz. Tornwaldet cyst

77 Q.. Nasopharyngeal carcinoma

78 Q.. Glomus tumor

79 سبحانك اللهم و بحمدك نشهد ان ال اله اال انت نستغفرك و نتوب اليك ssr-eg.net Thank you Mamdouh Mahfouz MD

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