Swelling in the head and neck. Bernhard Schuknecht. Order of business. Choice of diagnostic technique

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Swelling in the head and neck next speaker: Bernhard Schuknecht Bernhard Schuknecht MRI

on Choice of diagnostic technique the condition of the patient history /clinical

lesion should be related to subsequent tx!! 1.

infrahyoid related complications Developmental lesion related Glandular Inflammation:

etiology Infectious: abscess: Imaging depicts deep extension!

patient history /clinical findings time course, duration, location of swelling, guide

1 Swelling in the head and neck next speaker: Bernhard Schuknecht Bernhard Schuknecht MRI Medical Radiological Institute Zurich Switzerland ESHNR Sept Krakow Depends on Choice of diagnostic technique the condition of the patient history /clinical findings time course, duration, location of swelling, suspected anatomic location of a lesion should be related to subsequent tx!! 1. Periorbital/ midface swelling Dental source Order of business Infections Supra infrahyoid related complications Developmental lesion related Glandular Inflammation: IgG4, IMFT Vascular lesions Neoplasms: SCC, lymphoma categorize lesions according to etiology Infectious: abscess: Imaging depicts deep extension! Morphologic findings in conjunction with advanced imaging the condition/age of the patient history /clinical findings time course, duration, location of swelling, guide subsequent tx or add. diagnostic procedures!! Etiology infectious developmental vascular neoplastic Submandibular swelling Imaging requires a stabilized clinical condition 1

2 Suprahyoid neck spaces: parapharyngeal space Suprahyoid neck: parapharyngeal space parapharyngeal space Parapharyngeal space abscess marked airway compromize assess retropharnygeal + carotid space! Parapharyngeal space abscess w submandibular extension Suprahyoid neck spaces: pharyngeal mucosal space Retrotonsillar abscess For tx : Septations? Retropharyngeal extension? Vessels? 3. Tonsillar + pharyngeal mucosal space swelling Suprahyoid neck: masticator space Deep masticator space abscess + phlegmonous infiltration 4. Perimandibular/ temporal swelling 2

3 Submandibular abscess Secondary chronic osteomyelitis In submandibular abscess imaging is rarely required for therapeutic reasons! Imaging to identify the source: dental, osseous, salivary gland origin? Acute orphyrnygeal infection Suppurative lymphadenitis Complications: Lemierre syndrome: Jugular vein thrombosis Tender swollen neck 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: Descending necrotising fasciitis Infection from oral cavity /oropharynx infiltration and diffuse thickening cutis / subcutaneous cellulitis superficial deep fascia fascitis platysma, scm, strap m. myositis uncommon: gas collections, mediastinitis, effusion Developmental: Thyroglossal duct cyst Radiographics 2010 Becker M et al. Radiology 1997 foramen cecum thyroid bed + infection 90% of nonodontogenic congenital cysts hyoid level 50%; supra-, infrahyoid 25% each infrahyoid in paramedian location 3

4 nd branchial apparatus cyst 1st branchial cleft lesion 1st BCA 8% osteocartilagenous junction of EAC I periauricular II periparotid - angle of mandible + 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 CT guided biopsy 3rd branchial apparatus lesion chronic abscess 1st branchial cleft 3 rd BCA 3% along sternocleido m. lateral to carotid in ant/post cervical space - supraclavicular 4th branchial apparatus lesion Glandular: submandibular sialadenitis usually obstructive apex of piriform sinus to upper aspect of left thyroid lobe cyst or abscess w thick walled track inflammation of left- thyroid gland STIR and DWI b 1000 more sensitive than T1Gd 4

Sialadenitis of submandibular gland usually obstructive Sialadenitis of parotid gland Obstructive: dilated

Bacterial: localized, from LN Viral : 75% bilateral (clinical d) Autoimmune: bilateral; Sm, Sl? Star vibe 0.

IgG4-related disease chronic fibroinflammatory systemic condition w tumefactive lesions may affect every

the pancreas as systemic disease in 2003 Histo: lymphoplasmocytic infiltration, fibrosis, obl.

concentrations (>280 mg/dl) Encompasses conditions: like Mikulicz, inflammatroy pseudo- tumor retroperitoneal

Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic

involvement Mikulicz disease= lymphoplasmocytic fibrosis with bilateral swelling of lacrimal and salivary

IgG4-related Disease of the Head and Neck: CT and MR Imaging Manifestations Radiographics 2012;32 Katsura M

IgG4-Related Inflammatory Pseudotumor of the Trigeminal Nerve: Another Component of IgG4-Related Sclerosing

AJNR 20111; 32: E150-152 IgG4 related perarteritis thickening of carotid wall centered at carotid bifurcation

myofibroblastic tumour mesenchymal tumor usually affects lungs, separate entity 1994 extrapulmonary: abdomen,

5 Sialadenitis of submandibular gland usually obstructive Sialadenitis of parotid gland Obstructive: dilated duct, calculus? Bacterial: localized, from LN Viral : 75% bilateral (clinical d) Autoimmune: bilateral; Sm, Sl? Star vibe 0.5mm acute sialadenitis contraindication to sialography Inflammation: New entity 1. IgG4-related disease chronic fibroinflammatory systemic condition w tumefactive lesions 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: IgG4 related manifestations sialadenitis - trigeminal nerve involvement Mikulicz disease= lymphoplasmocytic fibrosis with bilateral 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: E IgG4 related perarteritis thickening of carotid wall centered at carotid bifurcation T2, enhancement of vessel wall on MR ± lumen narrowing DD carotidynia Inflammation: New entity Inflammatory myofibroblastic tumour mesenchymal tumor usually affects lungs, separate entity 1994 extrapulmonary: 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 :

6 Inflammatory myofibroblastic tumour IMFT of temporal bone a more aggressive and unpredictable course DD to IMFT Fibromatosis Nodular fascitis Proliferative myositis connective tissue tumour benign reactive process benign myofibroblastic aponeurosis, fascia, muscle superficial and deep fascia tumor like conditions Venous vascular malformation Vascular: Lymphatic vascular malformation 29/30y m lymphatic m. venous malformations arterio-venous composed of primitive lymphatic sacs nonunion lymphatic + venous system sequestration enlarge in conjunction with infection F-up Palatine tonsil carcinoma Congenital venous vascular arrest with endothelial lined vascular sinusoids, Lobulated ± phleboliths Piriform sinus carcinoma N3 nodal metastases extracapsular spread 6

7 Carcinomatous lymphangitis Nodal Non-Hodgkin Lymphoma 5% of H&N neoplasms high grade salivary adeno-ca 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 Hodgkin Lymphoma Extranodal Non-Hodgkin Lymphoma 30% have extranodal manifestations non nodal lymphatic : palatine, lingual tonsil non nodal extralymphatic: salivary lacrimal glands, palate, thyroid Presentation: neck adenopathy single or contiguous nodes, 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 Pats mean age 55 years L M 43 ktrans, Ve and AUC Burkitt lymphoma 19y f tonsillar swelling quantitative asessement by advanced MR CB F CBV star vibe 0.5mm Kar-ho Lee F et al. Eur J Radiol 2012;

8 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 assessment based on modality specific, know how combine morphology, DWI, DCE, DSC perf. Focus!! aspects of diagnostic/therapeutic relevance Anything new? bschuknecht@mri-roentgen.ch 8

The many faces of extranodal lymphoma

The many faces of extranodal lymphoma Frank Pameijer Departments of Radiology and Radiation Oncology University Medical Center Utrecht Special thanks to Ilona M Schmalfuss, MD University of Florida Gainesville,