Head&Neck Imaging Parapharyngeal Spaces ssregypt.com Mamdouh mahfouz MD mamdouh.m5@gmail.com
Definitio n Fat filled triangular space lateral the pharynx Extends from the skull base to the oropharynx
Parapharyngeal Space
Content s Fat Arteries [ascending pharyngeal, internal maxillary] Veins [ pharyngeal veins] Nerves [ branches of the mandibular nerve]
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
Scanning techniques AXIAL CORONAL
C T AXIAL Calcification Bone erosions Hyperostosis CORONAL
Closed magnet M RI Superior contrast resolution Direct multiplanar imaging Vascular imaging without contrast injection No bone artifacts
Dynamic magnet
Anatomic relations Antrolateral Postrolateral Medial ANTRO- LATERAL ASPECT POSTRO- LATERAL ASPECT
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
Antrolateral aspect [ Infratemporal fossa ] Masticator space Parotid space MASTICATOR SPACE PAROTID SPACE
Antrolateral aspect [Infratemporal fossa] Masticator Space Muscles of masticatio [ masseter, temporalis, pterygoid muscles] Mandibular ramus Mandibular nerve branches Fat behind the antral wall
Postro -lateral aspect space ] Stylo mandibular tunnel [ Parotid Parotid gland (deep lobe) External carotid artery Retromandibular vein Facial nerve Lymph nodes
[ 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]
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
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)
Nasopharyngeal anatomy Eustachian tube fossa Fossa of Rosenmuller
Nasopharyngeal carcinoma F 55Y
Nasopharyngeal carcinoma
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
Nasopharyngeal carcinoma with nodes
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
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
Nasopharyngeal Carcinoma Medially nasopharyngeal air space, retropharyngeal to the contra lateral side Inferiorly Oropharynx, tongue Superiorly skull base, intracranial extension
Nasopharyngeal Carcinoma F 37Y
Nasopharyngeal Carcinoma
Nasopharyngeal Carcinoma, otitis
M 60Y Nasopharyngeal Carcinoma T4
Nasopharyngeal Carcinoma T2 55Y M
Other malignancies Lymphomas 20% Others 10% Rhabdomyosarcoma Adenoid cystic carcinoma Melanoma, plasmacytoma,.. F 16 Y
Nasopharyngeal NHL M 66Y
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
Rhabdomyosarcoma F 6Y
Adenoid Cystic Carcinoma
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
Nasopharyngeal angiofibroma Arises near the sphenopalatine foramen Almost exclusively in adolescent boys Epistaxis
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
Grading of nasopharyngeal Angiofibroma I II III Confined to the nasopharynx Extension into pterygopalatine fossa or Intracranial or intraorbital extension masticator space M 17Y
Nasopharyngeal angiofibroma M 18Y
Nasopharyngeal angiofibroma M 18Y
Oro -pharyngeal anatomy
Tonsillit is F 21Y
Lymphoid hyperplasia
Oro -pharyngeal carcinoma
NHL tonsils, oropharynx, supraglottic region
Oro -pharyngeal carcinoma
Lateral Patholo aspect gy [ Parotid space]
Adenoid cystic carcinoma
Mucoepidermoid carcinoma M 41Y
Deep lobe parotid tumor
Lymphoma of the nasopharynx and parotid gland M 21Y
Antro Patholo -lateral aspect [ gy Masticator space]
Adamantinoma of the mandible F 45Y
Chondrosarcoma of the hard palate M 45Y
Recurrent fibrosarcoma of the maxilla M 50Y
Mandibular osteosarcoma M 27Y
NHL 10Y M 10Y
Rhabdomyosarco ma F 8Y
Metastatic renal cell carcinoma in the masticator space
Deposit of bronchogenic Carcinoma
[ 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]
Glomus Nodes Neurofibrom a
LATERAL RETROPHARYNGEAL NODES INTERNAL JUGULAR NODES MEDIAL RETROPHARYNGEAL NODES
F 54Y
Cystic neurofibroma M 44Y
Glomus tumor Rare, slowly growing hypervasculer tumor Incidence 1: 1,300,000 Male : female 1: 3 40-60 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]
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
Carotid body tumor
Glomus tumor Common presenting symptoms Palsatile tinnitus, cranial nerve palsies,vascular retro-tympanic mass M 41Y
Glomus tumor Common jugular fossa masses Meningioma, neurofibroma, deposits, congenitally wide or dehiscent M 55Y
Lymphadenopat hy Reactive homogenous,young patient less than 1cc Lymphoma bulky homogenous Direct invasion from near by malignancy Inflammatory septic focus abscess formation
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
Metastatic nodes from thyroid carcinoma F 21 Y
PPS LESIONS Antro-lateral aspect Maxilla Mandible Muscles Medial aspect Nasopharynx Oropharynx Tonsil Lateral aspect Deep lobe parotid Posterior aspect Glomus Nodes Neurofibroma
Quiz. Tornwaldet cyst
Q.. Nasopharyngeal carcinoma
Q.. Glomus tumor
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