Head and neck

The thyroid gland consists of two lobes which are interconnected by the isthmus. The gland is directly attached to the larynx and trachea. The standard view is axial, visualising the main overlying (strap) muscles, the great vessels and lymphnodes and the oesophagus, as well. The main congenital abnormalities are thyroglossal duct cyst, lingual thyroid gland and aberrant thyroid tissue. Diagnosis of the thyroid masses/nodules is done by sonography using the TI-RADS classification and colour-doppler, lesion size suspicion grade, and fine needle aspiration biopsy (FNAB) reaching an accuracy of 94%. Very important is to differentiate malignancy (papillary /follicular/anaplastic/medullary carcinoma) and inflammatory changes (Hashimoto and DeQuervain thyroiditis). Standard imaging procedures for the parathyroidea are sonography and Sesta-MIBI-SPECT reaching an accuracy of 97%. In unclear cases 4D-CT and/or MRI + contrast may be used additionally.

This presentation offers a clinically orientated approach to imaging salivary gland disease in which the alignment between findings and further management is defined. Salivary imaging has been changed dramatically by the development of cross-sectional imaging. Ultrasound, CT and MRI have consigned radiographs and sialograms to a subsidiary role. Scintigraphy offers the best measure of global salivary gland function, but currently is not widely used in practice. Today investigation is closely related to the underlying pathology of salivary disorders and to provide reliable guide to surgical or medical treatment. Masses are well detected by cross-sectional imaging, which provides accurate guidance on appropriate approaches for surgical management. Differential diagnosis cannot always be achieved, but this is rarely a clinical problem because biopsy or resection are usually indicated. Sialography remains a reliable method of showing calculi and ductal changes in sialadenitis, but cross-sectional techniques, especially ultrasound and MRI, have advantages in inflammatory disease and complete sensitivity in detecting ductal disease may not be necessary in practice because patients may be treated symptomatically. A strong case can be made for using MRI as a sole investigation as this has been shown to be sensitive to both surgical and medical conditions. On this basis, the radiologist may be well placed to offer a primary referral service with triage, directing clinical management of patients or further referral on the basis of findings on MRI. Salivary interventional techniques have more recently extended the role of the radiologist.

In case of a visible or palpated neck mass, lymph node enlargement is routinely included in the differential diagnosis list. Medical imaging can be effectively used to distinguish other causes of cervical swelling, as well as characterizing enlarged lymph nodes. Although commonly used as a criterion, nodal size is not reliable in characterization. Imaging parameters including internal structure, vascularity pattern, degree of enhancement, and perinodal tissue changes may shed light on the etiology of any lymphadenopathy, which may be reactive hyperplasia, infection, inflammation or neoplastic infiltration. Characteristically, reactive hyperplastic lymph nodes have well-defined borders, reniform shape and central fatty hilum contiguous with adjacent cervical fat tissue. In children, and in most of the adult cases with a low risk of malignancy, ultrasound is the first choice of imaging modality owing to its radiation-free nature, and due to practical reasons. However, when further characterization of nodal abnormality or evaluation of sonographically inaccessible anatomic locations is required, use of other cross-sectional techniques, like CT and MRI are mandatory. They provide not only more detailed information including anatomic localization, size, number, internal structure, and enhancement characteristics of lymph nodes, but also important data about perinodal soft tissue and other associated pathologic processes in the region. Although the choice of imaging modalities to be used in the evaluation of cervical lymph nodes changes according to the means, experience, and preferences of institutions, the role of medical imaging remains pivotal and decisive in this common indication.

The approach to orbital mass analysis follows two basic rules. The first rule emphasizes the general fact that diseases arise from pre-existing tissues or structures unique to different spaces in the orbit. The second rule highlights exceptions to the general rule. For example, metastatic or other systemic diseases may involve the orbit, while trans-spatial pathological processes such as infiltrative lesions may affect multiple compartments simultaneously or metachronously. The orbit can be divided (by the muscle cone) into an intra-conal and an extra-conal compartment. Structures in the intra-conal compartment include the optic nerve/sheath complex and the surrounding fibro-fatty tissues, small vessels and small nerve branches. The contents of the extra-conal space include the lacrimal gland, cranial nerves (V1 and V2) and the periosteum of the orbit. Hence, knowledge of the applied anatomy of the orbit with a working knowledge of commonly seen diseases is a prerequisite for generating lists of differential diagnoses. The analysis of orbital masses should always be carried out in the clinical context of the patient. Tentative as well as definitive diagnosis can often be made with reference to the clinical information. For example, a lesion with unusual morphology or location can be tentatively diagnosed as metastatic disease in the presence of a history of malignancy elsewhere. In conclusion, the integration of knowledge of orbital anatomy, pathology and clinical information provides the basis of sound radiological differential diagnoses for further patient management.

Cystic and tumorous pathologies of the jaws can be imaged with cone-beam CT, CT and MRI. These pathologies include, e.g. in most cases inflammation or tumours. PET-CT or PET-MR may also be used. CT may be used without or with the i.v. application of iodinated contrast material dependent on the pathology. The images can be documented in soft-tissue- and/or bone-window-level setting. Imaging planes are usually axial, coronal or sagittal depending on the pathology. MRI has the advantage of higher soft tissue contrast and the possibility of using different sequences. Depending on the pathology, e.g. fat-suppressed T2-weighted, diffusion-weighted, T1-weighted sequences before and after the i.v. use of gadolinium and T1-weighted contrast-enhanced sequences with fat suppression are used. The imaging planes may be axial, coronal or sagittal. In this refresher course, the normal anatomy of the jaw, variants mimicking osteolytic or osteoblastic lesions, and cystic and tumorous pathologies of the jaws will be shown, and the imaging characteristics will be explained.

Soft tissue masses of the supra and infrahyoid neck are a rather heterogeneous group of tumours, classified by WHO in nine categories, based on their histologic differentiation: adipocytic, fibroblastic or myofibroblastic, fibrohistiocytic, smooth muscle, skeletal muscle, vascular, pericytic, and chondro-osseous tumours, and tumours of uncertain differentiation. Based on their clinical behavior and history such tumours may be described as benign, malignant or intermediate, the latter further subclassified as locally invasive or metastatising at distant sites. US is generally the first imaging step in infrahyoid neck lesions; MDCT or MRI are mandatory in suprahyoid masses, but are also needed to better define the deep extent and anatomic relationships of infrahyoid tumours. In many cases, imaging findings are overlapping and insufficient for tumour characterisation; nonetheless, some specific clues may orient the differential diagnosis. Site of origin of the lesion is probably the first brick in the wall; therefore, knowledge of the space-based neck anatomy is essential prerequisite. Patient’s age, size and number of lesions, presence and pattern of calcifications are useful additional details. Some specific density or signal intensity patterns may cut the list of differentials, whereas the potential role of the additional information provided by DWI-MRI or dual-energy CT is far from being fully elucidated. However, it is clearly assumed that imaging diagnosis does not replace pathologic assessment, which in a significant number of cases can be accurately obtained with FNA.

Variant: “Something that is slightly different." Imaging methods can provide an extraordinary amount of useful data to specialists treating head and neck (cancer) patients. It is crucial that these data are used to full advantage of individual patients. The most important factor in this process is mutual cooperation between the physicians in charge of patient care and the diagnostic imaging specialist. Anatomical variants in the head and neck are frequently encountered and may result in interpretation problems for the radiologist: usually, anatomical variants are without clinical consequence. However, normal variants may simulate disease. If not recognised, normal variants (or pseudolesions) may lead to unnecessary interventions. The presentation aims to familiarise general radiologists, who have an interest in head and neck imaging, with common anatomical variants encountered on head and neck CT and MR studies. Many examples from daily practice will be discussed.

Several anatomic variants may pose a threat during surgery. A large part is found in the sinonasal region, basically due to the widespread use of endoscopy which, inherently, provides the operator with narrow accesses and limited exposure of submucosal anatomic structures. Onodi cell is probably the most feared anatomic threat, because if not correctly indicated by the radiologist and identified by the surgeon, it generates a high risk of disastrous intracranial penetration. Similarly, bone dehiscence of the lamina papyracea of the ethmoid increases the risk of iatrogenic damage, mainly of intrinsic ocular muscles. The inferior
alveolar nerve is at high risk of surgical damage during molar teeth extraction, particularly when the curved apices of roots embrace the inferior wall of the nerve canal. In the neck the main threats are related to anomalous course of major vessels: not infrequently the common and/or internal carotid artery display a medialized course reaching the lateral aspect of the pharyngeal wall or even protruding in the retropharyngeal space towards the midline. Simultaneous medial deviation of the arteries on both sides is referred to as kissing (common or internal) carotids. The risk in these eveniences are mainly related to the possible effects of a deep biopsy performed by an unaware surgeon. At the cervico mediastinal junction, vascular rings may embrace the trachea or the oesophagus and, consequently, pose a threat during intubation or tracheostomy.

Head and neck manifestations of systemic disease is characterized by a multitude of maladies that have manifestations in the head and neck. This lecture relates commonly encountered head and neck symptoms and signs to an array of diseases and disorders that should be considered in the differential diagnosis. During this lecture, systemic disorders with head and neck manifestation (e.g., Sjögren`s syndrome, Adamantiades-Behcet's disease, granulomatous disease like Wegener`s granulomatosis), infectious disease (e.g., tuberculosis fungal rhinosinusitis and HIV related disease), malignant disease (e.g., lymphoma, myeloproliferative disorders and leukemia, malignant melanoma, histiocytosis, sickle cell anaemia, and rhabdomyosarcoma) or other systemic disorders (e.g., Paget`s disease of bone and fibrous dysplasia) will be presented.

Radiological assessment is critical in the management of skull base and facial trauma. CT is the preferred imaging technique, combining detailed visualization of bony and soft tissue injuries with the ability to perform 3D reconstructions and aid surgical planning. The scope of this presentation is broad and therefore we will concentrate on producing useful reports by differentiating Le Fort injuries from naso-orbitoethmoid and zygomaticomaxillary fracture patterns. We will consider orbital and temporal bone injuries and briefly touch upon laryngeal trauma, which in itself could account for a whole session. If attendees feel more comfortable reporting a facial trauma scan by the end of the presentation than they did at the start, our aims will have been achieved!

Computed tomography (CT), magnetic resonance imaging (MRI) and occasionally ultrasonography (US), play a major role for the correct diagnosis of a variety of infectious head and neck conditions seen in the emergency situation. The purpose of this lecture is to familiarise the radiologist with the most common types of infectious emergencies in the head and neck. A systematic review will include key radiologic features of these potentially life-threatening conditions. The following entities are discussed: otomastoiditis, complicated sinusitis and sialadenitis, suppurative lymphadenitis, paratonsillar, retropharyngeal, parapharyngeal and other neck abscesses, cellulitis, myositis, necrotising fasciitis, osteomyelitis, thrombophlebitis and septic deep venous thrombosis. Associated complications affecting the mediastinum and lung, meninges and brain will be discussed with emphasis on the early detection of lesions. Typical spread patterns of infection within the neck will be summarised. The detection of foreign bodies as a cause of secondary infection, as well as pitfalls and limitations of individual imaging techniques will also be addressed. Major emphasis will be put on what is the most appropriate imaging modality in which clinical situation, how should imaging be performed in an optimal fashion and how to report the findings in a structured and comprehensive way.

Arterial embolisation is the preferred treatment for refractory epistaxes and for certain hemorrhages of the ENT area. When carried out by trained radiologists, it proves to be an efficient method that presents little risk of complications. Hemorrhages of the ENT area are of different nature and etiology. Their approach should be considered according to specific clinical context. The treatment of hemorrhages of venous origin does not fall under the competence of interventional radiology ; endovascular or percutaneous embolization treatment of vascular malformations will not be treated in this article. According to circumstances, several types of arterial hemorrhages of the ENT sphere can be distinguished: (1) Hsemorrhages of nasal origin (epistaxes). They can be essential or symptomatic (2) Life threatening ENT haemorrhages in oncology, pre- or postoperative by hemostasis disorders or secondary bleeding specifically after a laryngectomy or a tonsillectomy devascularisation of hypervascular tumours (paragangliomas and nasopharyngeal fibromas) by preoperative embolisation. (3) Carotid blow out, linked to the presence of a progressive tumour, or post-radiation, or traumatic. In some cases, these haemorrhages are cataclysmic and require extreme emergency care. In all cases, close collaboration with the ENT surgery department, the presence of an anaesthetist, and at least a sedation are determining factors in the improvement of care and therefore in the success of the embolisation. Every patient and/or family is to be given true, clear and appropriate information

During the lecture we will first discuss the complex anatomy of the temporal bone with special regards to conductive and sensorineural hearing loss. Next, we will go through most common causes of conductive hearing loss, with emphasis on middle ear tumours including cholesteatoma, and chronic inflammation. Afterwards we will focus on sensorineural hearing loss, including acquired inner ear pathology and developmental anomalies. During second part of this lecture we will go through most important tumours of anterior, middle and posterior skull base. We will discuss the features of different malignancies on CT and MRI images, focusing on providing an informative report for the clinician

Radiological imaging of the nose, paranasal sinuses and the nasopharynx is applied in patients with inflammatory or suspected benign or malignant tumours. The knowledge of the normal anatomy and its variants is necessary to understand the pathways of inflammatory and tumourous pathologies and to establish the correct diagnosis. Multidetector-spiral-CT (MDCT) and MRI are the methods of choice for radiological imaging. Additionally, positron emission-computed tomography (PET-CT) is an extremely valuable imaging tool in patients with malignant disease. It is a combination of MDCT and PET. A contrast-enhanced CT is performed - in most cases for staging covering the whole body - and a PET scan after the intravenous application of a tracer (in most cases, fluorodeoxyglucose). Malignant tissues take up the tracer and with the CT-scan the pathology can be exactly anatomically localised. In recent times, positron emission-magnetic resonance tomography (PET-MR) has been introduced. The normal anatomy and its variants as well as the importance of close neighbouring anatomical structures, which can be involved in inflammatory and tumourous disease, will be described. Pathology consists of inflammation and tumours. Inflammation can be differentiated into acute and chronic. Tumours can be either benign or malignant. It is important to describe the exact localisation and extension of the different pathologies. Imaging characteristics and involvement of the surrounding structures may help to differentiate between benign and malignant disease. Uptake of contrast material and tracer - especially when using PET-CT or PET-MR - may well differentiate benign from malignant disease and additionally enable a whole-body scanning with the exact radiological staging.

The purpose of this lecture is to review common pathologic conditions of the oral cavity, oropharynx, hypopharynx and larynx, to describe the key anatomic structures relevant to tumour spread and to discuss the clinical implications of CT and MRI in the pre-therapeutic work-up of neoplastic lesions, in particular squamous cell carcinoma of the head and neck. A systematic review will include key radiologic features and characteristic patterns of submucosal tumour spread and implications of cross-sectional imaging for staging and treatment. The lecture will also review the characteristic aspect of less common tumours and tumour-like conditions affecting this area. Typical radiologic features will be discussed with an emphasis on potential pitfalls and on how to avoid them. Imaging aspects of Human papilloma Virus (HPV) positive and HPV- negative squamous cell cancers will be addressed and the impact of the new TNM classification on radiologic reporting will be discussed. Emphasis will be put on what the clinician needs to know and how to report the findings in a systematic way.