Neuro - ENT/Head & Neck Flashcards
What is Labryinthitis?
Inflammation of the membranous labryinth
Usually due to viral respiratory tract infection
Findings:
Cochlea and semicircular canals will be enhancing on MRI T1 post contrast
What is Vernet syndrome?
V vocal
Syndrome which develops when there is pathology of JUGULAR FORAMEN
Affects cranial nerves IX, X and XI (all pass through jugular foramen)
- Loss of taste posterior third tongue
- Vocal cord paralysis
- Weakness sternocleidomastoid and traps
- Dysphasia
What are features of optic neuritis?
High T2 signal
(In mengingioma, there is post contrast peripheral enhancement with central non enhancement)
What are features of optic nerve meningioma?
T1 and T2
Can be variable signal on T1 and T2 (possibly iso iso)
AVID contrast enhancement
1/3 have calcifications - tram track
**DISTAL portion of the optic nerve is usually spared**
What is Rathke Cleft cyst?
High T2 lesion which sits between anterior and posterior pituitary
Mural enhancement
Generally Asymptommatic
Middle ear mass with blue tympanic membrane
What diagnosis is top of list?
Cholesterol granuloma
High T1 and T2
Name 2 destructive lesions of the clivus?
Chordoma (agressive lesion)
- can cause mass effect on pons and basilar
- can have calcific fragments within
Mets
How to differentiate orbital tumour from Graves eye disease?
Orbital pseudotumour causes enlargement of the muscle belly. Can involve tendons and be painful.
What are adamantinomas?
What are ameloblastomas?
Rare malignant bone tumours
Usually grow in tibia
-Multilocular expansile lytic lesion in tibial diaphysis
Ameloblastomas are benign agressive tumours which grow in jaw
-Cortical destruction
-Soap bubble appearance
Where are intra conal and conal lesions located?
Differentials within each space
Outside the globe there are three conditions which are included in all of the other orbital compartments namely sarcoidosis, pseudotumours and lymphoproliferative lesions.
Remember Rhabdomyosarcomas occur in young patients therefore thyroid eye disease is more likely in older patients with a conal lesion
What MRI apperances can be present after denervation injury to tissue?
T1 and T2 apperances of tissue
T1 low
T2 high
Same appearance can be seen in acute inflammation during early recovery
Displacement of pharyngeal space directions
5 Spaces
What are brown tumours?
Tumours associated with hyperparathyroidism
It is a reparative cellular process rather than agressive lesion
Histologically identical to Giant Cell Tumors (important to remember and check Ca and PTH levels therefore)
Can be in hands/jaw/skull to name a few
What are the features of an inverted papilloma?
-Vascular tumour arising from the lateral wall of nasal cavity and causes destruction through medial wall of maxillary sinus
-10% have a squamous cell cancer
Features of Antrochoanal polpy
Young adults
Widening of the maxillary ostium
Polyp can extend into the nasopharynx
What are the 2 types of Cholesteatoma?
What is most common?
- Pars flaccida (most common)
- erodes scutum and extends superiorly
- displaces ossicles medially - Pars tensa
- Erodes ossicles
- Extends medially
What is best scan to look for ectopic parathyroid adenoma?
Methionine-PET most sensitive
or
99Tc MIBI and USS can be an option if PET not listed
What is Tullio phenomenon?
Vertigo and nystagmus induced by loud noises
Can be due to Superior semicurcular canal dehiscence (where there is absence of bony covering of superior semicircular canal)
Cholesteatoma recurrence vs complications - how to tell apart?
What is most common thyroid cancer and how does it appear on US?
Papillary thyroid cancer
Irregular outline
Punctate calcifications are suggestive of papillary
Regional lymph nodes present in 40% and tend to cavitate
Note Medullar cancers can also have calcifications
If calcified lymph nodes - MORE LIKELY MEDULLARY
Opaque Maxillary Antrum
How to differentiate Graves disease from Orbital pseudotumour?
Graves eye disease starts with one muscle involved but can progress to involve others too. The mnemonic for remembering the order in which the eye muscles are affected in Graves eye disease is: I’m Slow (Inferior, Medial, Superior, Lateral).
Petrous apex lesions differential
What are cholesterol granulomas a result of?
What clinical feature do they demonstrate?
Recurrent otitis media infection
- Haemorrhage within middle ear leads to formation of granulation tissue
- Can cause bony expansion
-Classically BLUE TYMPANIC membrane on examaination (careful as this is also case in jugular bulb dehisicence)
High signal on T1 due to methaemoglobin
-cholesteatoma is ISODENSE T1
What is Gradenigo syndrome?
What is petrous apicitis?
Triad of:
- Otitis media/Otomastoiditis
- Retro-orbital pain
- 6th Nerve palsy
Due to abscess in aerated petrous apex (apicitis)
Usually caused by pseudomonas or enterococcus
Name 5 differentials for nasal masses?
Which ones occur in young patients?
1. Sinonasal lymphoma (non-hodgkins)
Homogenous mass with bony destruction. LOW T2 SIGNAL***
Older patients >60 years
2. SCC
Aggressive soft tissue mass in maxillary antrum
Low T2
3. Nasopharyngeal angiofibroma
Exclusively adolescent males
Flow voids on T1
Treated with radiation therapy
4. Enthesioneuroblastoma
Dumbell shaped tumour with waits at cribriform plate
5. Antrochoanal polyp
Young adults.
Arise from maxillary sinus and cause widening of maxillary antrum
What is best sequence to detect optic atrophy?
Coronal CISS
This is a heavily T2 weighted sequence
Look for excess CSF around optic nerve
Pleomorphic adenoma features?
What is 80% rule?
Cystic on MRI
Low T1, High T2
80% in parotid gland
80% benign
Differential is Warthin tumour
- assc with smokers
- usually bilateral or multiple unilateral
- warthin tumours dont enhance
- usually in tail of parotid whereas pleomorphic can be superficial
Enhancing mass in middle ear with aplastic foramen spinosum
What is diagnosis?
Abberant internal carotid artery
(Pulsatile mass is a feature)
Enhancement of which parts of the facial nerve are abnormal?
- Intracranial segment (cisternal)
- Meatal segment inside internal auditory canal (Canalicular)
- Extratemporal segment
Causes of abnormal enhancement
Bells palsy (cannalicular segment)
Lymes
Ramsey Hunt
Think Cancer if nodular enhancement
Enlarged vestibular aqueduct
Most common inner ear issue associated with progressive sensorineural hearing loss
SEEN IN Pendred syndrome
Often bilateral
-Ass with cochlear deformity
Vestibular aqueduct is bony canal that connects inner ear to endolymphatic sac
(menieres associated with small vestibular aqueduct)
What are 2 causes of deafness in the neonate?
Explain difference
1. Mondini Malformation
Cochlear hypoplasia
Only 1.5 turns instead of 2.5
Assc with large vestibule and large vestibular aqueduct
Sensorineural hearing loss (high pitch sounds preserved)
2. Michel Aplasia
‘Complete labryinthe aplasia
Absent cochlea, vestibule, vestibular aqueduct
Deaf
What is an endolyphatic sac tumour?
What is it assc with?
Tumour of endolymphatic sac and duct
Ass with Von hippel lindau
- Will have internal amorphous calcifications
- T2 bright with intense enhancement
- Vascular flow voids present
Pagets of the skull?
How does it affect it?
Involves both inner and outer tables
A large well defined lucent lesion can be seen - this osteolysis circumscripta
Other findings
- Cranial nerve palsies
- Deafness
- Secondary oestosarcoma
If thinking this looks like fibrous dysplasia - LOOK AT AGE
Fibrous dysplasia favours younger patients under 30 years of age and favours outer table
Pagets is older person
What is a Ranula?
Benign mucous retention cystic lesions at the floor of the mouth
Arise from sublingual space
A plunging ranula extends into the submandibular space
Treatment
Surgical excision of cyst and submandibular gland
Incision and drainage will just result in reaccumulation
Name 2 agressive lesions of the parotid gland?
Adenoid cystic carcinoma
Malignant tumour that can occur in minor salivary glands, lacrimal glands, sinuses and head & neck
Major thing to know is they they can exhibit Perineural spread
Lymphoma
Patients with sjogrens have a 1000x risk of non-hodgkins MALT lymphoma
Presents as bilateral lymphoma in sjogrens
‘Honeycombing appearance’
1.
What are the 3 main types of paraganglioma?
What are appearances of a ganglioma?
Hypervascular
‘Salt and pepper’ appearance due to flow voids
- Can be bilateral as part of other conditions*
- Octreotide accumulates in these masses*
1. Carotid body tumour
At carotid bifurcation
Causes splaying of the ICA and ECA
2. Glomus jugulare
Destruction of jugular foramen
Destruction of middle ear floor
3. Glomus tympanicum
Confined to middle ear
Overlies the cochlear promontory
If middle ear intact = glomus tympanicum
If not intact = glomus jugulare
2.
Apperances of schwannoma in context of carotid space masses?
- Ovoid, heterogenous cystic and solid mass*
- Commonly affect CN 10 - Vagus nerve schwannoma*
- (9,11, 12 can be effected)*
Heterogenous
Bright T2
Avid enhancement of solid components
Picture is of vagus nerve schwannoma
3.
Neurofibromas in context of carotid space masses
Less common than schwannoma
Tend to be more homogenous than schwannoma
Demonstrate classic target sign with Decreased T2 central signal
What is contained in Masticator space?
Muscle of mastication and inferior alveolar nerve
Beware that the space extends superiorly along the side of the skull via the temporalis muscle
What is the most common cause of masticator space mass?
Dental abscess is most common cause
If you see a masticator abscess, next thing to do is look at the mandible on bone windows for signs of erosion/cavity/recent extraction that would explain source
Be aware of spread via the pterygopalatine fossa to the orbital apex and cavernous sinus
Lymph node levels in the neck
Level 1: Submental and submandibular
-anterior belly digastric separates 1a/1b
1a = submental nodes
1b = submandibular nodes
Level 2: Upper internal jugular (deep cervical chain)
-hyoid bone separates levels II and III
Level 3: Middle internal jugular (deep cervical chain)
-cricoid cartilage separates III and IV
Level 4: Lower internal jugular (deep cervical chain)
-includes supraclavicular nodes and virchows node
Level 5: Posterior triangle
Level 5a - posterior to levels II and III
Level 5b - posterior to level IV
Where is most common place for a Nasopharyngeal cancer to start?
Fossa of Rosenmuller
Located in the posterolateral pharyngeal recess
Nasopharyngeal Cancer:
-most common in asians
involvement of parapharyngela space confers worse prognosis
-nodal mets present in >90% of nasopharyngeal tumours
Laryngeal Cancers
How are they divided?
What are boundaries of supraglottic larynx?
1. Supraglottic
2. Glottic
3. Subglotic
Supraglottic
Extends from tip of epiglottis to laryngeal ventricle (slit like space between true and false vocal cords - seen as the slight indentation on axial CT just before true vocal cords appear)
What are boundaries of glottic larynx?
- True vocal cords
- Anterior commisure
- Posterior commisure
What are boundaries of subglottic larynx?
From inferior surface of the true vocal cords to inferior aspect of cricoid cartilage
Where are 2 areas supraglottic cancers usually arise?
1. Usually are centered on the epiglottis
Tends to spread anteriorly into pre-epiglottic fat
-More agressive
- -Early lymph node mets*
- -DONT GET HOARSENESS*
2. Centrered on false cord
False cord mass spreading laterally into paraglottic fat
Spread to the fat makes this a T3
What are glottic cancers centered on?
Most common laryngeal cancer
Progressive and continuous hoarseness
- -Best outcome*
- -Grow slowly*
- -Mets are late*
Usually centered on the vocal cord
Spreads anteriorly to the anterior commisure
Where are subglottic cancers seen?
Soft tissue thickening between airway and cricoid ring
- -Less common*
- -Can have bilateral nodal disease and mediastinal extension*
What is located in epitympanum?
Where is Prussek space?
What is in the mesotympanum?
Cystic lesions in the mandible
Where are the tonsils located? Oropharunx or hypopharynx
What is Morquio syndrome?
Many cases present at ~2 years of age and have normal intelligence. Clinical features:
- severe dwarfism (<4 foot)
- joint laxity
- corneal opacification/clouding
- lymphadenopathy
- progressive deafness
- spinal kyphoscoliosis
- prominent mandible and lower face
- short neck
Sturge Weber
Features?
Pial angioma
Hemiatrophy
Seizures
Port wine naevi
Where is Prussek space?
Epitympanum
Behind the upper part of tympanic membrane
