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FRCR Part Dhá > Head and Neck > Flashcards

Head and Neck Flashcards

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1
Q
A

Cholesterol granuloma

Smooth expansile, well marginated petrous apex lesion

High T1 and T2
Doesnt suppress fat
No diffusion restriciton

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2
Q
A

Cholesteatoma

Petrous apex lesion with smooth expansile bony changes

low T1, high T2
without central parenchymal enhancement restrict diffusions

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3
Q

Smooth lobulated cystic expansion of the petrous apex ?

A

Cephalocele

-Hernation of CNS through defect in cranium.

-In petroux apex, no brain tissue, just CSF/cystic, herniation from meckels cave into the petrous apex

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4
Q

Acute (children) or chronic suppurative otomastoiditis (adults) infection spreads via mastoid air cells or venous channels to Apical petrous. What is complication ‘Grendengio’ syndrome?

A

Grendengio triad of symptoms
Acute OM
deep facial pain (CNV),
lateral rectus palsy (CNVI)

Cortical erosion on CT

MRI enhancement of of PA, adjacent structures - clivus, dura, IAC, carotid canal

Complication - ICA narrowing ICA/vasospasm, subdural empyema, menigitis, venous sinus thrombosis

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5
Q

Permeative bone destruction of the posterior petrous ridge. T2 Bright and intense enhancement. lesion extending into the CPA?

A

Endolymphatic sac tumour

**Strongly associated with VHL **

Very vascular often with flow voids.

Retrolabyrinthine: Posteromedial T-bone

Large lesions can involve the CPA cistern, middle ear/mastoid, & jugular foramen

Bone CT: Central intratumoral bone spicules & posterior rim Ca⁺⁺
MR: High-signal foci on unenhanced T1 (haemorrhage and cholesterol). Heterogenous enhancement

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6
Q

Other lesion cause for permeative destruction of petrous apex?

A
  1. Paraganglioma of Glomus Jugulare

Invade the occipital bone/jugular foramen first . Jugular spine eroded

Then spread superolateral to PA and middle ear.

T1
“Salt” refers to hyperintense foci within tumor related to hemorrhage or slow flow.
= Hyperintense foci (quite rare)
+
“Pepper” refers to numerous hypointense foci within tumor, representing high-velocity arterial flow voids
=Hypointense foci common

T1+ C = intense enhancment

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7
Q

Sharply marginated, enlarged JF on bone CT
Fusiform, enhancing mass enlarging JF on T1WI C+ MR?

A

Jugular Foramen Schwannoma

NO Flow voids
Cranial nerve palsy of 9,10,11 (Vernet syndrome)

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8
Q

Permeative-sclerotic involvement of bone around JF on CT
Enhancing JF mass spreading centrifugally along dural surfaces on enhanced MR

A

Jugular Foramen Meningioma

permeative** sclerotic** changes along the JF and lateral clivus

Extend into middle ear, jugular tubercle marrow space and nternal auditory canal

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9
Q

Progressive sensorineural hearing loss. CT shows enlarged vestibular aqueduct?

A

Large vestibular aqueduct syndrome - aka Pendred syndrome

Commonest cause congenital sensorineural hearing loss

Axials - The vestibular aqueduct is never larger than the adjacent posterior semicircular canal

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10
Q

Tinnitus and hearing loss after meningitis in child ?

A

Labyrinthitis ossificans

ossification of membranous labyrinth

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11
Q

Conductive hearling loss in an adult female?

A

Otosclerosis

Temporal bone CT: Lucent (otospongiotic) foci involving bony labyrinth

Usually in context of normally aerated middle ear

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12
Q

Difference between pars flaccida and pars tensa cholesteatoma?

A

.Par flaccida -
-superior part of the tympanic membrane.
-erodes the scutum and filling/extends into Prusak space and Tegman tympani (roof)
-**Medial displacement of the head of the malleus **
- Labyrinth fistula - into the lateral semi-circular canal
- long process of incus erosion is common

Pars Tensa
-Less common
**-Often congenital **
- Inferior tympanic membrane
- erodes ossicles, invades and flattens the tympanic CNVII canal, and is primarily medial to the ossicles
- More common in children.
- -often intact tympanic membrane

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13
Q

Noise induced vertigo?

A

Dehiscence of the superior semi-circular canal

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14
Q

What segment of the Facial nerve do not normally enhance?

A

Cisternal, canalicular and labyrinthine segement should NOT enhance.

**The infratemporal course (tympanic and mastoid) does enhance **

abnormal enhancement in bells, lymes, ramsay-hunt and malignancy.

Bells = LABYRINTHE

Damaged in = Transverse Temporal # > longitudinal’

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15
Q

Features of pagets disease of the skull?

A
  1. Well defined and sharp margin of radiolucency affecting the frontal and occipital bones = OSTEOLYSIS CIRCUMSRIPTA
  2. Thickened and expanded sclerotic skull.

OLD person 80s

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16
Q

Pagets skull related complications ?

A

**Deafness
Cranial nerve paresis
Basilar invagination = hydrocephalus = brainstem compression
Secondary High grade osteosarcoma

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17
Q

Young 20-year-old with lytic skull lesion with ground glass appearance?

A

Fibrous dysplasia

Spares the optic capsule - no hearing issues

**McCune-Albirght syndrome = **
Multi-focal fibrous dysplasia, cafe-au-lait spots and precocious puberty

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18
Q

Teenage male with nose bleeds. Mass centred in the sphenopalatine foramen and extends into the pterygopalatine fossa?

A

Juveline nasal angiofibroma

Very vascular.

Blood supply from the ascending pharyngeal artery and or internal maxillary artery.

Not IR. 80% cured by radiation!

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19
Q

Adult 30-40s with nasal obstrictive symptoms. large solitary opacification extending into the nasal cavity from the maxillary sinus with widening of the maxillary antrum?

A

Antrochoanal polyp

effectively a large solitary sinonasal polyp

**No bone destruction, smooth enlargement of the sinus. ** ‘Dumbell shape’

Peripheral enhancement.

Water signal on CT/MRI

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20
Q

Sinus mass arising from the lateral wall of middle meatus, with extension into the antrum?

A

Inverting Papilloma

Cerebriform pattern of enhancement on MRI.

Focal hyperostosis on CT suggests tumour origin/stalk,

Destruction of the medial wall of the maxillary sinus

Trapped sectrions

10% harbour a SCC

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21
Q

Soft tissue mass in the maxillary antrum with destruction of the sinus walls?

A

SCC

Can extend into orbits, brain etc

Decreases T2 signal relative to other sinus pathologies = hypercellular

maxillary antrum is involved in 80% of cases

Note Sinonasal Adenocarcinoma - predilection for ethmoid sinus and enhances more.

Impossible to distinguish from SNUC

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22
Q

20 year old Dumbbell shaped mass with waist at the cribriform plate , with upper portion in the anterior cranial fossa and lower portion in the upper nasal cavity?

A

Esthesioneuroblastoma

Bimodal -m20s or 60s

Avid homogenous enhancement

Somatostatin positive = uptake on octeride scan

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23
Q

Heterogenous sinonasal mass with bone destruction & rapid growth

A

Sinonasal undifferenced carcinoma (SNUC)

Very aggressive. at least 4cm at presentation.

Ethmoid origin more common that maxillary

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24
Q

Homogeneous soft tissue mass with predilection for nasal cavity, bone destruction and low signal on T2?

A

Sinonasal lymphoma

Also low on T2 and bone destruction like SCC but = Nasal cavity

SCC = Maxillary antrum

Very nonspecific imaging features
can mimic variety of neoplasms & aggressive inflammatory disorders

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25
well circumscribed midline mass in the floor of the oral cavity predominantly of flood density with intralesional fat density cysts?
Floor of mouth dermoid 'sack of marbles' Epidermoid will ne homogenous fluid signal
26
Simple well-defined thin walled cyst in the sublingual space?
Rannula Thin-walled SMS cyst with SLS tail = Diving rannula Crossed mylohyoid
27
Which duct/gland sialolithiasis commonly affects?
Whartons duct/submandibular gland
28
Young adult with new level 2a neck mass?
HPV related SCC HPV-positive OPSCC can have **small primary tumours but large and often cystic-appearing nodal metastases ** The US appearances of the nodal involvement in level 2 can mimic 2nd brachial cleft cyst
29
Most common location for ectopic thyroid tissue?
Tongue base - 'Lingual thyroid' Will be hyperdense like thyroid.
30
Anterior midline suprahyoid or midline/paramidline infrahyoid cystic neck mass?
Thyroglossal cyst wall enhancement and soft tissue stranding = infected Nodularity or Ca2+ suggests papillary carcinoma
31
Which thyroid goitre is at risk of developing primary thyroid lymphoma?
Hashimotos low on tech-99m
32
Which thyroid goitre has significant increased radioactive iodine uptake?
Graves disease 50-80%. Visualisation if the pyramidal lobe is accentuated on nuclear medicine. De Quervain's/subacute thyroitis uptake is decreased
33
Acute suppurative thyroidits in a child, what is the mechanism?
Infection starts in the 4th Brachial cleft anomaly and travels/fistula via the pyriform sinus into the thyroid gland (usually left)
34
Thin-walled thyroid cysts with multiple echogenic foci and comet-tail artifacts?
Colloid cyst Suspicious features -Microcalcifications - increased vascularity - larger than 1.5cm
35
Thyroid cancer with macrocalcifications?
Papillary Most common (P for Popular) **Mets via lymphatics - Calcification in a node!!! ** Good prognosis and responds well to iodine therapy
36
Second most common thyroid cancer?
Follicular Spread/Mets haematogenously to bone, lung, liver etc Survival is ok. Responds to iodine therapy Hurthle cell type = seen in elderly and doesn't not take up iodine as well as follicular.
37
Uncommon thyroid cancer associated with MEN 2 syndrome?
Medullary Local invasion , lymph and haematogenous spread. CALCIFIED LYMPH NODES DOESNT respond to iodine Elevated Calcitonin
38
Thyroid cancer seen in elderly ?
Anaplastic Uncommon and undifferentiated Rapid growth and lymphatic spread DOESNT respond to iodine
39
Causes of hyperparathyroidism?
Hyperfunctioning adenoma (90%) Multi-gland hyperplasia (8-10) Cancer (1-3) CT parathyroid adenoma shows early arterial enhancement with delayed washout. Can't differentiate from cancer - look for cervical adenopathy
40
Contents of the parotid gland?
Parotid gland Facial nerve Retromandibular vein
41
Sharply marginated, intraparotid ovoid mass with uniform enhancement. Very bright T2 signal ?
Pleomorphic adenoma/Parotid Benign Mixed Tumor Small < 2cm - well defined Large > 2cm - Lobulated **90% arise in superficial lobe**. Nb 'pear shaped' when arising from the deep lobe Most common benign/any major and minor salivary gland tumour. **Can occur in SM and SL glands.** but parotid 90% differentiate from a partoid warthins - Pleomorphic adenoma can have CALCIFICATION
42
Second most common benign tumour in parotid gland?
Warthin Only occur in parotid gland. Usually solid/cystic, male and smoker. Bilateral (15%)
43
Two malignant tumours that favour the minor salivary glands?
**Adenoid cystic carcinoma (ACCa)** -Strong propensity for perineural spread -Tends to hematogenous spread to lungs -Slow-growing; may metastasize many years later - Most common malignant tumour of submandibular gland **Mucoepidermoid carcinoma (MECa)** -Tends to spread to lymph nodes -Most common malignant tumour of parotid gland
44
What is the relationship between sjorgens and parotid lymphoma?
Sjorgens has a 100X risk of primary NH MALT type lyphoma of the parotid gland. If bilateral homogenous masses in Sjogren's = lymphoma Can be secondary lymphoma to the parotid gland.
45
Painless diffusely enlarged bilaateral parotid glands, in patient with HIV?
Benign lymphoepithelial disease Mixed solid and cystic Can mimic Sjorgens!! - differentiate with no calcification and often cervical adenopathy
46
Enlarged parotid(s) with surrounding fat stranding/ surrounding cellulites
Acute parotitis Often secondary to stone blocking stensens duct or mumps
47
Bilateral enlarged parotids with multiple cystic & solid intraparotid lesions ± smooth, round intraglandular calcifications
Sjorgens Honeycombed or leopard skin appearance of the gland Female in 60s/ dry eyes and mouth
48
what structures are in the carotid space?
Carotid artery Jugular vein Cranial nerve 9,10,11 Internal jugular chain lymph nodes - II, III, IV
49
What are the three classic carotid space tumours?
Paraganglioma Schwannoma Neurofibroma (NF-1)
50
Imaging features of paraganglioma?
'Salt and pepper' from flow voids and heterogenous content Hyper vascular - Intense tumour blush on angio Octreotide positive
51
What are the different types of carotid paraganglioma?
1. Carotid body - at level of bifurication (splaying the ICA and ECA) 2. Glomus vagale - above carotid bifurication but below the jugular foramen 3. Glomus Jugulare - Level of jugular foramen **middle ear floor/PA destroyed 4. Glomus Tympanicum - Confined to middle ear, pulsatile tinnitus. DOESNT destroy destriy the middle ear
52
Imaging features of jugular foramen schwannoma
Sharply marginated, enlarged JF on bone CT Fusiform, enhancing mass enlarging JF on T1WI C+ MR No flow voids Can have cystic changes Not octreotide avid Not all that vascular on angio
53
Imaging features of Glomus jugulare?
Mass in JF with permeative-destructive change of adjacent bone on CT Multiple black dots ("pepper") in tumor indicate high-velocity flow voids from feeding arterial branches on MR
54
Contents of the masticator space
Ramus and angle of the mandible Inferior alveolar nerve Muscles of mastication
55
Commonest mass in the masticator space?
Odontogenic infection In kids can have angry masses like rhabdomyosarcoma
56
What is Grisels Syndrome ?
Torticollis and atlanto-axial joint inflammation seen in H+N surgery or retropharyngeal abscess
57
What is Lemierres syndrome?
Neck infection or Recent ENT surgery leads to jugular vein thrombosis and septic emboli Bacteria is - FUSOBACTERIUM NECROPHORUM
58
Asian with unilateral mastoid effusion and a pathological retropharyngeal node were should look for ?
Fossa of Rosenmuller for a Nasopharyngeal SCC
59
Which type of laryngeal SCC has the best outcome?
Glottic Least lymphatics and symptomatic early Most common Subglottic can be silent and presents with lymphadenopathy
60
What is a radiologically contraindication for laryngeal conservation surgery ?
Invasion of the cricoid cartilage
61
What additional features make laryngeal SCC at least T3?
Fixation of the cords Invasion of the paraglottic space (look on coronals)
62
Thin-walled, fluid- or air-filled lesion communicating with laryngeal ventricle,
Laryngocele Stenosis at the laryngeal ventricle can be an obstruction from a tumour (15%) +/- extra laryngeal extension through the thyrohyoid membrane
63
Where to review if you see a left sided vocal cord paralysis ?
AP window - left recurrent laryngeal nerve Nb the right arises from the CN X at subclavian artery Ipsilateral - Ballooning of laryngeal ventricle - sail sign Enlarged pyriform sinus Medially displaced aryepiglottic fold
64
Focal discontinuity at the posterior globe ?
Coloboma if bilateral think CHARGE syndrome Coloboma Heart defect Atresia - Chonal atresia Retraded growth Gentials - Hypogonadsim Ears - small
65
Most common benign tumor of the orbit?
Dermoid Arises superior and lateral, arissing from the frontozygomatic suture. Young child
66
what is tolosa hunt syndrome?
Histologically same as pseudotumor but involves the Orbital apex and adjacent cavenrous sinus Painful and cranial nerve palsies. Responds with steroids
67
What is the most common malignant orbital mass in a child?
Retinoblastoma Chromosome 13 RB suppressor gene - same as osteosarcoma. risk of facial osteosarcoma after radiation therapy 1/3 bilateral. **Calcification in globe of child is classic**
68
What is trilateral and quadrilateral retinoblastoma ?
Tri - Bilateral orbits and pineal gland Quad - Bilateral orbits, pineal and suprasellar
69
what is the most common intraocular metastatic lesion in an adult?
Metastatic melanoma Enhancing soft tissue mass in the posterior aspect of the globe
70
What orbital lesion is chlamydia psittaci linked iwth?
Orbital MALT Lymphoma upper outer orbit and classically associated with the lacrimal gland. will enhance homogenously and restriction diffusion
71
What are some of the key differences between a orbital lymphangioma and a venus varix?
Lymphangioma - malformed veins and lymphatics - Money shot = they do not increase with the valsalva -Fluid-fluid levels - mutlilocuted cystic components - transpatial involvement - pre, posr septal, intra and extra conal Varix -Veins only, weak wall and valves - massive dilatation of orbital veins - Distend with provocative measures - imaging can look normal with no Valsalva - Most common cause of spontaneous orbital haemmorhage
72
What is the most common vascular orbital lesion in adults?
orbital Cavernous venous malforation/cavernous haemangioma Weak arterial supply - so slow enhancement with delayed washout - progressive fill in classic lateral intraconal sparing orbital apex Low T1 signal pseudocapsule
73
Where does Per-septal and post-septal cellulitis usually originate?
Preseptal = Teeth and face Post septal = Paranasal sinusitis
74
Well circumscribed round rim enhancing lesion centered into the lacrimal fossa?
Dacroyocyctitis
75
lentiform, rim-enhancing, low-density fluid collection along orbital wall Adjacent sinusitis, particularly ethmoid with breach of the lamina papyracea?
Orbital subperiosteal abscess
76
Common causes of raccoon eyes on physical examination of a child?
Metastatic neuroblastoma Basilar skull #
77
What type of breast cancer metastases to the orbits?
Invasive lobular carcinoma Present many years later from index diagnosis with Enophthalmos (posterior displacement of the globe)
78
Classic imaging appearances of optic neuritis?
Enhancement of optic nerve increase T2 signal Unilateral and pain
79
What is neuromyelitis optica?
bilateral optic neuritis + myelitis Ocular pain, visual loss, paralysis relapsing and remitting
80
Classic imaging appearance of thyroid orbitopathy?
Enlargement of the belly of extraocular muscles sparing tendon IMSLO - inferior, medial, superior, lateral, oblique Increased volume of infraorbital fat and exophthalmos
81
What are orbital findings associated with NF-1?
Orbital pathway glioma -WHO grade 1 pilocyctic astrocytoma -Expansion nd enlargement of the entire nerve Plexiform neurofibroma (PNF) -Serpentine, unencapsulated, infiltrative masses - enlarge skull base foramina sphenoid wing dysplasia - Cause pulsatile exophthalmos buphthalmos (visible enlargement of the globe) lisch nodules
82
What are orbital findings carotid cavernous fistula?
Pulsatile exophthalmos Proptosis Enlarged cavernous sinus Prominence of left superior ophthalmic vein Cranial nerve palsy - 3,4, V1 and V2 and 6
83
Small eye (microphthalmia) with increased vitreous density?
Persistent hyperplastic primary vitreous can cause V shaped retinal detachment
84
Main causes of Leukocoria (loss of red eye reflex) in a child ?
Retinoblastoma Coats disease Persistent hyperplastic primary vitreous Coats -Normal-sized globe, hyperdense; no Ca⁺⁺ -Subretinal exudate with retinal detachment PHPV -Retrolental tissue & stalk - **small eye** Retinoblastoma -Calcification present in vast majority
85
What are classic features if optic nerve sheath meningioma?
Tram track sign -Enhancing tumor surrounding the non enhancing optic nerve Possible calcification and hyperostosis of adjacent bone Bilateral = NF-2
86
Young boy with painless enlarging orbital mass, proptosis and visual changes?
Rhabdomyosarcoma
87
Masses in mandible
Odontoma - - Most common lucent lesion in mandible -Over time shows calcifications that coalesce to form a dense lesion with a lucent rim. - 2nd decade of life **-associated with gardners syndrome ** Ameloblastoma – -Soap appearance , fluid levels -classically arise near the angle of the mandible -locally aggressive so additional features such as tooth resorption and cortical erosion through the bone into adjacent tissues Dentigerous cyst - -Benign, developmental lucent lesion surrounding the crown of unerupted tooth. -Also know as follicular cyst **-crown of a tooth projecting in to the cystic space is pathognomonic** Periapical cyst - any tooth --often the result of a **dental infection **and an associated dental cavity may be seen Odontogenic keratocysts -*destructive, multilocular* lesions centered about the ramus or body of the mandible -Unlike a dentigerous cyst, an odontogenic keratocyst can erode through the cortex of the mandible -multiple odontogenic keratocysts = basal cell nevus syndrome
88
Benign cyst of jaw with aggressive behavior and high recurrence rate
Odontogenic Keratocyst If multiple, with midface hypoplasia, calcification of falx, frontal bossing and prognathism = GORLIN basal cell naevus syndrome
89
Orbital lesions
see picture
90
Deep spaces neck and displacement of PPS
Masitactor space - Posterior-medial Parotid space - Antero-medial Carotid - antero-lateral Pharyngeal muscosa - Posterio-lateral
91
Cervical lymph nodes
Level 1 = below mylohyoid and above hyoid anteriorly (1a submental and 1b submandibular) seperated by anterior belly of digastric Level 2 = Jugulodisgastric (base of skull to hyoid) Level 3 = Deep cerivical (hyoid to cricoid) Level 4 = Virchow (cricoid to clavicle ) Level 5 = Posterior triangle (Va and Vb High and low spinal accessory nodes Level 6 = Pretracheal/pre laryngeal/delphian nodes Level 7 = Superior mediastinum
92
Anatomy middle ear
The **epitympanum**, also known as the attic, is the superior portion above the highest point of the tympanic membrane. **Head of the malleus and short crus of the incus** (These give the appearance of an ice-cream cone on an axial CT).   The **mesotympanum **is the space posterior to the tympanic membrane. *Body of the incus, the manubrium of malleus (connected to the tympanic membrane), anterior process of the malleus and the stapes*. stapes = oval window of the cochlea. T Round window placed more inferiorly which bulges to allow compression waves transmitted from the stapes to the oval window to travel through the cochlea
93
Large vestibular aqueduct and inherited sensorineural hearing loss?
Pendred syndrome DDx large vestibular aqueduct? Chochlear hypoplasia Mondini syndrome Nb. Meniere disease = small or absent vestibular aqueduct
94
Boundaries of Nasopharynx, oropharynx and hypopharynx?
oropharynx divided from hypopharynx by valleculae.

FRCR Part Dhá (11 decks)

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