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1
Q

What are the types of head and neck paragangliomas?

A 
Carotid body tumour
- most common (60-70%)
Glomus tympanicum tumour
Glomus jugulotympanicum tum.
Glomus jugulare tumour
Glomus vagale tumour

these tumours tend to be innervated by the parasympathetic system.
They arise from nonchromaffin paraganglion cells (glomus)

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2
Q

Where are glomus tympanicum located

A

Most commonly at the cochlear promontory, but they arise along the course of the tympanic nerve (jacobson’s nerve)

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3
Q

How many turns does the cochlea have?

A

2.5

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4
Q

What are the directions of the three components of the vestibule of the ear

A

Horizontal
Posterior
Superior

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5
Q

What are the branches of the external carotid artery?

A

Some Anatomists Like Fucking, Others Prefer S&M

S: superior thyroid artery
A: ascending pharyngeal artery
L: lingual artery
F: facial artery
O: occipital artery
P: posterior auricular artery
S: superficial temporal artery
M:maxillary artery
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6
Q

What is the most common site of an inverted papilloma?

A

Lateral wall of the nasal cavity, most frequently related to middle turbinate and maxillary ostium.

As the mass expands it results in bony remodeling and resorption and often extends into the maxillary antrum.

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7
Q

What is the purpose of identifying focal hyperostosis (when present) when assessing a nasal cavity mass?

A

In the setting of an inverted papilloma, focal hyperostosis tends to occur at the site of tumor origin.

This helps to suggest the diagnosis and aids in surgical planning as the origin of the tumor determines the extent of surgery required.

The presence of calcification is also helpful in suggesting the diagnosis of inverted papilloma

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8
Q

What is a convoluted cerebriform pattern (ENT)?

A

A convoluted cerebriform pattern is a term used to denote the appearance of a sinonasal inverted papilloma on MRI. The appearance is seen on both T2 and post contrast T1 images and appears as alternating roughly parallel lines of high and low signal intensity.

This sign has been reported as present in 50-80% of cases, whereas it is uncommon in other sinonasal tumours (

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9
Q

What is the name of the duct of the submandibular gland?

A

Wharton’s duct

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10
Q

What is the name of the duct of the parotid gland?

A

Stensen’s duct

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11
Q

Normal limits for size of node of rouvier?

A

5mm in short axis

8mm in long axis

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12
Q

Where is the fossa of rosenmuller location and why is it important?

A

It is located superior and posterior to the torus tubarius (the posterior projection of the cartilaginous portion of the eustachian tube), and is formed by mucosal reflection over the longus colli muscle. The fossa of Rosenmüller appears posterior to the ostium of the eustachian tube on axial images and superior to the ostium of the eustachian tube on coronal images.

It is the most common site of origin for nasopharyngeal carcinoma.

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13
Q

What is the ostiomeatal complex?

A

It is a channel that links the frontal sinus, anterior and middle ethmoid sinuses and the maxillary sinus to the middle meatus that allows air flow and mucociliary drainage.

On coronal views, it is a small channel connecting the ethmoid air cells and maxillary sinus, located just superior to the uncinate process.o

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14
Q

What is silent sinus syndrome?

A

Maxillary sinus atelectasis that results in painless enophthalmos, hypoglobus and facial asymmetry.

Chronic occlusion of the maxillary sinus ostium results in gradual resorption of the air.
Negative pressure is generated within the sinus which results in gradual inward bowing of all four of the maxillary walls.

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15
Q

What are the imaging findings of vocal cord paralysis?

A

The imaging features of vocal cord paralysis include:

atrophy of the thyroarytenoid muscle
​most characteristic finding is the result of atrophy of the thyroarytenoid muscle, which makes up the bulk of the true cord

anteromedial deviation of the arytenoid cartilage

paramedian vocal cord

enlarged laryngeal ventricle/piriform sinus

atrophy of the posterior cricoarytenoid muscle

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16
Q

What structures is Waldeyer’s ring composed of?

A

lymphoid tissue located in the nasopharynx and oropharynx at the entrance to the aerodigestive tract.

The structures composing this ring are:

palatine tonsils
adenoid tonsils
the lateral bands on the lateral walls of the oropharynx
lingual tonsils at the base of the tongue

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17
Q

What is the ostiomeatal complex?

A

It is a common channel that links the frontal sinus, anterior and middle ethmoid sinuses and the maxillary sinus to the middle meatus that allows air flow and mucociliary drainage.

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18
Q

Name the five structures that compose the ostiomeatal complex

A

maxillary ostium: drainage channel of the maxillary sinus

infundibilum: common channel that drains the ostia of the maxillary and ethmoid sinuses to the hiatus semilunaris

ethmoidal bulla: usually a single air cell that projects inferomedially over the hiatus semilunaris

uncinate process: hook-like process that arises from the posteromedial aspect of the nasolacrimal duct and forms the anterior boundary of the hiatus semilunaris

hiatus semilunaris: final drainage passage; a region between the ethmoid bulla superiorly and free-edge of the uncinate process

Middle meatus

Some authors include the frontal recess

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19
Q

Where is the superior orbital fissure located and what does it contain?

A

It is a triangular slit between the greater and lesser wings of the sphenoid.

It transmits:

1st division of CNV
CNIII
CNIV
CNVI
superior ophthalmic veins
branch of middle meningeal artery
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20
Q

What structures does the optic foramen contain?

A

it transmits the optic nerve and ophthalmic artery from the optic canal

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21
Q

What structures does the inferior orbital fissure contain?

A

Infraorbital nerve (branch of V2 of CNV)
infraorbital artery
inferior ophthalmic veins

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22
Q

What are the insertion sites of the constrictor muscles of the esophagus?

A

The superior pharyngeal constrictor is attached anteriorly to the inferior extension of the medial pterygoid plate (the pterygoid hamulus), and to a raphe joining this to the inner surface of the mandible.

The middle constrictor muscle is attached anteriorly to the hyoid bone and lower part of the stylohyoid ligament. Its upper fibres overlap the superior constrictor muscle superficially.

The inferior constrictor muscle attaches anteriorly to cricoid and thyroid cartilages and overlaps the inferior part of the middle constrictor. Its lowermost fibres are horizontally orientated and merge with the circular fibres of the oesophagus.

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23
Q

What is labyrinthitis ossificans?

A

Membranous labyrinth ossification as healing response to infectious, inflammatory, traumatic or surgical insult to inner ear.

On imaging, there is high density/low intensity bone deposition within the membranous labyrinth, replacing the normal fluid density/intensity

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24
Q

What is enlarged vestibular aqueduct syndrome?

A

Enlargement of the vestibular aqueduct, diameter >2mm (or larger than the adjacent semi-circular canal). It is associated with unilateral hearing loss and incomplete partition of the cochlea.

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25
Q

What is enlarged vestibular aqueduct syndrome?

A

Enlargement of the vestibular aqueduct, diameter >2mm (or larger than the adjacent semi-circular canal). It is associated with hearing loss and incomplete partition of the cochlea.

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26
Q

Name 3 situations in which the tympanic segment of the facial nerve is at risk for paralysis

A

middle ear cholesteatoma
surgery for cholesteatoma
otitis media

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27
Q

What are the segments of the facial nerve?

A

Intracranial (cisternal) segment

meatal segment - IAC

labyrinthine segment - IAC to geniculate ganglion

Tympanic segment - geniculate ganglion to pyramidal eminence

mastoid segment - pyramidal eminence to stylomastoid foramen

extratemporal segment

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28
Q

At which point in its course does CNVII do a ~180° turn and run back posteriorly along its trajectory?

A

geniculate ganglion, separating labyrinthine from tympanic segment

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29
Q

At which point in its course does CNVII do a ~180° turn and run back posteriorly along its trajectory?

A

geniculate ganglion

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30
Q

What are the branches of the labyrinthine segment of CNVII?

A

Greater superficial petrosal nerve
lesser petrosal nerve
external petrosal nerve

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31
Q

What are the branches of the mastoid segment of CNVII?

A

nerve to stapedius
chorda tympani
nerve from the auricular branch of CNX

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32
Q

What are the branches of the mastoid segment of CNVII?

A

nerve to stapedius

chorda tympani

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33
Q

In the extratemporal segment of CNVII, what are the 5 branches that emerge after it reaches the anterior aspect of the parotid gland?

A

Tall Zulus Bear Many Children

temporal
zygomatic
buccal
mandibular
cervical
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34
Q

In parotid gland surgical planning, what anatomic landmark is useful in determining whether a lesion has entered the deep parotid gland, and thus crosses the path of the facial nerve?

A

the retromandibular vein lies deep to the facial nerve and superior to the external carotid artery. If a mass reaches it, then we can assume it has crossed the path of the facial nerve

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35
Q

What is a Mondini malformation?

Mondini triad?

A

AKA incomplete partition of the cochlea
Cochlear deformity where the patient does not have the normal 2 and a half turns of the cochlea, and instead has 1 and a half turns (normal basal turn) and a cystic apex.

The triad additionally includes:
Enlarged vestibule with normal semi-circular canals
Enlarged vestibular aqueduct containing a dilated endolymphatic sac

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36
Q

Name some findings that help in the differentiation between a cholesteatoma and chronic otitis media

A

Erosions are common in cholesteatoma (lateral wall of the epitympanum and ossicular chain) but not in chronic otitis media (10%)
Antidependent mass in cholesteatoma
Displacement of the ossicular chain in cholesteatoma
Thickened mucosal lining in chronic otitis media

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37
Q

What is the origin and pattern of extension of pars flaccida and pars tensa cholesteatomas?

A

Pars flaccida: Arises anterosuperiorly, from Prussack’s space. It extends laterally towards the ossicular chain and into the epitympanum.

Pars tensa: Arises posterosuperiorly. It extends posteriorly towards the facial recess and tympanic sinus, and medially towards the ossicular chain.

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38
Q

What are the anatomic boundaries of Prussack’s space?

A

It is located just below the scutum and bordered by the tympanic membrane, the malleus and the lateral ligament of the malleus.

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39
Q

What criteria should you use to evaluate pathological lymph nodes?

A

CRISPS

clustering, rounded shape, inhomogeneity, size, periphery, sentinel location (drainage pathway of known malignancy)

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40
Q

What are the size criteria for cdrvical lymphadenopathy?

A

Short axis:
Station 2A: 11mm or more
Retropharyngeal (rouviere): >5mm
All others: 10mm or more

Long axis:
Station 1/2: >15mm
Retropharyngeal (rouviere): >8mm
All others: >10mm

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41
Q

Define: cluster of lymph nodes

A

A group of 3 or more nodes in the first or second drainage area of a tumor

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42
Q

When assessing for lymphadenopathy, what is the typically pattern of spread for lip SCC?

A

Level 1A and 1B

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43
Q

When assessing for lymphadenopathy, what is the typically pattern of spread for oral tongue SCC (anterior two-thirds of tongue)?

A

Level 1B, 2 and 3

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44
Q

When assessing for lymphadenopathy, what is the typically pattern of spread for floor of mouth SCC?

A

Level 1B, 2 and 3

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45
Q

When assessing for lymphadenopathy, what is the typically pattern of spread for retromolar/anterior tonsillar pillar SCC?

A

1B, 2 and 3

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46
Q

When assessing for lymphadenopathy, what is the typical pattern of spread for tonsillar fossa SCC?

A

Level 2, 3 and 4

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47
Q

When assessing for lymphadenopathy, what is the typical pattern of spread for base of tongue SCC?

A

Level 2 and 3

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48
Q

When assessing for lymphadenopathy, what is the typical pattern of spread for hypopharynx SCC?

A

Level 2, 3, 4 and 5B

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49
Q

When assessing for lymphadenopathy, what is the typical pattern of spread for supraglottic larynx SCC?

A

Level 2, 3 and 4

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50
Q

When assessing for lymphadenopathy, what is the typical pattern of spread of nasopharyngeal carcinoma?

A

Level 2, 3, 4 and 5. Also, retropharyngeal (rouviere) and posterior auricular.

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51
Q

What is Lemierre syndrome? Typical patient population? Most common organism?

A

Lemierre syndrome is venous thrombophlebitis of the tonsillar and peritonsillar veins, often with spread to the internal jugular vein. Immunocompetent adolescents and young adults are typically affected.

The most common infectious agent is the anaerobe Fusobacterium necrophorum

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52
Q

What is the difference between a ranula and a plunging ranula?

A

A ranula is a mucous retention cyst that arises from the sublingual gland as a sequela of inflammation. All ranulas arise from the sublingual gland and hence begin in the sublingual space.

A plunging ranula extends from the sublingual space into the submandibular space by protruding posteriorly over the free edge of the mylohyoid or by extending directly through a defect in the mylohyoid.

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53
Q

What is a bezold abscess?

A

Bezold abscess is a complication of otomastoiditis where there is necrosis of the mastoid tip and resultant spread of infection into the adjacent so tissue.

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54
Q

What is the base of the tongue called?

A

Foramen cecum

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55
Q

Although thornwaldt cysts are usually asymptomatic, what symptom can they cause?

A

Halitosis

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56
Q

How can you identify the false vocal cords on axial imaging?

A

The false vocal folds are mucosal infoldings superior to the laryngeal ventricle. They can be identified on cross-sectional imaging by the presence of the paraglottic fat laterally

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57
Q

How can you identify the true vocal cords on axial imaging?

A

The true vocal cords are identified in the axial plane on CT or MRI by identifying the transition of paraglottic fat to muscle (thyroarytenoid muscle) within the wall of the larynx

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58
Q

What are the components of the glottis?

A

True vocal cords

Thyroarythenoid muscle

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59
Q

What composes the supraglottic larynx?

A

It extends from the epiglottis to the laryngeal ventricle, including the false vocal cords, aryepiglottic folds and arythenoid cartilage

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60
Q

What are the borders of the subglottic larynx?

A

The subglottic larynx begins 1cm inferior to the apex of the laryngeal ventricle and extends down to the first ring of the trachea

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61
Q

The recurrent laryngeal nerve innervates all laryngeal musculature except the ______________, which is innervated by the ____________.

A

Cricothyroid muscle

Superior laryngeal nerve

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62
Q

When a laryngocele is present, what important pathology/etiology should you assess for?

A

Laryngeal obstruction by neoplasm (SCC) should be excluded. It is typically fluid filled.

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63
Q

Isolated sinus disease of the maxillary sinus is most likely due to obstruction of the ______________ or _________, while sinus disease affecting the maxillary, frontal, and anterior ethmoid sinuses is most likely due to obstruction of the _______________.

A

Maxillary sinus ostium or infundibulum

Hiatus semilunaris

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64
Q

What structure separates the anterior from the posterior ethmoid air cells?

A

The basal lamella

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65
Q

What structures drain into the superior and inferior meati?

A

Superior: posterior ethmoid cells and sphenoid sinus (via sphenoethmoidal recess)
Inferior: Lacrimal duct

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66
Q

What is an Onodi air cell and why is it important to be aware of its presence?

A

Sphenoethmoidal (or Onodi) air cell is defined as an ethmoidal air cell that lies posteriorly to the sphenoid sinus. Rarely it may lay superiorly to the sphenoid sinus and is called a central Onodi air cell.

As a result of its location the optic nerve, and less commonly, the internal carotid artery, are very closely related with as little as 0.03 mm (median 0.08 mm) of bone separating them, with potential to damage these structures during FESS

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67
Q

What complications of sinusitis should you look for on CT?

A 
Periosteal abscess
Osteomyelitis
Orbital cellulitis
Ophthalmic vein thrombosis/cavernous sinus thrombosis
Meningitis
Intracranial abscess
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68
Q

True or false:

Unlike chronic allergic fungal sinusitis, invasive fungal sinusitis is hyperdense on CT.

A

FALSE

Unlike chronic allergic fungal sinusitis, invasive fungal sinusitis is NOT hyperdense on CT.

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69
Q

What is an antrochoanal polyp and how is it treated?

A

An antrochoanal polyp is a benign polyp extending from the maxillary sinus into the nasal cavity, with characteristic widening of involved ostium. It may erode bone and extend into the nasopharynx. Complete resection is necessary to prevent recurrence.

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70
Q

What is the only salivary gland to contain lymphoid tissue, and why?

A

During embryological development, the parotid gland is the last major salivary gland to become encapsulated, and is therefore the only salivary gland that contains intrinsic lymphoid tissue.

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71
Q

What is the standard treatment for pleomorphic adenoma?

A

Although pleomorphic adenoma is benign, complete surgical resection is the standard treatment. Left unexcised, the tumors can continue to grow, and there is an increasing risk for malignant transformation to carcinoma ex pleomorphic adenoma. Additionally, it is not possible to distinguish between benign pleomorphic adenoma and malignant mucoepidermoid carcinoma by imaging alone.

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72
Q

What are the MRI characteristics of a pleomorphic adenoma

A

CT is insensitive for detecting a small parotid tumor, so MRI is preferred. The T1 and T2 characteristics of a pleomorphic adenoma are similar to water. Unlike a simple cyst, however, enhancement is typical for pleomorphic adenoma.

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73
Q

What is the 2nd most common benign parotid tumor?

A

Warthin tumor

Warthin tumor generally appears as a cystic neoplasm. Unlike pleomorphic adenoma, Warthin tumor does not enhance.

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74
Q

What key feature does Adenoid cystic carcinoma have a tendency to present with?

A

Adenoid cystic carcinoma has a tendency to spread along the nerves (perineural spread) and often presents with cranial nerve palsy or paresthesia.

It enhances

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75
Q

What is the most common primary parotid malignancy?

A

Mucoepidermoid carcinoma (5% of all parotid tumors)

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75
Q

What is the most common submandibular/sublingual gland malignacy?

A

Adenoid cystic carcinoma

It is also the 2nd most common parotid gland malignancy (behind mucoepidermoid)

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76
Q

What are the MRI characteristics of carcinoma ex pleomorphic adenoma?

A

In contrast to benign pleomorphic adenoma, malignant carcinoma ex pleomorphic adenoma is hypointense on both T1- and T2-weighted images
Enhances with gadolinium

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77
Q

What is the risk of malignant degeneration of pleomorphic adenoma?

A

A benign pleomorphic adenoma has a 1.5% risk of malignant degeneration during the first 5 years. That risk increases to 9.5% in tumors present for 15 years.

78
Q

What is the typical presentation of parotid involvement in sarcoidosis?

A

Involves up to 30% of cases of sarcoidosis

Bilateral painless parotid swelling

79
Q

What is uveoparotid fever and what pathology causes it?

A

Uveoparotid fever, which presents with bilateral uveitis, parotid enlargement, and facial nerve palsy, is considered pathognomonic for sarcoidosis.

80
Q

What are the imaging findings in the parotid glands in sjogren syndrome?

A

there is atrophy and fatty replacement of the salivary glandular tissue, with multiple nodules, abnormal enhancement, numerous small cystic foci, and punctate calcification.

81
Q

Any new dominant parotid mass in the setting of Sjögren syndrome should raise concern for ____________.

A

Lymphoma

82
Q

What salivary glands are affected in HIV lymphoepithelial lesions?

A

Parotid (only salivary glands with lymphoid tissue). Presents with enhancing masses and lymphoepithelial cysts bilaterally

83
Q

What courses through the vidian canal?

A

Vidian artery and nerve

84
Q

What courses through the foramen spinosum?

A

Middle meningeal artery

85
Q

What are the contents of the pterygopalatine fossa?

A

the pterygopalatine ganglion and branches of the internal maxillary artery.

86
Q

What spaces does the pterygomaxillary fissure connect?

A

It connects the pterygopalatine fossa to the masticator space

87
Q

What are the foramina of the pterygopalatine fossa?

A 
Pterygomaxillary fissure
Sphenopalatine foramen
Inferior orbital fissure
Greater and lesser palatine canals
Foramen rotundum
Vidian canal
88
Q

What is the sphenopalatine foramen?

A

The sphenopalatine foramen is the medial exit of the pterygopalatine fossa. It leads into the nasopharynx via the superior meatus.

89
Q

What connects the pterygopalatine fossa to the oral cavity?

A

The pterygopalatine canal, via the greater and lesser palatine foramina

90
Q

What are the 3 classic findings in juvenile nasopharyngeal angiofibroma?

A
  1. Nasopharyngeal mass.
  2. Expansion of the pterygopalatine fossa.
  3. Anterior bowing or displacement of the posterior maxillary sinus wall.
91
Q

Where does juvenile naspharyngeal angiofibroma arise from?

A

Nasal aspect of the sphenopalatine foramen, which is the medial boundary of the pterygopalatine fossa.

92
Q

What are the imaging features of juvenile nasopharyngeal angiofibroma?

A

On imaging, JNA enhances very avidly and is centered in the nasopharynx. As the mass continues to grow, extension into the pterygopalatine fossa or the orbits is commonly seen.
It causes expansion of the pterygopalatine fossa.

93
Q

What is juvenile nasopharyngeal angiofibroma and what is the affected patient population?

A

Highly vascularized benign nasopharyngeal tumor typically affecting adolescent males. Most commonly presents with nasal obstruction and epistaxis.

94
Q

What role does the radiologist play in the treatment of juvenile nasopharyngeal angiofibroma?

A

Pre-operative embolization is often performed to reduce the vascularity of the lesion prior to resection.

95
Q

What is an esthesioneuroblastoma?

A

Esthesioneuroblastoma, also known as an olfactory neuroblastoma, is a malignant neural crest tumor that arises from specialized olfactory epithelium. The histology is similar to other neural crest tumors, such as small cell lung carcinoma and neuroblastoma.

96
Q

What are the MRI characteristics of adenoid cystic carcinoma?

A

Adenoid cystic carcinoma demonstrates water signal on T1- and T2-weighted images, but unlike a cyst, enhancement is characteristic.

97
Q

What are the imaging characteristics and epidemiology of esthesioneuroblastoma?

A

Bimodal distribution, teenage and middle age.

They begin as masses in the superior olfactory recess and initially involve the anterior and middle ethmoid air-cells unilaterally. As they grow, they tend to destroy surrounding bone and can extend in any direction.

On imaging, the tumor appears as an aggressive mass that is slightly hyperattenuating on CT and intermediate intensity on both T1- and T2-weighted images due to high cellularity. Calcification is often present. There can also be peripheral tumors cysts at the margins of the intracranial portion of the mass.

98
Q

In EAC atresia, which ossicles are usually abnormal?

A

Malleus and incus (1st branchial cleft structures)

99
Q

What is surfer’s ear?

A

External ear canal exostosis, a bony exostosis

100
Q

What subgroup of patients are affected by necrotizing external otitis (malignant otitis externa) and what are the pathogens involved?

A

Elderly diabetic - Pseudomonas Aeruginosa

Immunocompromised - Aspergillus Fumigatus

101
Q

What are the imaging findings of necrotizing external otitis?

A

Agressive, rapidly progressing external ear inflammation with enhancement and bone erosion.

It can extend to the inner ear and skull base

102
Q

Where do acquired cholesteatomas originate?

A

In prussack’s space, typically causing erosion of the inferior aspect of the scutum and the malleus and incus.

103
Q

What is the most common malignancy of the external ear canal?

A

Squamous cell carcinoma

104
Q

The footplate of the stapes articulates with the __________

A

Oval window

105
Q

What is a glomus tympanicum?

A

A glomus tympanicum is an extra-adrenal pheochromocytoma (paraganglioma) isolated to the middle ear. Glomus tympanicum is the most common primary middle ear tumor and typically presents with pulsatile tinnitus or conductive hearing loss.

106
Q

TRUE OR FALSE:

Cholesterol granuloma and cholesteatoma both cause bone erosion.

A

TRUE

Cholesterol granuloma and cholesteatoma are often considered together in the differential diagnosis of a soft tissue middle ear mass with bony erosion.

107
Q

Potential involvement of what 3 key landmarks needs to be described in the evaluation of a cholesteatoma?

A

The lateral semicircular canal
the tegmen tympani (the bony roof separating the mastoids from the brain)
the facial nerve

108
Q

What are the MRI characteristics of a cholesteatoma?

A

T1 variable
T2 intermediate to slightly hyper
No enhancement
+ve DWI

DWI and postcontrast are most important sequences

109
Q

What MRI features help differentiate a cholesterol granuloma from a cholesteatoma?

A

Cholesterol granuloma does not restrict on DWI and is T1 hyperintense (although cholesteatoma is variable on T1 and can also be hyperT1)

110
Q

The _____________ is the bony superstructure containing the fluid- filled spaces of the cochlea, vestibule, and semicircular canals.

A

The otic capsule is the bony superstructure containing the fluid- filled spaces of the cochlea, vestibule, and semicircular canals.

111
Q

The cochlea is a two-and-a-half turn spiral containing numerous neuroepithelial hair cells of the organ of _______

A

Corti

112
Q

What is an incomplete partition type II of the cochlea?

A

It is the most common form of congenital cochlear dysplasia, characterized by incomplete development of the normal two and a half turns of the cochlea, resulting in confluence of the apical and middle turns and preservation of a distinct basilar turn.

AKA Mondini deformity, but this term is controversial.

113
Q

When assessing for enlarged vestibular aqueduct syndrome, what internal reference can be used?

A

The vestibular aqueduct should not be larger (in diameter) than the posterior semi-circular canal.

114
Q

What patient population is most often affected by otospongiosis?

A

Young and middle aged women

115
Q

True or false:

Otospongiosis is unilateral 85% of the time.

A

FALSE

Otospongiosis is bilateral 85% of the time.

116
Q

What is the difference between fenestral and retrofenestral otospongiosis?

A

Fenestral: Most common type. Occurs at the fissula ante fenestrum (located directly anterior to the oval window), and usually affects the oval window.

Retrofenestral: (cochlear) type, it is thought to represent a more severe form with involvement of the otic capsule in addition to the lateral wall of the labyrinth.

117
Q

What is the differential diagnosis of cochlear demineralization?

A

Retrofenestral otospongiosis
Osteogenesis imperfecta in a child
Fibrous dysplasia in a young adult
Paget disease in an older adult

118
Q

What are the 3 stages of chronicity of labyrinthitis and their MRI characteristics?

A

Acute labyrinthitis: The only MRI abnormality is diffuse enhancement of the affected inner ear structures. The main DDx is a schwannoma, but it will be a focal abnormality.

Fibrous labyrinthitis: Fibrous strands in the fluid filled cavities of the inner ear structures causing decreased T2 signal. Possible mild residual enhancement.

Labyrinthitis ossificans: Bony replacement of the fluid filled cavities of the inner ear structures, dark on T2 without enhancement. CT is better for evaluation.

120
Q

What is an antrochoanal polyp?

A

Antrochoanal polyps (ACP) are solitary sinonasal polyps that arise within the maxillary sinus but pass through and enlarge the sinus ostium and posterior nasal cavity to the nasopharynx.

121
Q

What are the imaging findings of an antrochoanal polyp?

A

CT:

  • Defined mass with mucin density is seen arising within the maxillary sinus.
  • Widening of maxillary ostium and extending into the nasopharynx.
  • No associated bony destruction but rather smooth enlargement of sinus

MRI:

T1: intermediate to low
T2: high homogeneous (may vary if chronic or fungal infection)
Gado: peripheral enhancement

122
Q

What is the name of the structure that serves as the interface between the air-filled middle ear and the fluid-filled inner ear?

A

Oval window

123
Q

What percentage of longitudinal temporal bone fractures are associated with facial nerve injury? Transverse fractures?

A

20% of longitudinal fractures

50% of transverse fractures

124
Q

What is the most common petrous apex lesion?

A

Cholesterol cyst

125
Q

What are the MRI characteristics of a cholesterol cyst?

A

Commonly seen in a pneumatized petrous apex

Expansile mass
Internal hemorrhage and fluid
No fat suppression

126
Q

What is Gradenigo syndrome?

A 
Otomastoiditis (apical petrositis)
trigeminal neuropathy (facial pain)
lateral rectus palsy (CNVI palsy at dorello's canal)
127
Q

Name this syndrome:

Otomastoiditis (apical petrositis)
trigeminal neuropathy (facial pain)
lateral rectus palsy (CNVI palsy at dorello's canal)
A

Gradenigo syndrome

128
Q

What are the possible vascular complications of apical petrositis?

A

internal carotid arteritis

dural venous thrombosis

129
Q

What is the difference in location between a congenital and an acquired cholesteatoma?

A

Acquired cholesteatoma: middle ear

Congenital cholesteatoma: anywhere in the temporal bone

130
Q

What percentage of paragangliomas undergo malignant degeneration?

A

less than 5%

131
Q

What gives the classic salt and pepper MRI pattern in paragangliomas?

A

Intra-tumoral flow voids

132
Q

What is the most common primary neoplasm of the jugular foramen?
What is the typical patient to be affected, and with what symptoms?

A

glomus jugulare

late middle age woman
pulsatile tinnitus and conductive hearing loss

133
Q

What is the differential diagnosis of a vascular, red, retro-tympanic mass on otoscopic evaluation?

A

glomus tympanicum
aberrant carotid artery
tympanic membrane hemangioma

134
Q

What is the origin of a glomus tympanicum?

A

Jacobson nerve at the cochlear promontory (won’t see nerve on imaging, but the location is typical)

135
Q

What is the cochlear promontory?

A

The cochlear promontory is the name given to the bone that overlies the basal turn of the cochlea protruding into the middle ear cavity.

It is the site of origin of a glomus tympanicum

136
Q

Which segments of CN7 can enhance normally on MRI?

A

There can be normal enhancement extending from the labyrinthine to the mastoid segments

The cisternal, meatal and extratemporal segments should not enhance

137
Q

What is the Ddx of spontaneously hyperdense opacification of the sinuses?

A

Fungal disease
Inspissated secretions
Blood

138
Q

What are the MRI signal characteristics of fungal disease of the sinuses

A

Dark T1 and dark T2, because of the high protein content (although proteinaceous fluid is typically bright, once it crosses a certain treshold (28%), it becomes dark)

Can mimic aerated sinus, hence the value of correlating with a CT

139
Q

What is the name of the roof of the ethmoid air cells?

A

Fovia ethmoidalis

140
Q

What are the most common causes of a mucocele?

A

Chronic infection
Previous surgery
Trauma
Allergic sinonasal disease

A mass can also cause a mucocele, but it is less common.

141
Q

What are the 2 most common skull base lesions?

A

Fibrous dysplasia

Osteoma

142
Q

multiple para-nasal osteomas are found in which syndrome?

A

multiple para-nasal osteomas are found in Gardner’s syndrome, which also includes cutaneous and soft tissues tumors in addition to colonic polyps with a predilection to malignant degeneration.

143
Q

What is the most common neoplastic cause of multiple solid parotid masses?

A

Warthin tumour

144
Q

What percentage of Warthin tumours are bilateral or multifocal?

A

20%

Most common bilateral or multifocal benign parotid tumour

145
Q

What is the most common location of a Warthin tumour?

A

AKA papillary cystadenoma lymphomatosum

Tends to favour the parotid tail region at the level of the mandibular angle

146
Q

What is the typical imaging presentation of a Warthin tumour?

A

Well defined heterogeneous solid cystic lesion within the superficial lobe of the parotid/parotid tail
No calcification
Moderate enhancement
Presence of mural nodule is strongly suggestive of Warthin tumour

On MRI:
The cystic components contain cholesterol, therefore there are elements of high T1 within the cystic components
Usually no enhancement with gado

147
Q

What middle ear abnormalities can present with tinnitus?

A 
glomus tympanicum
glomus jugulotympanicum
aberrant or dehiscent ICA
jugular bulb variants
cavernous hemangioma
148
Q

What is a Michel aplasia?

A

AKA Complete labyrinthine aplasia

The cochlea normally develops in the third gestational week. In michel deformity, the inner ear structures are absent and instead there is a small cystic/multicystic cavity.

149
Q

What seperates the submandibular from the sublingual space on imaging?

A

The sublingual space is medial to the mylohyoid muscle.

150
Q

What are the contents of the carotid space?

A

Carotid artery
Internal jugular vein
CN IX-XII
Lymph nodes

151
Q

TRUE OR FALSE

CNVII is located lateral to the retromandibular vein

A

TRUE

152
Q

What is the most commonly involved location in superior semicircular canal dehiscence?

A

Apex of the superior semicircular canal

Posterior aspect is less frequently involved

153
Q

Name this structure:

Bony landmark that divides the superior compartment of the internal acoustic meatus into an anterior and posterior compartment.

A

Bill’s bar

154
Q

What is the nervus intermedius?

A

aka nerve of Wrisberg

A part of the facial nerve which contains sensory and parasympathetic fibers.

Travels along the same course as CNVII, coursing through supero-anterior aspect of internal acoustic canal.

Joins motor root of facial nerve at geniculate ganglion

155
Q

What is Ramsay-Hunt syndrome?

A

Herpes zoster oticus

Herpes zoster infection of the facial nerve.
Presents with external acoustic meatus/tympanic membrane vesicles + CNVII palsy.

156
Q

What is the name of the small bone formation within the cochlea?

A

Modiolus

157
Q

Which semi-circular canals share a common crus?

A

The superior and posterior semi-circular canals share a common posterior crus

158
Q

Where is the tympanic portion of the facial canal located in relation to the lateral semi-circular canal?

A

Inferior to the lateral semi-circular canal

159
Q

Where is the tympanic portion of the facial canal located in relation to the lateral semi-circular canal?

A

Inferior to the lateral semi-circular canal

160
Q

What is medial canal fibrosis?

A

Fibrous tissue formation in the medial part of the bony external auditory canal. The tissue conforms to the shape of the tympanic membrane. No erosion, destruction or expansion.

161
Q

When assessing an external auditory canal pathology, what feature allows differentiation between benign or aggressive lesions?

A

Bone erosion should not be present in benign disease.

162
Q

What are the 2 types of acquired cholesteatomas?

A

Pars flaccida and pars tensa cholesteatoma.

The pars flaccida cholesteatoma has the typical appearance, in Prussack’s space.
The pars tensa cholesteatoma has a more inferior location, without involvement of Prussack’s space or erosion of the scutum.

163
Q

TRUE OR FALSE

Asymmetric enhancement of CNVII is abnormal.

A

FALSE

60% of patients have normal asymmetric enhancement

164
Q

TRUE OR FALSE

Enhancement of CNVII in the internal auditory canal or beyond the stylomastoid foramen is abnormal.

A

TRUE

The segments of CNVII located in the mastoid bone can enhance normally, but there shouldn’t be enhancement in the internal auditory canal or beyond the stylomastoid foramen.

165
Q

What is the differential diagnosis for jugular foramen masses?

A 
Glomus jugulare
Schwannoma (IX, X, XI)
Meningioma
Metastasis
Skull base bony primary (chondrosarcoma)
166
Q

TRUE OR FALSE

In deep space infections of the neck, peritonsillar abscess is more common than intratonsillar abscess.

A

TRUE

Intratonsillar abscess is very rare. The presence of fluid attenuation within a tonsil usually represents purulent material within the tonsillar crypts and should not be interpreted as an abscess.

167
Q

What is the differential diagnosis of bilateral cystic parotid lesions?

A

Warthin tumour
benign lymphoepithelial lesions of HIV
Sjögren syndrome
sialocoeles

168
Q

What is the differential diagnosis of a unilateral cystic parotid lesion?

A 
Warthin tumour
Sialocoele
First branchial cleft cyst
Necrotic lymph node (SCC)
Infected lymph node
169
Q

Which branchial cleft cyst is usually associated with the parotid gland?

A

1st

170
Q

What is the male to female ratio of juvenile nasopharyngeal angiofibroma?

A

Almost exclusively occurs in males.

171
Q

Name this pathology:

Benign, frequently bilobulated bony exostosis that arises from the midline of the hard palate, protruding into the oral cavity.

A

Torus palatinus

172
Q

Which structure seperates the sublingual space from the submandibular space?

A

The myelohyoid muscle delineates the sublingual space superorly and the submandibular space inferorly

173
Q

What are the boundaries of the submandibular space?

A 
Anterolateral: mandible
Medially: anterior belly of digastric muscles (separating it from the submental space)
Posteriorly: muscles of the tongue
superiorly: mylohyoid muscle
inferiorly: hyoid bone
174
Q

What seperates the nasopharynx from oropharynx?

A

Palate

175
Q

What seperates the oropharynx from hypopharynx?

A

Lateral glosso-epiglottic folds

176
Q

What are the 5 neurovascular structures surrounding the hyoglossus muscle?

A

Medial:
lingual artery
CN 9

Lateral:
Warthon’s duct
CNV V3
CN XII

177
Q

Which spaces span the supra and infrahyoid neck?

A

Carotid space
Prevertebral space
Retropharyngeal space

178
Q

What is the short axis criteria for abnormal level II cervical lymph node size?

A

1.1cm

179
Q

What is the short axis criteria for abnormal retropharyngeal cervical lymph node size?

A

0.5cm

180
Q

What is the short axis criteria for abnormal cervical lymph node size (excluding level II or retropharyngeal)?

A

1cm

181
Q

When assessing a head & neck tumor, what is the pathological size criteria for a cluster of lymph nodes?

A

Has to be in the drainage area of the primary tumor

3 or more nodes
Level II: Long axis 8-15mm or short axis 9-10mm
Elsewhere: Long axis 8-15mm or short axis 8-9mm

182
Q

In head and neck cancer, what impact does extra-nodal spread of tumor have on survival?

A

50% decrease in survival

183
Q

What is the size criteria for abnormal Rouviere cervical lymph node size (short and long axis)?

A
  1. 5cm short axis

0. 8cm long axis

184
Q

What structure seperates the internal auditory canal into superior and inferior components?

A

crista falciformis

185
Q

What structure seperates the superior compartment of the internal acoustic meatus into anterior and posterior components?

A

bill’s bar

186
Q

What are the 2 nerves located in the anterosuperior quadrant of the internal acoustic meatus?

A

CNVII

nervus intermedius

187
Q

What is the salivary/lacrimal gland involvement in IgG4 disease?

A
  • Panless bilateral enlargement of the lacrimal and salivary glands (Mikulicz disease)
  • Chronic sclerosing sialadenitis of the submandibular glands (Kuttner tumor)
188
Q

What is DDx of bilateral salivary/lacrimal gland enlargement?

A

Lymphoma
Acute phase Sjogren syndrome
IgG4 related disease

189
Q

What are the MRI findings in IgG4 related lacrimal/salivary gland disease (Mikulicz disease)?

A

HypoT2 (fibrosis)
HypoT1 (fibrosis)
homogeneous enhancement

190
Q

What are the 2 forms of thyroid dinvolvement in IgG4 related disease?

A

1- Riedel thyroiditis: Chronic inflammatory process with extensive fibrosis of thyroid parenchyma and surrounding tissues.

2- Fibrous variant of Hashimoto thyroiditis

191
Q

What are the CT findings in Riedel thyroiditis?

A

Focal or diffuse low attenuation of the thyroid with minimal contrast enhancement relative to normal thyroid tissue

192
Q

What is Rosai-Dorfman disease?

A

Sinus histiocytosis with massive lymphadenopathy

Rare benign idiopathic proliferative disease that involves phagocytic histiocytes.

193
Q

What is the eponym of Sinus Histiocytosis with Massive Lymphadenopathy?

A

Rosai-Dorfman disease

194
Q

What is the most commonly involved location in Rosai-Dorfman disease?

A

Cervical lymph nodes

ENT (2 decks)

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