Head & Neck Imaging Parapharyngeal Spaces

Para - pharyngeal spaces Definition Fat filled triangular space lateral the pharynx Extends from the skull base to the oropharynx

Para pharyngeal spaces Contents Fat Arteries [ascending pharyngeal, internal maxillary] Veins [ pharyngeal veins] Nerves [ branches of the mandibular nerve]

PPS Scanning An anatomic landmark for the adjacent spaces Imaging plane is directed for the site pathology

Coronal

Axial

CT and MRI

5 mm slices Axial and coronal planes Contrast injection

CT Calcification Bone erosions Hyperostosis

MRI Superior contrast resolution Direct multiplanar imaging Vascular imaging without contrast injection No bone artifacts

MRI Open

MRI Closed

Extremity MRI

Dynamic Magnet

The bed rotates from Upright to Recumbent, stopping at any angle in between

Patient with Low Back Pain After Surgery

Does a Lie-Down-Only Scanner see the patients problem ? NO

PPS Clinical aspects Is difficult to be evaluated clinically Presenting symptoms Sore throat Dysphagia Change of voice Nasal obstruction Cranial nerves IX XII A mass bulges posterior to the angle of mandible

PPS Anatomic relations Anterior Posterior Medial Lateral

PPS anatomy Antro -lateral aspect [ Infratemporal fossa ] Masticator space Parotid space Masticator Space Muscles of mastication [ masseter, temporalis, pterygoid muscles] Mandibular ramus Mandibular nerve branches Fat behind the antral wall

PPS anatomy Antro -lateral aspect [ Parotid space ] Stylo mandibular tunnel Parotid gland (deep lobe) External carotid artery Retromandibular vein Facial nerve Lymph nodes

PPS anatomy Postro -lateral aspect [ Post styloid space ] [ extends from the skull base to aortic arch Carotid canal Internal carotid artery Internal jugular vein Cranial nerves 9 to 12, sympathetic plexus Lymph nodes [Internal jugular + lateral retropharyngeal

PPS anatomy Medial aspect [ Pharyngeal mucosal space ] The pharyngeal mucosal space is separated from the PPS by the pharyngo - basilar fascia The PBF is a tough membrane Maintains patent airway Crossed only by aggressive lesions

PPS Pathology Medial aspect [ Pharyngeal mucosal space ] Displacement of the PPS fat laterally 98% of masses are carcinomas 80% squamous cell type Other carcinomas [ adenoid cystic & mucoepidermoid] Lymphomas and sarcomas (children) Angiofibroma, plasmacytoma, melanoma

Nasopharyngeal carcinoma N1 = Unilateral single or multiple nodes all 6 cm N2 = Bilateral multiple all 6cm N3a = Single or multiple nodes > 6 cm N3b = Supra clavicular nodes

Nasopharyngeal carcinoma Clinical triad A symptomatic mass due to LN Hearing loss due to otitis media Bloody nasal discharge NB T4 has multiple cranial nerve palsies Mass in the lateral wall of the naropharynx Before age 50 Y M: F = 2.5: 1 Strong relation ship with Epstein Barr virus

Nasopharyngeal Carcinoma MRI Obliteration of the fat strip between the tensor and levator veli palatini muscles on T1 WIs Extension into the PPS fat Obliteration of the fat plane between the nasopharynx and prevertebral muscles

Nasopharyngeal carcinoma Staging T1 Confined to the nasopharynx T2 Extension to Oropharynx or nasal fossa (axial) T3 Invasion of bones or sinuses (axial) T4 Intracranial extension or hypo pharynx or orbit

Nasopharyngeal carcinoma Extensions Effacement of the FR and ET Heterogeneously enhancing mass in the lateral wall of the nasopharynx Anteriorly nasal fossa, maxillary sinus, infratemporal fossa Posteriorly prevertebral muscles, carotid sheath Laterally Para pharyngeal space, mastecator space

Nasopharyngeal carcinoma Extensions Medially nasopharyngeal air space, retropharyngeal to the contra lateral side Inferiorly Oropharynx, tongue Superiorly skull base, intracranial extension

Other malignancies Lymphomas 20% Others 10% Rhabdomyosarcoma Adenoid cystic carcinoma Melanoma, plasmacytoma,..

Rhabdomyosarcoma The most common sarcoma of the head and neck Arise from the primitive mesenchymal cells 70% arise before the age of 12 years Orbit > nasopharynx >temporal bone > sinuses Presents by pain and cranial nerve palsies Soft tissue mass with bone destruction Deposits to the lung and bones DD nasopharyngeal carcinoma , angiofibroma ,NHL

Tornwaldts cyst Benign lesions A mucous retention cyst Occurs in the midline nasopharynx Low signal in T1 and high signal in T2 WIs

Nasopharyngeal angiofibroma Arises near the sphenopalatine foramen Almost exclusively in adolescent boys Epistaxis

Nasopharyngeal angiofibroma Hyper vascular lesion with intense enhancement Supplied by the ascending pharyngeal & ascending palatine branches of the internal maxillary artery Forward displacement of the posterior wall of the maxillary sinus [Holman- Miller sign]classical

Grading of nasopharyngeal Angiofibroma I Confined to the nasopharynx II Extension into pterygopalatine fossa or masticator space III Intracranial or intraorbital extension

PPS anatomy Postro -lateral aspect [ Post styloid space ] [ extends from the skull base to aortic arch Carotid canal Internal carotid artery Internal jugular vein Cranial nerves 9 to 12, sympathetic plexus Lymph nodes [Internal jugular + retropharyngeal nodes]

lateral

Glomus Nodes Neurofibroma


Glomus tumor Rare, slowly growing hypervasculer tumor Incidence 1: 1,300,000 Male : female 1: 3 40 - 60 Y Arise from the glomus bodies in and around the jugular bulb Benign hyper vascular lesion supplied by Ascending pharyngeal Carotico -tympanic [ICA] Anterior tympanic [ECA] Stylomastoid [ECA] Meningeal branches [ vertebral]

Glomus tumor Mass in the jugular fossa with bone destruction Large at presentation 2-6 cm, intense enhancement Intracranial and extra cranial extension Metastases in 4%, Lung , nodes, liver, bones Salt and pepper appearance on MRI

Lymphadenopathy Reactive homogenous ,young patient less than 1cc Lymphoma bulky homogenous Direct invasion from near by malignancy Inflammatory septic focus abscess formation

Metastatic nodes The most common nodal disease Any malignancy can spread to the retro-pharyngeal nodes Enlarged nodes > 0.8 cm with central necrosis and stranding of the perinodal fat 75% of nasopharyngeal carcinoma , 20% of oropharyngeal , 5% of thyroid carcinoma have metastatic nodes at presentation