1 ). Lhermitte \200\231s sign is characteristic but not Imaging Currently a combination of clinical, laboratory, and radiological tests are used to make the diagnosis. The only radiological investigation of routine value is MRI. MRI (Fig. This is the investigation of choice as no other modality can demonstrate the plaq ues. A combination of T1-weighted, FLAIR, and post-contrast (gadolinium) enhanced can be us ed to detect these. The whole of the brain and the spinal cord should be covered. 10.12 ) Classically plaques are seen in the corpus callosum, U- \201 bres, temporal lobes, brainstem, cerebellum, and the spinal cord. Temporal lobe involvement is hi ghly speci \201 c for MS. Plaques show low signal on T1-weighted, high signal on FLAIR, an d enhance post-gadolinium in the brain (after they have been present for a month). Dawson \200\231s \201 ngers are typical for MS \200\224 these are ovoid lesions running perpend icular to the ventricles secondary to in \202 ammation around penetrating venules. Information for the radiologist \200 Has the patient had any other neurological events? \200 What is their current neurological status? Reference WI , 1 McDonald A , Compston Edan G , et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis 50 ( 1 ): . Ann Neurol 2001 ; 121 \200\223 7 . SUBASH KC/NMC-15TH/2014 MULTIPLE SCLEROSIS 165 (a) (b) Fig. 10.12 oedema of the cord consistent with a plaque. b) Axial FLAIR image of the brain. This shows multiple periventricular plaques. a) T2-weighted axial MRI image from the upper cervical spine showing SUBASH KC/NMC-15TH/2014 166 CHAPTER 10 Neurology conditions Epilepsy Epilepsy is a common chronic neurological disorder characterized by the occurrence of at least 2 unprovoked seizures 24 hours apart. Seizures result from an abnormal paroxys mal discharge of cerebral cortical neurons. Classi \201 cation \200 Generalized seizures: Tonic \200\223clonic (grand mal). \200 Absence (petit mal). \200 Myoclonic (rare involu ntary muscle jerks). Partial seizures: Simple partial (no impairment of consciousness, e.g. Jacksonian seizures). \200 Complex p artial (with impairment of consciousness, e.g. temporal lobe epilepsy). Clinical presentation This depends on the location of seizure activity in the cortex as wel l as the extent and pattern of its propagation in the brain. Imaging Neuroimaging should not be routinely requested when a diagnosis of idi- opathic gen eralized epilepsy has been made clinically. CT This can be used to identify gross pathology if MRI is not available or is contraindicat ed. MRI This is the imaging investigation of choice in individuals with epilepsy, par- ticularl y in those: \200 Who develop epilepsy before the age of 2 years or in adulthood. \200 W ho have any suggestion of a focal onset on history, examination or electroencephalography (EEG). In whom seizures continue in spite of \201 rst-line medication. Routine brain MRI may well reveal an underlying cause, such as neoplasia. This should be pe rformed within 4 weeks of presentation (NICE epilepsy guidelines 1 ). The principal role of MRI in epilepsy however, is in the de \201 nition of structural abnormalities that underlie seizure activity. In patients with drug-resistant ep ilepsy, excision of such a lesion may be curative or may improve seizure control. MR spectroscopy is sometimes used to assess concentrations of cerebral metabolites and some neurotransmitters non-invasively. Scintigraphy This can be used as a further means of imaging in potentially preopera- tive M RI-negative cases. PET may provide data on regional cerebral blood \202 ow, glucose metab olism, and the binding of speci \201 c ligands to receptors. SUBASH KC/NMC-15TH/2014 EPILEPSY 167 Information for the radiologist \200 Symptoms and signs at presentation and current seizu re activity. \200 Response to medical treatment. \200 If surgery is being considered. (a) (b) Fig. 10.13 a) Axial contrast-enhance CT demonstrating a mixed attenuation lesion anterior l eft insula region. b) Coronal T1 post gadolinium image con \201 rming this high-grade tumo r with extensive oedema. A 30-year-old patient who presented with 3 seizures over a week. Reference 1 NICE . primary and secondary care The epilepsies: the diagnosis and management of the epilepsies in adults and children in . London : NICE , 2004 . SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 169 Chapter 11 Head and neck differential diagnosis Bare orbit 170 Orbital calci \201 cation 170 Absent or hypoplastic paranasal sinuses Opaci \201 cation of maxillary antrum Nasopharyngeal mass 170 170 170 SUBASH KC/NMC-15TH/2014 170 CHAPTER 11 Head and neck differential diagnosis Bare orbit \200 Neuro \201 bromatosis. \200 Metastatic disease. \200 Meningioma. Orbital calci \201 cation \200 Cataract. \200 Retinoblastoma. \200 Previous infectio n. \200 Meningioma. \200 Vascular calci \201 cation. Absent or hypoplastic paranasal sinuses \200 Congenital. \200 Down \200\231s syndrome. \200 Kartagener \200\231s syndrome. \200 Paget \200\231s disease. \200 Fibrous dyspla sia. Opaci \201 cation of maxillary antrum \200 Trauma. \200 Infection. \200 Malignancy. \200 Fibrous dysplasia. \200 Wegener \200\231s granulomatosis. \200 Dentigerous/mucou s retention cyst. Nasopharyngeal mass \200 Normal adenoids (esp. in children). \200 Mass lesions: Nasopharyngeal cancer. \200 Lymphoma. \200 Angio \201 broma. \200 Rhabdomyosarcoma. \200 Trauma. \200 Infection. SUBASH KC/NMC-15TH/2014 171 Chapter 12 Head and neck presenting syndromes Neck lumps 172 Hoarse voice 173 Dysphagia 174 SUBASH KC/NMC-15TH/2014 172 CHAPTER 12 Head and neck presenting syndromes Neck lumps Differential depends on position: \200 Super \201 cial (within skin): Lipoma. \200 Sebaceous cyst. Anterior triangle: Lymph nodes (reactive or malignant). \200 Branchial cleft cyst. \200 Carotid body tumor . \200 Aneurysm. \200 Vascular malformation. Midline: Thyroid mass. \200 Thyroglossal duct cyst. \200 Laryngocoele. \200 Dermoid cyst. \200 Submandibular: \200 Lymph node. \200 Salivary gland infection. \200 Salivary gl and tumor. \200 Sialolithiasis. \200 Posterior triangle: Commonly lymph nodes. \200 Cervical rib. \200 Pharyngeal pouch (rare). Imaging Ultrasound Usual \201 rst-line modality for assessment of palpable lumps, it allo ws accu- rate localization and characterization, as well as guiding biopsy if required. CT Useful in assessment of deeper structures, especially if infection and abscess formation are being considered. MRI Gives better soft tissue characterization than CT and should be used if suspecting meta static disease from a nasopharyngeal and oropharyngeal primary. Fluoroscopy Sialography (contrast injection in the salivary gland ducts) gives accurate ima ges of the glandular structure, as well as stones or strictures in the duct. Nuclear medicine PET-CT is used in the assessment of malignant lymph nodes with no known pr imary. Scintigraphy is also used in cases of thyroid and parathy- roid enlargement. SUBASH KC/NMC-15TH/2014 HOARSE VOICE 173 Hoarse voice The commonest causes of a sudden change in voice quality are infection, laryng itis, pharyngitis, and epiglottitis. Imaging plays a role in cases where direct inspection raises the possibility of tumors on the vocal cord, or recurrent laryngeal nerve palsy. The left recurrent laryngeal nerve passes into the mediastinum and loops under the aortic arch before coming back up into the neck, and so is potentially invo lved in diseases affecting the left side of the mediastinum. The right recurrent laryngeal nerve doesn \200\231t come so far down, looping under the brachiocephalic artery, and so is less often affected. Imaging Plain \201 lm CXR may show a lung or mediastinal mass to account for a laryngeal nerve palsy. Ultrasound Little role, but can be used to search for and characterize lymph nodes if appro priate. CT Used to stage laryngeal tumors, and to investigate the course of the laryngeal nerve, if vocal cord palsy has been diagnosed at endoscopy. SUBASH KC/NMC-15TH/2014 174 CHAPTER 12 Head and neck presenting syndromes Dysphagia De \201 ned as dif \201 culty swallowing, and may be due to problems in the pha rynx or lower down in the esophagus. Pharyngeal causes are often associated with odynophagi a (painful swallowing). Remember gradually progressive dysphagia over several weeks, especially in the elderly, is strongly suggestive of malignancy. Differential includes: Infection: Tonsillitis. \200 Pharyngeal abscess (quinsy). \200 Oesophagitis. Foreign body. \200 Pharyngeal pouch. \200 Malignancy: Pharyngeal. \200 Oesophageal. \200 Gastric. Benign oesophageal stricture. \200 Globus hystericus. Imaging Plain \201 lm Lateral soft tissue view of the neck may reveal a foreign body (if radio- opaque such as a chicken bone) or widening of the pervertebral space in cases of pha ryngeal abscess. CXR will show oesophageal dilatation if signi \201 cant, or possibly a hiatus hernia. Fluoroscopy Contrast swallow studies are used to assess the swallowing mechanism, as well a s the structure of the pharynx and esophagus. Can also demon- strate aspiration and re \202 ux. CT To assess the neck and mediastinal structures, especially in cases of extrinsic compress ion. MRI Used to assess pharyngeal malignancy. Nuclear medicine PET-CT has an increasing role in the staging of many tumors, including oes ophageal. SUBASH KC/NMC-15TH/2014 175 Chapter 13 Head and neck conditions Nasopharyngeal tumors 176 Oropharyngeal tumors 178 Laryngeal carcinoma 180 Thyroid nodules and masses 182 Primary hyperparathyroidism 184 Hypoparathyroidism 186 Sinus disease Parotid and submandibular salivary glands: infection Sialolithiasis Parotid and submandibular sali vary glands: tumors Branchial cleft cysts 188 190 192 194 196 SUBASH KC/NMC-15TH/2014 176 CHAPTER 13 Head and neck conditions Nasopharyngeal tumors Most nasopharyngeal malignancies are squamous cell cancers and they m ost commonly occur in the lateral wall of nasopharynx within the fossa of Rosenm ller (are a around the ostium of Eustachian tube). Men are more frequently affected than women. Risk factors include Epstein \200\223Barr virus, exposure to smoke or to chemical pollutants, an d ingestion of salted \201 sh. Imaging has an important role in staging as well as planning the treatment of nasopharyngeal cancers. Clinical presentation The most common presenting symptom is a neck mass due to metastatic l ymphadenopathy. Other symptoms include epistaxis, nasal obstruction, hearing loss due to bl ockage of Eustachian tube, and cranial nerve palsies due to skull base invasion. T-staging \200 Tis: carcinoma in situ. \200 T1: tumor con \201 ned to nasopharynx. \200 T2: tumor extends to oropharynx and/or nasal fossa: T2a: without parapharyngeal extension. \200 T2b: with parapharyngeal extension. T3: tumor invades bony structures and/or paranasal sinuses. \200 T4: tumor with intracran ial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space. Imaging MRI The preferred imaging modality for the evaluation of the primary tumor due to b etter soft tissue contrast and multiplanar capability compared to other modalities (Fig. 13.1 ). Ultrasound Cannot accurately assess the primary tumor but is useful in the assess- ment of cervical nodal disease, and can also guide biopsy of suspicious lymph nodes. CT Useful in the evaluation of nodal involvement. The primary draining lymph nodes from nas opharyngeal cancer are the retropharyngeal nodes. CT also detects early bony cortical invas ion. Nuclear medicine \200 PET-CT is used in the assessment of residual and recurrent disease following treatment, looking for metastases, and searching for primary lesions in cases of unexplained nodal disease. Biopsy is the only de \201 nite way to establish the diagnosis. Information for the radiologist \200 Detailed clinical history and result of endoscopy if already performed. SUBASH KC/NMC-15TH/2014 NASOPHARYNGEAL tumors 177 (a) (b) Fig. 13.1 a) Axial MR image with gadolinium enhancement revealing a large nasopharyngeal tu mor involving the skull base and spreading into the infra temporal fossae on both sides. b) Sagittal MR image of the same patient as (a). SUBASH KC/NMC-15TH/2014 178 CHAPTER 13 Head and neck conditions Oropharyngeal tumors 90 % of oropharyngeal malignancies are squamous cell cancers. Men are affected three times as frequently as women. Risk factors include heavy smoking, heavy alco hol consumption, chewing tobacco and betel (common in parts of Asia), and human papillomavi rus (HPV) infection. The oropharynx consists of: Pharyngeal wall between nasopharynx and pharyngoepiglottic fold. \200 Soft palate. \200 Tonsils. \200 Base of tongue. Clinical presentation Patients usually present with dysphagia, persisting sore throat or ot algia but advanced cases may present with trismus or severe pain. T-staging \200 Tis: carcinoma in situ. \200 T1: tumor \211 2cm in greatest dimension. \200 T2: tumor > 2cm but \211 4cm in greatest dimension. \200 T3: tumor > 4cm in gre atest dimension. \200 T4a: tumor invades any of these: larynx, deep/extrinsic muscle of t he tongue, medial pterygoid, hard palate, and mandible. T4b: tumor invades any of these: lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or encase the carotid artery. Imaging Imaging has an important role in de \201 ning the extent and accurately staging or opharyngeal tumors. Imaging is also used to monitor response to treatment and can in \202 uence treatment choice in certain cases. Ultrasound Cannot accurately assess the primary tumor but is useful in the assess- ment of cervical nodal disease, and can guide biopsy of suspicious lymph nodes. CT Useful in evaluating the extent of the primary tumor as well as nodal involvement. It is widely available, has the advantage of speed, and allows chest imaging at the same time (n ow part of standard staging protocols). MRI Superior in the assessment of soft tissue spread, perineural extension, and osseous inv olvement, particularly if dental amalgam is present (Fig. 13.2 ). Nuclear medicine PET-CT is used in assessing recurrent disease and may have a role in cases of nodal disease with an unknown primary. Information for the radiologist Detailed clinical history and result of endoscopy if alread y performed. SUBASH KC/NMC-15TH/2014 OROPHARYNGEAL tumors 179 (a) (b) Fig. 13.2 a) Axial MR image revealing a large tumor in the left side of the tongue spreadin g into the space behind the mandible. b) Gadolinium-enhanced MR image from the same patient as (a) revealing necrosis in the left-sided neck nodes. Biopsy con \201 rmed squamous cel l carcinoma. SUBASH KC/NMC-15TH/2014 180 CHAPTER 13 Head and neck conditions Laryngeal carcinoma Carcinomas of the larynx are classi \201 ed into supraglottic, glottic (true vocal cords) or subglottic depending on the site of origin. 95 carcinomas. Risk fact ors include smoking and alcohol use. % are squamous cell Glottic carcinoma is the commonest form of laryngeal cancer. It presents early with hoarsen ess and has the best prognosis. Supraglottic carcinoma arises above the true cords. Normally presents later, with non-speci \201 c symptoms such as dysphagia, odynophagia, and otalgia. Patients may present with a neck mass due to lymphatic spread. Subglottic carcinoma of the vocal cord and usually presents with hoarseness. The subglottis is a dif \201 cult area to assess endoscopically and imaging is especially important. is the least common. It arises from the undersurface Imaging Ultrasound Cannot accurately assess the primary tumor but is useful in the assessme nt of cervical nodal disease, and can also guide biopsy of suspicious lymph nodes. CT The role of imaging is to assess deep and submucosal spread that is blind to the endosco pe (Fig. cartilages and suffers fewer motion (swallowing and breathing) artifacts than MRI. Regional lymphadenopathy can be assessed and staging is com- pleted with CT of the chest. Coronal reformatted images are useful for assessing the craniocaudal extent of supraglottic tumors and to visualize the superior margin of the true vocal cord. 13.3 ). CT allows better assessment of the laryngeal MRI Better soft tissue contrast resolution than CT. Useful when cartilage inva- sion is equ ivocal on CT, and to assess tumor spread out from the larynx. Nuclear medicine PET-CT is used in initial staging and to assess response to therapy. Information for the radiologist \200 Smoking history. \200 Endoscopic and clinical \201 ndings. \200 If recurrence is suspected, details of previous surgery and radiotherap y are very important. SUBASH KC/NMC-15TH/2014 LARYNGEAL CARCINOMA 181 Fig. 13.3 side of the larynx with necrotic nodes in the right neck. Biopsy con \201 rmed s quamous cell carcinoma. CT image at the level of the hyoid revealing a soft tissue mass in the left SUBASH KC/NMC-15TH/2014 182 CHAPTER 13 Head and neck conditions Thyroid nodules and masses Thyroid nodules are very common, being found in 4 \200\2238 pati on and in 10 \200\22341 % by means of ultrasound. The majority are benign, due to cysts, ad enomas, or colloid nodules. Although uncommon thyroid cancer may also present as a solitary nodule. Investigation is therefore directed towards discriminating the small percentage of malignant nodules from the large number of benign ones. % of adults on pal- Thyroid cancer is classi \201 ed into papillary (commonest accounting for 60 % of cases), follicular, medullary, and anaplastic. Papillary and medullary carcinomas h ave a high incidence of spread to local lymph nodes whereas follicular carcinoma tends to s how early haematogenous spread to lung and bone. Lymphoma and metastases may also present a s a thyroid mass. Presentation Most patients with thyroid nodules are asymptomatic. A haemorrhagic cyst may p resent with sudden onset of pain and swelling in the neck. The presentation of thyroid cancer is variable and depends on the histological type. Neck pain from local invasion, dysphasia, or symptoms of distant metasta ses can all occur. Imaging Plain \201 lm \200 Limited role but CXR may detect tracheal deviation from retr osternal goiter, mediastinal lymph nodes, and lung metastases. Plain radiographs can show metastases in bone, which are usually lytic and expansile. Ultrasound The most sensitive method for diagnosing intrathyroid lesions. Features of a ben ign nodule are a well-de \201 ned margin, large cystic component, peripheral \200\230egg shell \200\231 calci \201 cation, and lack of internal vascularity. Features of a malignant lesion include hypoechogenicity, ill-de \201 ned margin, \201 ne internal calci \201 cation, heterogeneity, and internal vascularity. There is much overla p in these features so \201 ne needle aspiration is often required ( Figs. 13.4 and 13.5 ). CT Not sensitive in depicting intrathyroid lesions; however, it is useful for evalu- ating lymphadenopathy, local tumor extension, and distant metastases from thyroid cancer. It may also be useful for intrathoracic goiter to show its loca- tion and extent, to distinguish i t from other causes of superior mediastinal mass and assess tracheal compromise. MRI Has a limited role in characterizing thyroid nodules, although it is effective in the d iagnosis of cervical lymph node metastases and in staging thyroid lymphoma. Scintigraphy Used to determine the functional status of nodules. Nodules may be \200\230co ld \200\231, \200\230warm \200\231, or \200\230hot \200\231, depending on the uptake of t racer compared with normal thyroid. Thyroid cancers concentrate less radio-iodine than norm al SUBASH KC/NMC-15TH/2014 THYROID NODULES AND MASSES 183 thyroid tissue and hence appear \200\230cold \200\231. Although only 10 \200\22325 nodules contain tumor (benign causes include multinodular goiter, focal thyroiditis, and cysts) th is \201 nding always requires further assessment. % of cold Technetium-99m pertechnetate is most often used. Gallium-67 scintigraphy is a useful adjunct as thyroid lymphoma is the only thyroid malignancy that ta kes up this radionuclide. Information for the radiologist \200 The presenting symptoms and signs. \200 The result s of thyroid function tests. Fig. 13.4 There are no features of malignancy and the patient can be reassured. Ultrasound image of the right lobe of thyroid revealing an echo free cyst. Fig. 13.5 Ultrasound image from a different patient revealing a well de \201 ned solid nod ule in the thyroid isthmus. Ultrasound-guided \201 ne needle aspiration revealed no malig nancy. SUBASH KC/NMC-15TH/2014 184 CHAPTER 13 Head and neck conditions Primary hyperparathyroidism (HPT) may be primary, secondary, or tertiary. Hyperparathyroidi sm Primary HPT is caused by inappropriate excess of parathyroid hormone (PTH) resulting in hypercalcaemia and hypophosphataemia. It is usually due to a single adenoma, occasionally h yperplasia, and rarely carcinoma. The treatment of a symptomatic parathyroid adenoma is sur gical removal. Preoperative localization is the most common indication for imaging of the p arathyroid glands. Ectopic glands are seen in 20 found anywhere from the level of the hyoid bone down to the aortic root. % of patients and may be Clinical presentation Most patients with primary HPT present with mild hypercalcaemia disco v- ered incidentally. More severe hypercalcaemia produces nephrolithiasis, abdominal pain, nausea, constipation, pancreatitis, bone pain, arthralgia, and mental disturbance ( \200 \230stones, bones, groans, and psychic overtones \200\231). Imaging Imaging studies should be performed only after the diagnosis of primary HPT is esta blished on the basis of biochemical \201 ndings. Plain \201 lm Radiographs are useful in documenting the effects of HPT upon the bony skel eton, but not the underlying cause. Classic plain \201 lm signs include subperiosteal bon e resorption on the radial aspects of the phalanges and holes in the bone known as \200 \230Brown \200\231s tumors \200\231. Ultrasound This is the initial investigation of choice. Normal-sized parathyroid glands are usually not visualized. Parathyroid adenomas appear as discrete, oval, hypoechoic masses, usually posterior to the thyroid gland although their position can be very variable. Ultrasound-guided \201 ne needle aspiration may be performed to allow cytological con \201 rmation or PTH-assay. Nuclear medicine (Fig. Scintigraphy is the preferred method of examination if ultrasound do es not locate the adenoma. Parathyroids and thyroid take up isotopes at different rates and a subtraction method can be used to localize the adenoma. 13.6 ) CT May be used to detect an ectopic adenoma inaccessible to ultrasound. MRI Has better sensitivity than CT for localizing ectopic mediastinal glands. Information for the radiologist \200 Relevant previous surgical history (i.e. of the head /neck/chest). \200 Previous or current history of malignancy. \200 Any known co-existin g thyroid nodules. SUBASH KC/NMC-15TH/2014 PRIMARY HYPERPARATHYROIDISM 185 Fig. 13.6 adenoma localized to the superior mediastinum. (Image courtesy of Dr Andy Scarsbr ook.) Screen shot images from a SPECT scan showing an ectopic parathyroid SUBASH KC/NMC-15TH/2014 186 CHAPTER 13 Head and neck conditions Hypoparathyroidism Hypoparathyroidism may be congenital or acquired, due to accidental remo val of the parathyroid glands during thyroid surgery or their ablation by radio-iodine ther apy. Autoimmune disease is a less common cause. Biochemical \201 ndings are of hypocalcae mia and hyperphosphataemia. Clinical presentation The clinical features of hypoparathyroidism are due to hypocalcaemia. Symptoms include numbness around the mouth and extremities, followed by cramps, tetany (ca rpopedal spasm), convulsions, and death if untreated. Imaging The skeleton is usually normal. The principal radiological manifestation is calci \201 cation of the basal ganglia and areas of the cerebrum and cerebellum (seen on CT/MRI). In pseudohypoparathyroidism (same biochemical \201 ndings as hypoparathyroidism but with lack of response to parathormone), affected individuals are sho rt in stature with short metacarpals, metatarsals, and phalanges. The 4 teeth are hypoplast ic with defective enamel. These changes are best demonstrated on plain radiographs. th and 5 th metacarpals in particular are affected. The Information for the radiologist Relevant previous surgical history (i.e. of the head/neck/c hest). SUBASH KC/NMC-15TH/2014 HYPOPARATHYROIDISM 187 Fig. 13.7 Axial CT showing dense calci \201 cation of the basal ganglia due to hypopara- t hyroidism. There is also an acute right subdural haematoma and artifact from a cochlear imp lant on the left. Image courtesy of Dr. Daniel Warren. SUBASH KC/NMC-15TH/2014 188 CHAPTER 13 Head and neck conditions Sinus disease In \202 ammatory sinus disease may be acute or chronic. Each sinus has its own pattern of mucociliary clearance. Altering normal secretions, ciliary action, or the patency of ostia will result in pathology. Frontal, anterior ethmoid, and maxillary sinuses all drain into the middle meatus. The region where they drain is the osteomeatal complex (OMC). The sphenoid and post erior ethmoid sinuses drain into the superior meatus. Disease at the OMC causes obstruction of drainage pathways and is a major cause of recurrent acute or chronic sinusitis. Presentation Acute sinusitis is often due to secondary bacterial infection following viral upper respiratory tract infection. This results in overproduction of mucus by the in \202 amed mucosa. Clinically there may be headache, sinus pain, fever, and nasal discharge. Chronic rhinosinusitis clinically represents recurrent acute sinusitis or a prolonged acute episode refractory to treatment. Other disease entities such as sinonasal p olyposis and mucocoeles are often associated with chronic rhinosinusitis. Imaging Plain \201 lm Popular historically but are no longer widely used. CT The mainstay of modern sinus imaging. Mucosal thickening, polyps, and air \202 uid lev els are all clearly seen, as well as potential complications of acute sinusitis: \200 Ost eomyelitis: rare with the use of antibiotics. \200 Intracranial abscess: spread of infect ion from the frontal or sphenoid sinuses may give rise to cerebral abscess or subdural empyema. Orbital cellulitis: usually follows ethmoid sinusitis and may result in orbital abscess formation. CT of the sinuses is used in chronic rhinosinusitis prior to functional endo- scopic sinus surgery (FESS) to examine the extent of sinus disease, carefully assess the OMC, and note a ny anatomical variants (Fig. 13.8 ). CT can also assess nasal septal deviation and the presence of sinonasal polyposis \200\224 which is seen as soft tissue in the nasal cavity, usually arising from the ethmoid sinuses (Fig. 13.9 ). MRI MRI lacks the bony detail of CT but is useful in cases of sinus malignancy. Information for the radiologist \200 Full clinical details including features to suggest a complication of sinusitis. \200 Plans for surgery. SUBASH KC/NMC-15TH/2014 SINUS DISEASE 189 Fig. 13.8 Note the 2 osteomeatal complexes through which the maxillary sinuses drain into t he nose. Coronal reformat of a CT through the sinuses, revealing normal anatomy. Fig. 13.9 formation. Note also the previous surgery attempting to improve the sinus drainag e by widening the osteomeatal complexes. Coronal reformat of a CT revealing extensive nasal and maxillary polyp SUBASH KC/NMC-15TH/2014 190 CHAPTER 13 Head and neck conditions Parotid and submandibular salivary glands: infection Mumps is the commonest cause of acute parotitis but rarely requires imaging. Staphylococcal and streptococcal infections develop in debili- tated, dehydrated patients with poor oral hygiene. These patients present with t ender swollen glands and systemic signs of infection. Pus may be seen discharging from the parotid duct ori \201 ce. Imaging Ultrasound Allows assessment of the gland texture, any underlying duct abnormality, calculi, and abscess formation. Also will demonstrate associated nodes, and allow aspirati on if appropriate but it may be dif \201 cult to fully assess depth of infection. CT (Fig. Will show a diffusely swollen gland with in \202 ammatory stranding in the sur- r ounding fat. If an abscess is present this will appear as an area of absent enhancement (da rk area within bright gland) or irregular ring enhance- ment. CT gives a good overall view of the neck and better assessment of deeper structures than ultrasound. Also useful for det ecting stones and gas formation. 13.10 ) MRI Not so good at detecting calculi or gas as CT and little advantage in the acute setting . Information for the radiologist \200 History, especially risk factors such as previous st ones, radiotherapy, etc. \200 Blood results. SUBASH KC/NMC-15TH/2014 PAROTID AND SUBMANDIBULAR SALIVARY GLANDS: INFECTION 191 Fig. 13.10 originating in the salivary glands, now extending throughout the tissue planes o f the neck and into the mediastinum. Coronal reformat of a CT from a patient with suppurative infection SUBASH KC/NMC-15TH/2014 192 CHAPTER 13 Head and neck conditions Sialolithiasis Salivary gland calculi form as the result of stasis of saliva or infection. They are more common in the submandibular gland (80 more viscous and the ducts take an uphi ll course. Patients present with pain and swelling of the affected gland, related to meals. Occasionally the stone may be palpated in the \202 oor of mouth. Sialolithiasis may lead to chronic sclerosing sialadenitis with \201 brosis and atrophy of the gland. % ) because the saliva is Imaging Plain \201 lm The majority of stones are radio-opaque on plain \201 lms. Ultrasound Useful initial investigation. Calculi can be identi \201 ed as an echogenic foc us within the gland and associated duct dilatation will also be seen (Fig. 13.11 ). CT Unenhanced scans will demonstrate the stone and then IV contrast can be given to demonst rate any intraglandular abscess. MRI Thin section T2 MRI (MR sialography) is less satisfactory for identifying small stones because of signal voids. Sialography Contrast injected into the relevant duct opening in the mouth can identify ston es and secondary duct dilatation (Fig. 13.12 ). Information for the radiologist Appropriate history and clinical \201 ndings. SUBASH KC/NMC-15TH/2014 SIALOLITHIASIS 193 Fig. 13.11 Note the dense acoustic shadowing behind it. Ultrasound of the submandibular gland reveals a large stone in the duct. (a) (b) Fig. 13.12 calculus in the position of the duct. b) Following an injection of iodinated con trast the stone is con \201 rmed to lie within the duct. a) Control \201 lm from a submandibular sialogram reveals a well-de \201 ned SUBASH KC/NMC-15TH/2014 194 CHAPTER 13 Head and neck conditions Parotid and submandibular salivary glands: tumors 80 % of salivary gland tumors arise in th e parotid gland. Pleomorphic ade- nomas are the most common (50 % ). Patients present with a painless slow growing lump/swelling within the affected gland. Warthin \200\231s tumors m ake up around 10 % of benign parotid tumors and are usually found in the parotid tail, occa sionally bilaterally. Carcinomas are less common than benign lesions. Pain, rapid growth, and neurological involv ement (facial nerve palsy) all suggest malignancy. Imaging Ultrasound Suspected salivary gland tumors should be investigated by ultrasound in the \201 rst instance. Fine needle aspiration can also be performed, but cross- sectional imaging will often be required in addition. CT Findings depend on the particular tumor, but in general CT allows easy assessment of all the major salivary glands, tumor extent and depth, and regional nodal involvement (Fig. 13.13 ). MRI Allows more accurate assessment of the facial nerve than CT in cases of parotid maligna ncy and therefore useful prior to surgery (Fig. 13.14 ). Information for the radiologist \200 History and clinical \201 ndings are important for deciding the most appropriate investigations. Contraindications to IV contrast or MRI will help guide imaging. \200 If recurrence of ma lignant disease is suspected then a detailed history of previous surgery and radiotherapy is necessary to interpret dif \201 cult imaging \201 ndings. SUBASH KC/NMC-15TH/2014 PAROTID AND SUBMANDIBULAR SALIVARY GLANDS: tumors 195 Fig. 13.13 Axial CT image reveals a large, partly necrotic tumor arising from the left paro tid. This was a squamous carcinoma. Fig. 13.14 reveals a well de \201 ned homogeneous lesion in the gland. Biopsy con \201 rm ed a benign cyst. Heavily T2-weighted (with fat saturation) MR image of the left parotid SUBASH KC/NMC-15TH/2014 196 CHAPTER 13 Head and neck conditions Branchial cleft cysts These benign neck cysts usually appear before the age of 30. The 1 br anchial cleft develops into the external auditory canal. The 2nd, 3rd, and 4 th branchial c lefts merge to form the sinus of His, which will normally involute. When a branchial cleft does not properly involute, a branchial cleft cyst forms. See Table 13.1 for classi \201 c ation. st Clinical presentation Branchial cysts are usually asymptomatic, but they may become painful due to secondary infection. Alternatively, they may present with local mass effect such as respiratory compromise. Fine needle aspiration yields pus-like \202 uid that is rich in cholesterol crystals. The treatment is surgical excision. However, recurrence rates of up t o 20 % are reported. Imaging Ultrasound Useful initial investigation of any neck mass (Fig. 13.15a sound can con \201 rm the position and cystic nature of the mass, it does not adequately evaluate the e xtent and depth of neck lesions. ). Although ultra- MRI This more reliably con \201 rms the cystic nature of the mass and provides precise de \201 nition of the extent of the lesion and its relationship to surrounding structures (Fi g. type I 1 st branchial cleft cysts and for parapharyngeal masses that may be 2 nd branchi al cleft cysts. Wall thickness and enhancement following IV contrast administration varies according to the severity of any associ- ated infective/in \202 ammatory process. 13.15b ). MRI is especially advantageous for CT Branchial cleft cysts appear as well-de \201 ned, ovoid, \202 uid- \201 lled lesions . Information for the radiologist \200 Symptoms and signs at presentation. \200 Presence of raised in \202 ammatory markers (WCC, CRP). \200 Any clinical suspicion of malignancy (metastatic squamous cell carcinoma to cervical nodes may mimic a branchial cleft cyst). SUBASH KC/NMC-15TH/2014 BRANCHIAL CLEFT CYSTS 197 (a) (b) Fig. 13.15 in the right neck reveals a well-de \201 ned cystic lesion. b) Coronal T2c weig hted MR scan from the same patient as (a) con \201 rms the anatomical position and benign characteristics of a 2 a) Ultrasound image from a 19-year-old man with a painless swelling nd branchial cleft cyst. SUBASH KC/NMC-15TH/2014 198 CHAPTER 13 Head and neck conditions Table 13.1 Types of branchial cleft cysts 1 st Type I: located near the external auditory canal, most commonly inferior and posterior to t he tragus. May also be in the parotid gland or at the angle of the mandible Type II: associated with submandibular gland or found in the anterior triangle of the neck 2 nd Accounts for 95 % of branchial anomalies May present anywhere from the skin of the lateral neck, between the internal and external c arotid arteries, and into the palatine tonsil Most commonly seen along the anterior border of the upper 1/3 of sternocleidomastoid 3 rd Rare Characteristically located deep to sternocleidomastoid within the posterior triangle of the neck 4 th Extremely rare Arise in various locations, paralleling the course of the recurrent laryngeal nerve, includ ing the thyroid gland and mediastinum SUBASH KC/NMC-15TH/2014 199 Chapter 14 Genitourinary differential diagnosis Bladder \201 lling defects Renal calci \201 cation 200 Testicular lesions 200 Adrenal ca lci \201 cation 201 Dilated ureter 200 201 SUBASH KC/NMC-15TH/2014 200 CHAPTER 14 Genitourinary differential diagnosis Bladder \201 lling defects \200 Blood clot. \200 Tumor (transitional cell carcinoma ( TCC) adult and rhabdomyosarcoma child). Calculus. \200 Infection/debris. \200 Prostate. \200 Foreign body. \200 Ureterocoel e. Renal calci \201 cation \200 Calculi. \200 Dystrophic calci \201 cation due to locali zed disease: Infection. \200 Carcinoma. \200 Aneurysm. \200 Nephrocalcinosis: Medullary: hyperparathyroidism, renal tubular acidosis, medullary sponge kidney etc. Cortical: acute cortical necrosis, chronic glomerulonephritis, chronic transplant rejection. Testicular lesions Testicular masses \200 Germ cell tumors (GCTs): Seminoma: most common testicular tumor in adult. \200 Embryonal carcinoma: 20 \200\22325 % GCT. \200 Choriocarcinoma: rare. \200 Teratoma: 5 \200\22310 % . Non-germ cell tumors: usually benign. \200 Lymphoma or leukemia: may relapse in testis. \200 Metastases: kidney, prostate, bronchus, pancreas. \200 Orchitis. Extra testicular masses \200 Varicocoele. \200 Hydrocoele. \200 Hernia. \200 Testic ular torsion. \200 Epididymitis. \200 Epididymal cyst. \200 Scrotal trauma/oedema. Causes of hydrocoele \200 Congenital. \200 Infantile. \200 Secondary to trauma, infec tion, torsion, or neoplasm. SUBASH KC/NMC-15TH/2014 DILATED URETER 201 Adrenal calci \201 cation \200 Cyst. \200 Carcinoma: irregular, punctate calci \201 c ations. \200 Addison \200\231s disease. \200 Ganglioneuroma. \200 In \202 ammatory: TB/histoplasmosis. \200 Phaeochromocytoma. \200 Ureterocoele. Dilated ureter Obstruction Within the lumen: \200 Calculus. \200 Blood clot. \200 Slo ughed papilla. In the wall: \200 Oedema secondary to a stone. \200 Tumor. \200 TB. \200 Post surgi cal. \200 Ureterocoele. \200 Megaureter. Outside the wall: \200 Retroperitoneal \201 brosis. \200 Carcinoma (cervix, prostate, bladder, rectum). \200 Retrocaval ureter. \200 Pregnancy/postpartum. Other: \200 VUR. \200 Infection. SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 203 Chapter 15 Genitourinary presenting syndromes Acute pelvic pain 204 Chronic pelvic pain 206 Acute renal failure 207 Haematuria 208 Hydron ephrosis Hypertension 210 Intermenstrual bleeding 211 Postmenopausal bleeding 212 Testicula r pain 213 209 SUBASH KC/NMC-15TH/2014 204 CHAPTER 15 Genitourinary presenting syndromes Acute pelvic pain Acute pelvic pain is a common presenting complaint, especially in women. However, in addition to gynecological causes there are many other aetiologies: Causes Gynecological \200 Ectopic pregnancy. \200 Ovarian cyst: hemorrhage, torsion. \200 Hydrosalpinx. \200 Mittelschmertz. Urological \200 Renal colic. \200 Cystitis. \200 Acute urinary retention.