RADIOGRAPHIC PATHOLOGY OF THE HEAD AND NECK

Dr. Parish P. Sedghizadeh

Diplomate, American Board of Oral & Maxillofacial Pathology Assistant Professor, University of Southern California School of Dentistry and Center for Craniofacial Molecular Biolog y Division of Diagnostic Sciences; Orofacial Pain & Oral Medicine Center

Looking for abnormalities: Requires knowledge of normal anatomy first, what constitutes a good film or image, and why the imaging study is being done clinically.

Radiolucency , Opacity, or mixed

Differential Diagnostic process: Based on normal anatomy, then identifying abnormality as possibly an Odontogenic Cyst/Tumor, Neurovascular lesion, NonOdontogenic Cyst/Tumor, or other conditiondepending on the epicenter relationship to anatomic structures like the IA Canal.

Differential Diagnosis: Mandibular Radiolucencies Within the IA Canal

Neurovascular Lesion Benign:
Neurofibroma Neuroma Hemangioma

Malignant:
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Neurofibrosarcoma Neurogenic Sarcoma Angiosarcoma

Differential Diagnosis: Mandibular Radiolucencies Above the IA Canal (excludes infections

Odontogenic Cysts

Dentigerous (Developmental) Cyst

causing apical lesion)

Dentigerous Cyst (often contains crown of impacted tooth) Odontogenic Keratocyst (OKC) Lateral Periodontal Cyst Periapical Cyst Calcifying Odontogenic Cyst (COC)

Odontogenic Tumors
Ameloblastoma Adenomatoid Odontogenic Tumor Calcifying Epithelial Odontogenic Tumor (mixed lucency opacity) Odontoma (central opacification with peripheral lucency) Odontogenic Myxoma (multi-locular lucency)

Dentigerous (Developmental) Cyst

Dentigerous (Developmental) Cyst

Lateral Periodontal Cyst

Odontogenic Keratocyst

Odontogenic Myxoma

Residual Cyst

Calcifying Odontogenic Cyst

Odontomas (compound)

Odontoma (complex)

Periapical Cemento-Osseous Dysplasia

Differential Diagnosis: Mandibular Radiolucencies Below the IA Canal

Bone Tumors
Metastatic Carcinoma Osteosarcoma

Stafne Defect

Bone Cysts
Stafne bone defect (not a true cyst, but actually a salivary gland depression in the bone no Tx, follow) Traumatic Bone Cyst Aneurysmal Bone Cyst (ABC)

Bone Reactive / Inflammatory

Osteomyelitis Giant Cell Reaction

Size Difference?

Size Difference?

* Except for the Stafne defect, most of the lesions above often appear above the IA canal also, highlighting the fact that most lesions in the lower jaw occur above the IA canal.

Some small but important opacities

NO! CT scan or periodic radiographic evaluation

Sialolith

Idiopathic Osteosclerosis (formerly Condensing Osteitis )

Calcified (mineralized) Lymph Nodes (tuberculosis) Calcified (mineralized) Atherosclerotic Plaques of Carotid Artery

THE ROLE OF ADVANCED IMAGING IN DIFFERENTIATING BONE PATHOSES WITH OSTEOGENIC POTENTIAL, such as in cases demonstrating new periosteal bone formation

PERIOSTEAL REACTIONS IN THE FORM OF NEW BONE FORMATION

- Osteomyelitis
- (proliferative periostitis)

- Osteosarcoma - Metastatic Carcinoma - Langerhans Cell Disease

Periosteal Reactions
Varying etiopathogenesis Ranging from reactive to neoplastic Result is varying osteoblastic (forming) and osteoclastic (resorbing) activity physiologically/molecularly that is evident histopathologically also Demonstrates radiographic appearance likened to an onion-skin or hair-on-end pattern

Periosteal Reactions
Varying etiopathogenesis Ranging from reactive to neoplastic Result is varying osteoblastic (forming) and osteoclastic (resorbing) activity physiologically/molecularly that is evident histopathologically also Demonstrates radiographic appearance likened to an onion-skin or hair-on-end pattern

Periosteal Reactions
Clinically may demonstrate cortical osseous expansion, with or without tenderness depending on factors such as etiology and patients pain perceptions Definitive diagnosis may require clinical, radiographic, and histologic/ immunohistochemical correlation in many cases

Conditions in which new periosteal bone formation may be a feature

Osteomyelitis
- Proliferative Periostitis (Garrs)

Osteosarcoma Metastatic Carcinoma Langerhans Cell Disease

Osteomyelitis Proliferative Periostitis

Hypothesized that acute osteomyelitis, or inflammation of medullary bone, which is mainly lytic in nature, (from infection, trauma, etc) spreads to the periosteum Inflammatory cytokines then stimulate cortical resorption, while inflammatory exudate also lifts the periosteum and induces new bone formation which occurs parallel/lamellar to cortex, accounting for unique presentation

Osteosarcoma
Periosteal, Parosteal, and Gnathic in H&N Rare cases associated with Pagets disease and Cemento-Osseous dysplasia Radiolucent, radiopaque, or mixed radiographic appearance Lytic, loss of lamina dura, widening of PDL, destruction of adjacent structures, and ragged and ill-defined margins may be seen classically

Disrupted and disorganized periosteum may appear hair-on-end or sunburst Intact periosteum, more rarely, may show an onion-skin pattern, presumably mediated by molecular and chemical factors released from tumor cells and immune cells Bone Morphogenic Protein, Alkaline Phosphatase, Osteocalcin, Endothelin, and various growth factors

Metastatic Carcinoma
Variable radiographic appearance, with polymorphous shape and irregular, illdefined margins usually However, similar to previous conditions, metastatic carcinoma can also produce a periosteal reaction in the form of new bone formation, particularly prostate and breast cancers In vitro cell culture studies have shown prostatic acid phosphatase and its substrate -glycerophosphate stimulate calcification and osteogenesis in prostatic cases

Langerhans Cell Disease

Growing evidence indicates this is a neoplastic process, and many investigators favor malignancy of Langerhans cells as opposed to histiocytes (CD1a vs.CD68) Intraosseous lesions may result in radiographic appearance of teeth with unsupported bone, often termed teeth floating in space New periosteal bone formation similar to aforementioned inflammatory (cytokine) neoperiostosis may be a feature Mainly children and young adults affected

THE ROLE OF ADVANCED IMAGING IN DIFFERENTIATING BETWEEN BONE PATHOSES

CD1a stain

Langerhans cell disease

Copyright 2003, Elsevier Science (USA). All rights reserved.

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