DIAGNOSTIC IMAGING TECHNIQUES

Diagnostic imaging is an essential element in the evaluation of many otolaryngologic problems. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most commonly used imaging modalities, with positron emission tomography (PET) playing an ever-increasing role.

COMPUTED TOMOGRAPHY
CT scanning uses ionizing radiation to generate cross-sectional images based on differences in the xray attenuation of various tissues. Modern scanners are typically helical, meaning that x-ray source rotation and patient translation occur simultaneously; this results in the acquisition of a "volume" of data that is then partitioned and reconstructed into individual slices. Helical scanning is significantly faster than traditional slice-by-slice acquisition, thereby diminishing artifacts related to motion (eg, breathing, swallowing, and gross patient motion). The rapid data acquisition also allows for more and thinner slices to be obtained, which facilitates diagnosis by decreasing partial-volume averaging effects and allows for improved quality of multiplanar reconstructions. The most recent advance in CT imaging has been the introduction of "multislice" scanners. Multislice scanners have a variable number of parallel arcs of detectors that are capable of simultaneously acquiring volumes of data. The increased speed that results from multislice sampling can be traded for improved longitudinal resolution, an increased volume of coverage, or an improved signal-to-noise ratio. CT scanning of the head and neck is ideally performed with thin sections, usually 3 mm, in the axial

plane. Direct coronal imaging or coronal reformations are useful in some situations, notably in imaging of the paranasal sinuses and the skull base. CT scanning of the neck is usually performed following injection of iodinated contrast material because opacification of vessels helps to separate them from other structures such as lymph nodes and also helps to delineate and characterize pathology. If bony anatomy is the focus of the imaging study, as in imaging of the paranasal sinuses or temporal bones, then intravenous contrast material is not required.

MAGNETIC RESONANCE IMAGING

MRI exploits differences in tissue relaxation characteristics and spin density to produce an image that is exquisitely sensitive to soft tissue contrast. Depending on the parameters that are selected, variable tissue characteristics and contrast are produced. At least two different types of sequences in two planes are generally necessary to characterize lesions of the head and neck. The slice thickness should be no more than 5 mm. A gadolinium-based contrast agent is generally used to enhance the detection of pathology and improve tissue characterization, and also to aid in the generation of a differential diagnosis. In some circumstances, thinner sections covering a smaller anatomic area may be necessary for more precise diagnosis. In the head and neck, the following imaging sequences are typically obtained: (1) sagittal, axial, and coronal T1-weighted images; (2) axial fast spin-echo T2-weighted images with fat saturation; and (3) axial and coronal postgadolinium T1-weighted images with fat saturation. Additional planes may be useful in some circumstances, such as coronal fast spin-echo T2-weighted images with fat saturation for the assessment of paranasal sinus and anterior skull base pathology. Additional sequences such as magnetic resonance angiography (MRA) may be useful in certain circumstances (eg, paragangliomas and dural fistulas), but are not necessary for evaluating most processes of the head and neck. MR venography may be useful in the assessment of patients with

pulsatile tinnitus and in the assessment of the patency of the sigmoid sinus in patients with adjacent neoplastic or inflammatory disorders. Advanced modalities in widespread use in the brain (eg, MR spectroscopy, diffusion-weighted imaging, functional MR imaging) have for the most part not found a place in routine head and neck imaging, with the exception of diffusion-weighted imaging in the evaluation of epidermoid cysts and cholesteatomas. On a T1-weighted image, fat is bright and fluid (eg, cerebrospinal fluid [CSF]) is relatively dark. Muscle and most pathologies are of intermediate signal intensity. The large amount of fat in the head and neck provides intrinsic tissue contrast, which makes the T1-weighted image very sensitive to infiltrative processes that obliterate tissue planes or that replace marrow fat (Figure 31). Some hemorrhagic or proteinaceous lesions cause shortening of T1 relaxation time and appear bright on a T1-weighted image. On a T2-weighted image, fluid is very bright and most pathologies are relatively bright, whereas normal muscle is quite dark. The fast spin-echo technique is very useful in limiting artifacts related to motion and magnetic susceptibility compared with conventional spin-echo T2weighted imaging. Because fat remains bright on a fast spin-echo image, however, fat saturation should ideally be applied. In the nasal cavity and paranasal sinuses, T2-weighted images are particularly useful in distinguishing neoplastic masses from polyps, thickened mucosa, and retained secretions (Figure 32). Gadolinium is very useful for demonstrating pathology and tailoring a differential diagnosis based on enhancement characteristics. In a patient with head and neck cancer, postgadolinium imaging is also very useful in assessing cavernous sinus invasion, meningeal infiltration, and perineural spread of tumor (Figure 33). Fat saturation should ideally be applied on a postgadolinium T1-weighted image; otherwise, the contrast between an enhancing lesion and the high signal intensity of surrounding fat may actually be reduced compared with the pregadolinium image. Because low-field scanners often do not have fat saturation capability, high-field imaging (1.5 T) is generally preferred for assessing the head and neck and skull base. If a patient is severely claustrophobic, sedation may be necessary to accomplish the scan on a high-field system.
Figure 31. Add to 'My Saved Images' Axial T1-weighted image. Note the high signal intensity of subcutaneous fat and the marrow of the central skull base. Infiltrative neoplasm replaces normal fat in the right pterygopalatine fossa, the vidian canal, and portions of the sphenoid body (black arrowheads). The normal left pterygopalatine fossa (PPF) and vidian canal (VC) are indicated. A maxillary sinus polyp (P) is incidentally noted.

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Coronal fast spin-echo T2-weighted image with fat saturation (FS). Note the high signal intensity of the vitreous humor of the ocular globe, the high signal intensity of the CSF, and the lack of signal from subcutaneous fat. In this patient with squamous cell carcinoma, the intermediate signal intensity tumor (mass) stands in contrast to the very high signal intensity of edematous mucosa and retained secretions (M) in the left maxillary sinus and the mildly high signal intensity of the inferior turbinates (IT).

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Coronal T1-weighted image, postgadolinium, with fat saturation. Note the vitreous humor is dark as in a T1-weighted image, but subcutaneous and orbital fat are also dark due to fat suppression. The high signal intensity of the nasal mucosa, as well as the enhancement of vessels and extraocular muscles, indicates that gadolinium has been given. In this patient with a history of squamous cell carcinoma of the gingivobuccal sulcus and new chin numbness, the abnormal enlargement and enhancement of V3 in the inferior alveolar canal is seen (white arrow), consistent with perineural spread of tumor. The contralateral normal canal is also indicated (white arrowhead). View Large

It should be kept in mind that MRI requires more time and more patient cooperation than does CT, and therefore it is not necessarily suitable for acutely ill or uncooperative patients. In addition, there are certain absolute contraindications to MRI, including ferromagnetic intracranial aneurysm clips, cardiac pacemakers, and many cochlear implants. Therefore, patients must be carefully screened for these and other contraindications before undergoing MRI.

POSITRON EMISSION TOMOGRAPHY

PET provides a functional view of tissues rather than simply depicting anatomy. In the head and neck, it is used primarily for oncologic diagnosis and evaluation and is performed with the radiopharmaceutical
18

F-fluorodeoxyglucose (FDG). FDG is taken up into tissues in proportion to the

glycolytic rate, which is generally increased in neoplastic processes. Focal asymmetric uptake is suggestive of a tumor but is nonspecific, since FDG is also concentrated in areas of inflammation. FDG PET scanning is particularly helpful in the following situations: (1) the search for an unknown primary lesion in a patient presenting with metastatic neck disease (Figure 34), (2) the assessment of residual or recurrent disease after primary therapy, and (3) the search for synchronous or metachronous primary lesions or distant metastases. FDG PET scanning can also be useful for staging the neck, but there may be a significant number of false-negative studies in patients with clinically N0 necks because small tumor deposits (approximately 13 mm) are generally not detectable on an FDG PET scan. These small tumor deposits are found if a neck dissection is performed. At present, most FDG PET scanning is done on dedicated PET-CT scanners, such that precise anatomic localization of FDG uptake can be achieved.
Figure 34. Add to 'My Saved Images' Axial FDG PET image in a patient presenting with metastatic cervical adenopathy and no primary site visible on clinical examination or MRI. A large focus of activity (black arrow) is related to known level II lymphadenopathy, and a smaller focus of activity (black arrowhead) is suspicious for a primary site at the right base of the tongue. This was confirmed by panendoscopy and biopsy. The photopenic mandible (Ma) is indicated for orientation.

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IMAGING THE HEAD & NECK

SPATIAL ANATOMY OF THE HEAD & NECK

The spaces of the suprahyoid head and neck are defined by the three layers of the deep cervical fascia: the superficial, middle, and deep layers. The spaces so defined include the pharyngeal mucosal space, the parapharyngeal space, the masticator space, the parotid space, the carotid space, the retropharyngeal space, and the perivertebral space. The infrahyoid neck has traditionally been clinically defined by a series of surgical triangles, but can also be described as a series of fasciadefined spaces, which facilitates the understanding and interpretation of cross-sectional imaging modalities such as CT and MRI. The spaces of the infrahyoid neck are also defined by the three layers of the deep cervical fascia and include the superficial space (external to the superficial layer of the deep cervical fascia), the visceral space (including the thyroid gland, the larynx, and the esophagus), the carotid space, the retropharyngeal space, and the perivertebral space. The nasal cavity, paranasal sinuses, skull base, and temporal bone are considered unique subregions of the head.

Mucosal Disease of the Head & Neck

For mucosal disease of the head and neck, of which squamous cell carcinoma (SCC) is by far the dominant lesion, the traditional subdivisions are the nasopharynx, oropharynx, oral cavity, larynx, and hypopharynx. The pharyngeal mucosal space includes the nasopharynx, oropharynx, and hypopharynx.

NASOPHARYNX
Anatomy
The nasopharynx is bounded anteriorly by the posterior nasal cavity at the posterior choana; posterosuperiorly by the lower clivus, upper cervical spine, and prevertebral muscles; and inferiorly by a horizontal line drawn along the hard and soft palates (Figure 35). The lateral wall of the nasopharynx is composed of the torus tubarius, the eustachian tube orifice, and the lateral pharyngeal recess, also known as the fossa of Rosenmller (Figure 36). In addition to squamous mucosa, the contents of the nasopharynx include lymphoid tissue (adenoids), minor salivary glands, the pharyngobasilar fascia, and the pharyngeal constrictor muscles. The pharyngobasilar fascia represents the aponeurosis of the superior constrictor muscle and attaches it to the skull base. A gap in the upper margin of the pharyngobasilar fascia is known as the sinus of Morgagni. The distal eustachian tube and levator palatini muscle normally pass through this gap, which also serves as a potential route of spread for nasopharyngeal carcinoma to access the skull base.
Figure 35. Add to 'My Saved Images' Midline sagittal T1-weighted image indicates the bony and soft tissue anatomy related to the nasopharynx (NP), with the approximate inferior margin of the nasopharynx indicated by the horizontal white line. Indicated are the adenoids (A), clivus (C), C2 vertebral body (C2), sphenoid sinus (SS), soft palate (SP), hard palate (HP), and pituitary gland in the sella turcica (white arrowhead).

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NONMUCOSAL DISEASE OF THE HEAD & NECK

SPATIAL APPROACH TO THE SUPRAHYOID & INFRAHYOID HEAD & NECK

The terminology used to describe the traditional pharyngeal subdivisions of the head and neck is best suited to the assessment and staging of SCC. Because nonsquamous masses tend to spread within fascia-defined spaces, the head and neck can also be viewed as a series of deep spaces, an approach that facilitates an analysis of cross-sectional imaging of the head and neck. To simplify the discussion, the extracranial head and neck are divided into supra- and infrahyoid compartments because fascial attachments to the hyoid bone functionally cleave this region into two segments.

Suprahyoid Head & Neck

The spaces of the suprahyoid head and neck are defined by the three layers of the deep cervical fascia: superficial (investing), middle (buccopharyngeal), and deep (prevertebral). The spaces defined by these three fascial layers are shown diagrammatically in Figure 350.
Figure 350. Add to 'My Saved Images' Diagrammatic representation of the fascia-defined spaces of the suprahyoid neck at the level of the nasopharynx. The dashed line represents the deep layer of deep cervical fascia, also known as the prevertebral fascia. The dotted line represents the middle layer of deep cervical fascia, and the thick solid line represents the superficial layer of deep cervical fascia, also known as the investing fascia. The heavy solid line outlining the pharyngeal mucosal space represents the pharyngobasilar fascia, which connects the superior constrictor muscle to the skull base. PMS, pharyngeal mucosal space; PPS, parapharyngeal space; MS, masticator space; PS, parotid space; CS, carotid space; RPS, retropharyngeal space; PVS, perivertebral space; BS, buccal space. (Note that the buccal space does not represent a true fascia-defined space, but is often considered as a distinct space for the purposes of anatomic localization and differential diagnosis.) (Modified and reproduced, with permission, from Harnsberger HR. CT and MRI of masses of the deep face. Curr Probl Diagn Radiol 1987;16:141.)

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Pharyngeal Mucosal Space

The pharyngeal mucosal space has complex fascial margins and is not completely circumscribed by the three layers of deep cervical fascia. This space is bounded by the middle layer of deep cervical fascia along its posterolateral margin, whereas on its luminal or airway side, it has no fascial boundary. The most important components of the pharyngeal mucosal space are the squamous mucosa, the lymphoid tissue of the Waldeyer ring, the minor salivary glands, and the pharyngeal constrictor muscles. The dominant pathology in this space is SCC and the pharyngeal mucosal space, divided into its traditional subdivisions of nasopharynx, oropharynx, larynx, and hypopharynx, was reviewed previously.

Parapharyngeal Space
The parapharyngeal space (PPS) is a central, fat-filled space of the deep face that is frequently displaced by masses of the surrounding spaces (Figure 351). Assessing the center of a deep facial mass relative to the PPS and observing the direction in which this mass displaces the fat of this space indicates the site of origin of a mass of the head and neck and helps to tailor a differential diagnosis. The PPS is defined medially by the middle layer of the deep cervical fascia and borders the pharyngeal mucosal space. Laterally, it is defined by the superficial layer of deep cervical fascia and borders the