By : Isti Hadinata

HEAD AND NECK

Infrahyoid space
visceral space

Extends from the hyoid to the anterior

mediastinum and does not extend into the
suprahyoid space.
The CT section is at the level of the
supraglottic larynx and the thyroid cartilage.
Anterior to the thyroid cartilage are the
'strap' muscles:
sternothyroid, sternohyoid, thyrohyoid and
omohyoid .
Laryngocele
 Chondrosarcoma:
irregular calcifications as in all
malignant cartilage tumors.
Paraganglioma:
hypervascular lesion and this
lesion only has enhancing walls.
Schwannoma:
a rare lesion at this location and
we would expect a more solid
looking appearance, while this
lesion is completely cystic.
Multinodular Goiter
The thyroglossal duct
Runs from the base of tongue at the
foramen caecum to the thyroid
gland.
Normally, the thyroglossal duct
then involutes, but when the duct
persists, a thyroglossal duct cyst
can develop anywhere along this
tract (figure).
The location is in the midline or
paramedian.
65% are located infrahyoidal, 20%
suprahyoidal and 15% at the level of
the hyoid.
Ddx:
necrotic anterior cervical nodes and
thrombosed jugular vein.
Thyroglossal duct cyst
Thyroglossal duct cyst
Paramedian thyroglossal duct
cyst
This lesion not in the midline,
but the key finding is that this
lesion is cystic and embedded in
the strap musculature.
This lesion is located between the internal and external carotid artery and therefore is a
neural tumor. The differential diagnosis is limited to tumors arising from the vagus nerve
and sympathetic plexus. On CT and color doppler the mass is clearly hypervascular and
the only possible diagnosis is a paraganglioma.
Paraganglioma/ glomus tumor

Also called carotid body tumor.

Multiple in 4% of patients.
25% have a positive family
history.
Intense enhancement on CT and
MR.
Flow voids are frequently
present.
Best diagnostic clue
o Vascular mass splaying ECA and ICA
o Mass centered in crux of carotid bifurcation
o Typically unilateral; bilateral in 5-10%
o Circumferential contact of tumor to ICA predicts
surgical classification
Type I: < 180
Type II:> 180 and< 270
Type III:> 270
CT Findings
NECT
o Lobular mass splaying ECA and ICA
o Density similar to muscles
CECT
Avidly enhancing mass in crux at bifurcation between ECA and ICA
Extends cephalad from carotid bifurcation
Dynamic enhancement is rapid compared to nerve sheath tumors
and other masses
CTA
o Oblique sagittal reconstruction shows enhancing tumor in "Y" of
carotid bifurcation
 TlWI
o Mass signal similar to muscle
o "Salt & pepper" appearance in larger legions
"Salt"
Secondary to subacute hemorrhage
Uncommon finding of limited diagnostic value
"Pepper"
Hypointense serpentine or punctate vascular channels show
flow void
- Expected finding in tumors > 2 cm
 T2WI : Mildly hyperintense, signal higher
than muscle
TlWI C+
Intense rapid dynamic enhancement
Larger high-velocity flow voids still visible
Angiographic Findings
Splaying of ICA & ECA on early arterial
images
Prolonged, intense tumor blush
Arteriovenous shunting creates "early vein
phenomenon
Ascending pharyngeal artery is typical arterial
feeder
Angle of bifurcation predicts resectability
o Splaying > 90 indicates less easily resected
Second branchial cleft cyst

Key facts
95% of all branchial cleft anomalies arise
from the second branchial cleft.
Most common presentation: cyst, sometimes
in combination with a sinus or fistula.
Infection indicated by increased density,
septations and wall thickening.
Second branchial cleft cyst
Retropharyngeal abscess
MRI
T1: central low to
intermediate signal
T2: central high signal
T1 C+ (Gd): peripheral
enhancement
DWI: increased values,
indicative of restricted
diffusion
Retropharyngeal edema
Lymphangioma
Key facts
Benign non-capsulated lesion arising from expanding
embryonic lymph 'lakes' that do not develop normal lymphatic
drainage.
90% in children 10% in young adults.
May occur anywhere in the head and neck. Mostly located in
posterior cervical space.
T1WI : depends on protein content
T2WI : High signal
Hemorrhage results in rapid growth and fluid-fluid levels as
seen on MR.
Lymphoma
Sarkoma
Extra
 Paraganglioma of the Head and
Neck
They are divided according to location:
1. Carotid body tumour (or chemodectoma)
1. located at the carotid body, and splaying the carotid bifurcation
2. most common paraganglioma of the head and neck (60-67% of total)
2. Glomus tympanicum tumour
1. arise from the glomus tympanicum
2. confined to the middle ear overlying the cochlear promontory
3. arises from the inferior tympanic branch of glossopharyngeal nerve (CN IX)(or Jacobson's nerve)
4. second most common head and neck paraganglioma
3. Glomus jugulotympanicum tumour
1. arising from the glomus jugulotympanicum
2. extending between the cochlear promontory and jugular foramen
3. arising from Arnold's nerve, the mastoid branch of the vagus nerve (CN X)
4. Glomus jugulare tumour
1. arising from the glomus jugulare
2. confined to the jugular foramen
3. extending into the middle ear
5. Glomus vagale tumour
1. arising from the glomus vagale associated with vagus nerve (CN X)
2. least common head and neck paraganglioma
 Most commonly from the paraganglia within :
The carotid body
Vagal nerve
Middle ear
Jugulare foramen

GT : Glomus Tympanicum
GJ : Glomus Jugulare
GV : Glomus Vagale
CBP : Carotid Body Paraganglioma
Diagram of the Jugular fossa adjacent to the
middle ear.
Jacobson nerve (J), a branch of the
glossopharyngeal nerve.
Arnold nerve (A), a branch of the vagus nerve.
Glomus tympanicum occur along Jacobson nerve
in the middle ear adjacent to the coclear
promontory (CP).
Glomus Jugulare along Jacobson or Arnold nerves
within Jugular fossa.
Glomus tympanicum tumour

1. Arise from the glomus tympanicum

2. Confined to the middle ear overlying the
cochlear promontory, NOT involving the j
ugular foramen.
3. Arises from the inferior tympanic branch of
glossopharyngeal nerve (CN ix)(or jacobson's
nerve)
4. Second most common head and neck
paraganglioma
5. Pulsatile tinnitus,female
Best diagnostic clue
CT: Mass with flat base on cochlear promontory projecting
into mesotympanum.
MR: Focal enhancing mass with flat base on cochlear
promontory
Best imaging study: Bone-only CT without contrast
Floor of middle ear cavity is intact (if dehiscent, glomus
jugulare)
Differential Diagnoses
Glomus jugulare paraganglioma
Aberrant internal carotid artery
Dehiscent jugular bulb
Axial non-contrast
There is lobulated soft tissue in hypotympanum of right middle ear.
Glomus jugulotympanicum tumour

Definitions
Paraganglioma involving both the Jugular foramen
and middle ear cavity.
Jugular foramen mass extends superiolaterally into
the floor of the middle ear cavity
Best diagnostic clue
Mass in JF with "permeative-destructive" change of
adjacent bone on CT
Multiple black dots ("pepper") in tumor mass indicating
high-velocity flow voids from feeding arterial branches on
MR
CT Findings
NECT
o Poorly defined soft tissue mass centered over ]F

CECT
o Diffuse, intense enhancement

Bone CT
o Permeative-destructive bone changes along superolateral margin of JF mark
extent of tumor
jugular spine erosion is common
Vertical segment of petrous ICA posterior wall often dehiscent
Mastoid segment of facial nerve may be engulfed
o Mimics malignancy
MR Findings
TlWI
Lesions > 2 cm demonstrate characteristic "salt &pepper" appearance
T2WI
Mixed hyperintense mass with hypointense foci (" pepper")
TlWI C+
o Intense enhancement is characteristic
o Delineates tumor extent in skull base & middle ear
o Tumor may extend intraluminal within internal jugular vein or
sigmoid sinus
o Coronal: May show tongue of tumor curving up from ]F, through
middle ear floor, terminating on cochlear promontory
Glomus jugulare tumour

2nd most cmmon head and neck

paraganglioma
Mass arising from the Jugular foramen and
NOT involving the middle ear.
Arising in the Jugular foramen from the
tympanic branch (Jacobson nerve) of the
glossopharyngeal nerve or the auricular brach
(Arnold nerve) of the vagus nerve
 Imaging characteristic :
Bone CT demonstrates a mass in the Jugular foramen with permeative-
destructive changes of adJacent bone.
T1WI greater than 2 cm demonstrates characteristic salt and pepper
appearance
T2WI shows mixed hyperintense mass with flow foids
Intense enhancement
Computed tomography scan demonstrates a permeative destructive skull-
base mass with involvement of the mastoid air cells.
Axial contrast-enhanced T1-weighted
magnetic resonance image shows an
enhancing right skull-base mass
Selective external carotid angiogram
demonstrates a vascular skull-base mass.
Glomus vagale tumor

1. Arising from the glomus vagale associated with vagus

nerve (CN X)
2. Least common head and neck paraganglioma
3. Carotid space
4. Avidly enhancing mass in nasopharyngeal carotid
5. space centered - 2 em below jugular foramen
o Displaces carotid anteromedially
o Displaces jugular vein posterolaterally
o Displaces parapharyngeal fat anterolaterally
o Displaces styloid process laterally
6. Serpentine or punctate flow voids ("pepper") on MR
7. Hyperintense on T2WI and STIR
Differential Diagnoses
Carotid space schwannoma
Carotid space neurofibroma
Carotid space meningioma
Carotid body paraganglioma
Glomus vagale tumor.
Contrast-enhanced computed tomography scan demonstrating a large vascular
mass along the course of the left internal carotid artery and jugular vein above
the level of the carotid bifurcation