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Moeller Pediatric Oral Cavity & Oropharyngeal Cases.Pptx No Disclosures Pediatric Oral cavity & Oropharynx Karen K. Moeller, M.D. Norton Children’s Hospital University of Louisville Pediatric Oral Cavity & Oropharynx Oral Cavity ! Imaging of pediatric oral cavity & oropharynx has particular challenges related to small patient size, frequent need for sedation and pathologies that are unique to children. ! Inflammatory, congenital and developmental lesions play a more predominant role and there is less concern for squamous cell carcinoma. ! The anatomy is well depicted in patients of all ages and sizes. Oral Cavity Oral Cavity Oral mucosal space Sublingual space Oral mucosal space Sublingual space Root of tongue Submandibular space Root of tongue Submandibular space Oral Cavity Oral Cavity Oral mucosal space Sublingual space Oral mucosal space Sublingual space Root of tongue Submandibular space Root of tongue Submandibular space Oral Cavity Tongue: Oral cavity Oral tongue-anterior 2/3rd Oral mucosal space Sublingual space Root of tongue Submandibular space Oral tongue Tongue: extrinsic muscles Palatoglossus Styloglossus Genioglossus Hyoglossus T1 T2 Amirsys Intrinsic tongue muscles Tongue: extrinsic muscles Tongue: extrinsic muscles Palatoglossus Palatoglossus Styloglossus Styloglossus Genioglossus Genioglossus Hyoglossus Hyoglossus Amirsys Amirsys Tongue: extrinsic muscles Tongue: extrinsic muscles Palatoglossus Palatoglossus Styloglossus Styloglossus Genioglossus Genioglossus Hyoglossus Hyoglossus Amirsys Amirsys Tongue: extrinsic muscles Tongue: extrinsic muscles Palatoglossus (CN 10) Styloglossus (CN 12) Genioglossus (CN 12) Hyoglossus (CN 12) Amirsys Genioglossus Tongue: extrinsic muscles Tongue: extrinsic muscles Palatoglossus Styloglossus Tongue: extrinsic muscles Root of tongue Hyoglossus Root of tongue Root of tongue Genioglossus Lingual septum Floor of mouth Floor of mouth Mylohyoid Mylohyoid Geniohyoid 13 month girl 12 year old boy Floor of mouth Sublingual space Geniohyoid Mylohyoid msc Sublingual space Sublingual space Hyoglossus msc Mylohyoid msc Sublingual space Sublingual space ! Glossopharyngeal ! Glossopharyngeal nerve nerve ! Lingual artery & vein ! Lingual artery ! Hypoglossal nerve ! Hypoglossal nerve ! Sublingual gland ! Sublingual gland ! Lingual nerve ! Lingual nerve ! Submandibular duct & ! Submandibular duct & deep gland deep gland Sublingual space Sublingual space ! Glossopharyngeal ! Glossopharyngeal nerve nerve ! Lingual vein ! Lingual artery & vein ! Hypoglossal nerve ! Hypoglossal nerve ! Sublingual gland ! Sublingual gland ! Lingual nerve ! Lingual nerve ! Submandibular duct & ! Submandibular duct & deep gland deep gland Sublingual space Sublingual space ! Glossopharyngeal ! Glossopharyngeal nerve nerve ! Lingual artery & vein ! Lingual artery & vein ! Hypoglossal nerve ! Hypoglossal nerve ! Sublingual gland ! Sublingual gland ! Lingual nerve ! Lingual nerve ! Submandibular duct & ! Submandibular duct & deep gland deep gland Sublingual space Sublingual space ! Glossopharyngeal nerve Sublingual gland ! Lingual artery & vein ! Hypoglossal nerve ! Sublingual gland ! Lingual gland ! Submandibular duct & deep gland 2 year old boy Sublingual space Sublingual space Lingual artery Lingual vein Floor of mouth/sublingual space Submandibular space Mylohyoid Mylohyoid msc Platysma Submandibular space Submandibular space ! Submandibular gland ! Facial vein and artery ! Submandibular l.nodes ! Anterior belly of digastric msc. ! Submental l. nodes Submandibular space Submandibular space ! Submandibular gland ! Submandibular gland ! Facial vein and artery ! Facial vein and artery ! Submandibular l.nodes ! Submandibular l.nodes ! Anterior belly of ! Anterior belly of digastric msc. digastric msc. ! Submental l. nodes ! Submental l. nodes Submandibular space Submandibular space ! Submandibular gland ! Submandibular gland ! Facial vein and artery ! Facial vein and artery ! Submandibular l.nodes ! Submandibular l.nodes ! Anterior belly of ! Anterior belly of digastric msc. digastric msc. ! Submental l. nodes ! Submental l. nodes Submandibular space Submandibular space Submandibular gland Submandibular nodes Submandibular space Submandibular space Anterior belly of digastric Submental nodes Oral mucosal space Retromolar Trigone Pterygomandibular Raphe Pterygomandibular Raphe Buccinator msc. Amirsys Amirsys Pterygomandibular raphe Pterygomandibular Raphe Buccinator msc. Superior pharyngeal constrictor msc. Superior pharyngeal constrictor msc. Amirsys Buccal space Plexiform neurofibroma 7 year old boy with right side swelling 7 year old boy with NF-1 Neurofibroma ! Schwann cells, 17 year old boy fibroblasts, perineural & mast cells ! Rare in absence of NF-1 ! Low attenuation on CT ! Plexiform neurofibroma: ! Elongated, from multiple nerve fascicles ! Usually nonresectable ! Risk for malignant transformation ! Target sign on MRI 7 year old boy SAM Meningioma Hypoglossal nerve motor denervation secondary to skull base meningioma 17 year old boy 17 year old boy Hypoglossal nerve motor denervation 3 year old boy with neck mass ! Asymmetry of tongue demarcated linearly ! Acute (< 1 month) ! ½ tongue swollen ! +/- enhancement ! Subacute (1-20 months) ! Loss of volume ! ↑ fat, ↓ enhancement ! Chronic (>20 months) ! Fatty atrophy ! No enhancement 17 year old boy Langerhans Cell Histiocytosis Langerhans Cell Histiocytosis ! Uncontrolled proliferation of Langerhans cells, eosinophils, +/- necrosis ! Peak age 1-3, boys>girls ! Most commonly affects bone ! Head & neck- lymph nodes, skin/soft tissues, salivary glands 3 year old boy 3 year old boy 3 year old boy with neck mass Nontuberculous Mycobacterial (NTM) Adenitis 3 year old boy Nontuberculous Mycobacterial (NTM) Nontuberculous Mycobacterial (NTM) Cervicofacial Adenitis Cervicofacial Adenitis ! Healthy children < 5 years ! Healthy children < 5 years ! Violaceous skin discoloration ! Violaceous skin discoloration ! Unilateral nontender mass ! Unilateral nontender mass ! Submandibular, parotid space ! Submandibular, parotid space ! Contiguous rim enhancing ! Contiguous rim enhancing lesions, skin involvement* lesions, skin involvement* ! Less fat stranding c/w ! Less fat stranding c/w bacterial adenitis* bacterial adenitis* *Robson CD, Hazra R, Barnes PD, et al. Nontuberculous *Robson CD, Hazra R, Barnes PD, et al. Nontuberculous mycobacterial infection of the head and neck in mycobacterial infection of the head and neck in SAM immunocompetent children: CT and MR findings. AJNR Am J SAM immunocompetent children: CT and MR findings. AJNR Am J Neuroradiol 1999; 20:1829 Neuroradiol 1999; 20:1829 Teeth Pre- Dentition ! Primary dentition #20 ! Quadrant- 2 incisors (central & lateral), 1 canine, 2 molars ! Permanent dentition #32 Anterior ! Quadrant- 2 incisors, 1 canine, 2 premolars, 3 molars ! Naming sequence ! Dentition-»jaw-»side »tooth name ! Primary maxillary left central incisor Newborn Primary Dentition Primary Dentition 9 months 3 years Mixed Dentition Mixed Dentition 8 years 8 years Permanent Dentition Permanent Dentition 21 years 15 years 2 year old girl with right upper lip swelling Periapical Abscess 2 year old girl Periapical Rarefying Osteitis Periapical Rarefying Osteitis ! Loss of bone density ! Loss of bone density surrounding apex of surrounding apex of devitalized tooth devitalized tooth ! Material (inflammatory ! Material (inflammatory or bacterial) in pulp or bacterial) in pulp canal decompress canal decompress into periapical bone into periapical bone ! Periapical cyst, ! Periapical cyst, granuloma or abscess granuloma or abscess 2 year old girl 12 year old girl 3 month old girl with gum swelling Melanotic Neuroectodermal Tumor of Infancy 3 month old girl Melanotic Neuroectodermal Tumor of Infancy Oropharynx ! Infants < 1year ! Maxilla >> calvarium, mandible, CNS ! Fibroblasts, epithelial and neuroblastic cells ! Can have ossification ! Early resection is important 2 month old girl Oropharynx Oropharynx Circumvallate papillae Anterior tonsillar pillar Nasopharynx w/ palataglossus msc. Oropharynx Hypopharynx Oropharynx Oropharynx Soft palate with uvula Oropharynx Oropharynx Lingual tonsil Base of tongue - posterior 1/3rd Oropharynx Oropharynx Palatine tonsil Posterior pharyngeal wall 3 year old girl with fever Tonsillopharyngitis Tonsillopharyngitis ! Enlarged tonsils, +/- adenoid/lingual tonsil ! Striated enhancement ! Majority viral ! Group A streptococcus (GAS)- 30% age 5-15 ! Suppurative complications- abscess 5 year old boy ! Nonsuppurative complications- rheumatic fever, 3 year old girl glomerulonephritis Tonsillar Abscess Tonsillar Abscess ! Polymicrobial ! Polymicrobial ! * Group A streptococcus ! * Group A streptococcus ! Other aerobe, anaerobe ! Other aerobe, anaerobe ! Rim enhancement & ! Rim enhancement & central low attenuation central low attenuation 17 year old girl 11 year old girl 17 year old boy with throat pain and fullness Peritonsillar Abscess ! Polymicrobial ! * Group A streptococcus ! Other aerobe, anaerobe ! Abcsess extends outside of tonsil 15 year old girl Uvular Hydrops Uvular Edema ! Uvular Hydrops: ! Trauma, irritants ! Allergic reaction, angioedema (Quincke’s disease) ! NSAIDS, ACE inhibitors ! Idiopathic ! Uvilitis: ! Infection- Group A strep & haemophilus influenzae Uvular Hydrops 17 year old boy 17 year old boy 12 year old boy 12 year old boy Which statement is true regarding Plexiform Neurofibroma: References: A) Plexiform neurofibromas are hyperdense compared 1. Vijapura C, Aldin ES, Moritani T, et al. Genetic Syndromes Associated with Central Nervous System Tumors. Radiographics
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