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 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 to muscle on noncontrast CT. 2017;37:258-280 B) Plexiform neurofibromas are commonly seen in 2. Dombi E, Baldwin A, Widemann C, et al. Activity of Selumetinib patients with NF-2. in Neurofibromatosis Type 1- Related Plexiform Neurofibromas. N Engl J Med 2016; 375:2550 C) Plexiform neurofibroma can have a target 3. Aribandi M, Wood WE, Weiss DL, et al. CT Features of Plexiform appearance on T2WI. Neurofibroma of the Submandibular Gland. AJNR 2006; D) Once diagnosed, plexiform neurofibromas are 27:126-128 easily cured with surgical resection.

Plexiform Neurofibroma Nontuberculous Mycobacterial (NTM) Neurofibromas are benign tumors composed of schwann cells , infection in children: nonneoplastic fibroblasts, mast cells, macrophages, endothelial cells, pericytes and perineural cells. Subtypes of neurofibromas include cutaneous, subcutaneous, spinal and diffuse plexiform. A) only affects immunocompromised patients. Plexiform neurofibromas are seen in the setting of Neurofibromatosis-1, B) can present as a cervicofacial adenitits. not Neurofibromatosis -2, and are encountered in 20-50% of NF-1 patients. These lesions carry a lifetime risk of malignant transformation. Plexiform Contiguous ring enhancing lesions, skin neurofibromas are often present at birth and can enlarge during childhood involvement and minimal stranding of surrounding or young adulthood. They are distinguished from other neurofibromas by their involvement of multiple nerve fascicles, hypervascularity, growth fat are imaging characteristics. along the length of the nerve, and extension into surrounding structures, D) has a predilection for the oropharynx and all features rendering them challenging to resect. Several nonsurgical therapeutic options are under investigation, the most promising of which is sublingual space. selumetinib, an oral drug that inhibits mitogen-activated protein kinase E) presents clinically with palpable bilateral neck kinase enzymes (MEK 1 & 2). Neurofibromas including plexiform neurofibromas, have low attenuation at CT imaging. AT MR plexiform masses, high fever and normal skin examination. neurofibromas are infiltrative, serpentine, transpatial lesions, with variable contrast enhancement. The target sign is often seen, characterized by central T2 hypointensity surrounded by T2 hyperintensity. Nontuberculous Mycobacteria (NTM) The genus Mycobacterium is composed of more than 100 species characterized by an acid fast staining property due to complex lipid-rich cell References: walls. Obligate mycobacterium pathogens include Mycobacterium Tuberculosis and Mycobacterium Leprae. The other species , collectively 1. Lindeboom JA, Smets AM, Kuijper EJ, et al. The sonographic known as nontuberculous mycobacterium (NTM), live freely in the characteristics of nontuberculous mycobacterial cervicofacial environment. lymphadenitits in children. Pediatr Radiol 2006; 36:1063-1067 In adults, NTM can cause pulmonary disease, other focal infections, and 2. Robson CD, Hazra R, Barnes PD, et al. Nontuberculous disseminated disease, especially in patients with immunosupression or mycobacterial infection of the head and neck in underlying lung disease. immunocompetent children: CT and MR findings. AJNR Am J In children, NTM manifests as a cervicofacial lymphadenitis, affecting Neuroradiol 1999; 20:1829-1835 patients under the age of 5 who are otherwise healthy. The majority of these infections are caused by MAI complex ( mycobacterium intracellulare and mycobacterium avium). These patients present with violaceous skin discloration overlying a unilateral cervical lymphadenopathy involving submandibular ( 87%), preauricular (9%) or submental (3%) nodes. Imaging in these children is characterized by contiguous ring enhancing lesions with minimal stranding of surrounding fat.