High-Resolution Computed Tomography of the Paranasal Sinuses, Pharynx and Related Regions

Home , Hals (crater), Handel (crater), Infratemporal space, Lateral nasal cartilage, Nasal concha, Paranasal sinuses

HIGH-RESOLUTION COMPUTED TOMOGRAPHY OF THE PARANASAL SINUSES, PHARYNX AND RELATED REGIONS

Impact of CT-identification on diagnosis and patient-management Aan Map Aan mijn ouders HIGH-RESOLUTION COMPUTED TOMOGRAPHY OF THE PARANASAL SINUSES, PHARYNX AND RELATED REGIONS

Impact of CT-identification on diagnosis and patient-management

Hoge resolutie computertomografie van de sinus paranasales, pharynx en aangrenzende gebieden. Invloed van CT-identificatie op diagnostiek en therapie

(met een samenvatting in het Nederlands)

PROEFSCHRIFT

Ter verkrijging van de graad van Doctor in de Geneeskunde aan de Rijksuniversiteit te Utrecht. Op gezag van de Rector Magnificus Prof. Dr. J.A. van Ginkel. Volgens besluit van het College van Decanen in het openbaar te verdedigen op dinsdag 9 September 1986, des namiddags te 2.30 uur.

door

Gertrude Maatman geboren op 21 december 1938 te Nijverdal

1986 MARTINUS NIJHOFF PUBLISHERS a member of the KLUWER ACADEMIC PUBLISHERS GROUP DORDRECHT / BOSTON / LANCASTER Promotor: Prof, dr P.F.G.M. van Waes Co-promotor: Prof, dr L.A. Ravasz Referent: Prof, dr J. Vignaud CONTENTS

Acknowledgements

1. Introduction

2. Technique 2.1 Equipment 2.2 Scanogram 2.2.1 Purposes 2.2.1.1 Patient positioning and repositioning 2.2.1.2 Registration of slice positions 2.2.1.3 Diagnostic use of the scanogram 2.3 Positioning 2.4 Field of view and diameter of scanned area 2.5 Technique factor selection 2.6 Contrast media

3. Anatomy 9 3.1 Introduction 9 3.2 Nasal cavity 9 3.3 Paranasal sinuses 11 3.3.1 Frontal sinus J] 3.3.2 Ethmoid sinus 11 3.3.3 Maxillary sinus 11 3.3.4 Sphenoid sinus 11 3.4 Pharynx 13 3.4.1 Nasopharynx 13 3.4.2 Oropharynx 15 3.4.3 Hypopharynx 15 3.5 Oral cavity 15 3.5.1 Floor of the mouth and tongue 15 3.6 Spaces 15 3.6.1 Parapharyngeal space 15 3.6.2 Retromaxillary space 17 3.6.2.1 Infratemporal fossa 17 3.6.2.2 Pterygopalatine fossa 17 3.6.2.3 Pterygoid fossa 19 3.6.3 Submandibular space 19 VIII

3.7 Parotid gland 3.8 Lymphatic drainage of the head and neck

4. CT-identification 4. Axial sections 4. Nose, nasal cavity, nasopharynx, paranasal sinuses 4. . 1 Level of frontal sinus 4. .2 Level of nasal bone and orbit 4. .3 Level of maxillary sinus, retromaxillary space, upper part of nasopharynx and parapharyngeal space 4. .4 Nasopharynx 4. .5 Parapharyngeal space 4. .6 Parotid gland 4. .2 Oropharynx, oral cavity, tongue and floor of the mouth, hypopharynx 4. .3 Identification of lymph nodes on the axial sections 4.2 Coronal sections

5. Pathology of paranasal sinuses 5.1 Introduction 5.2 Review of the literature 5.3 Patients and methods 5.4 Results 5.5 Discussion 5.6 Illustrative patients and pathology 5.7 Conclusions

6. Pathology of pharynx, nasal and oral cavity 131 6.1 Introduction 131 6.2 Review of the literature 131 6.3 Patients and methods 133 6.4 Results 135 6.5 Discussion 136 6.6 Illustrative patients and pathology 137

6.7 Conclusions 163

7. Summary and conclusions 165

Subject Index 167

Samenvatting en conclusies 173

Curriculum Vitae 174 IX

ACKNOWLEDGEMENTS

This work was performed in the Department of Radiodiagnosis of Utrecht University Hospital, Utrecht, the Netherlands. The author wishes to thank Professors Ravasz and Van Waes for their support and enthusiasm during the writing of this thesis. She would also like to thank Prof, dr J. Vignaud, University of Paris, for her critical comments on the manuscript. She is very grateful to her tutors. Prof, dr A.C. Klinkhamer and Prof, dr C.B. A.J. Puylaert, and their associates for their confidence during the training period and for the hospitality which they provided afterwards, through which it became possible to finish this work. Many thanks are also due to Dr John A.M. de Groot, who spent so much time discussing a large number of patients, to Dr H. Barrowclough, who, voluntarily, undertook to correct the text, and to Mrs Barbara de Witt-Caspers, Instituut Schoevers, Arnhem, who typed the text with great care. She is also indebted to Mr F.W. Zonneveld M.Sc, who provided valuable advice on the principles of CT. The author is also grateful to the photographers Mr Jan de Groot, Mr Marcel Metselaar and Mr Joop Ramaekers for their help in the realization of all the photographs presented, and Miss Ingrid C. Janssen, illustrator, who took care of the drawings (and the coordinates on the CT images) with dedication and accuracy. She would like to thank Mrs Dr C. Verheyen-Voogd and Mrs M. de Nooij-van de Linden, who enabled her to collect reference material. Finally, the author is very grateful to all who followed the proceedings of this work with interest, as- sistance and moral support.

Oosterbeek, May 1986. Gertrude Maatman Chapter 1.

INTRODUCTION

After the first clinical examination in 1971 especially for E.N.T. specialists, dental surgeons with computerized axial scanning (tomography) of and radiotherapists. the human brain (G.N. Hounsfield, J. Ambrose), After a brief description of the examination very rapid development of this radiological tech- technique (Chapter 2), the normal anatomy of the nique took place. In the beginning, the first scanner paranasal sinuses, pharynx and related regions is (EMI) was restricted to examination of the brain. A described (Chapter 3). Subsequently, we attempted prototype body scanner was then developed and in to identify organs and structures on the normal CT 1974 the first patient was examined. After many re- images in the axial as welt, as the coronal plane servations with regard to the usefulness of whole (Chapter 4). Finally, we attempted to determine body CT, it soon became an integral part of radio- how often CT provided more diagnostic informa- logical armamentarium. The first publications con- tion than clinical examination, and whether CT in- cerning CT examination of the paranasal sinuses fluenced patient management. For this, 134 pa- appeared in about 1976, and soon it proved that CT tients were examined with pathological processes of could provide valuable complementary informa- paranasal sinuses, and pharynx, nasal or oral cavi- tion in clinical examination, especially in deter- ty. The results of this examination are discussed in mining the extension of a pathological process into Chapters 5 and 6. These chapters also present a the soft tissues. Since the soft tissues could not be number of illustrative patients. This study is princi- exactly visualized by the existing radiological tech- pally concerned with the pharynx and paranasal si- niques, we were interested in determining the influ- nuses. The larynx was excluded from this study\ ence of CT examination on patient management, Chapter 2.

TECHNIQUE

2.2 Scanogram (CT-survey radiograph, scoulview, 2.1 Equipment topogram. Deltaview. etc.)

In 1977, the first 2nd generation CT-scanners A scanogram is obtained by moving the table were installed in the Department of Radiology of with the patient into the gantry, while the X-ray the University Hospital in Utrecht. The Philips To- tube and detectors remain stationary. moscan 200 was replaced in 1979 by a third generation scanner (Tomoscan 300) and in the beginning 2.2.1 Purposes of 1982 a Tomoscan 310 was installed. Our material contains predominantly images from the Philips 2.2.1.1 Patient positioning and repositioning Tomoscan. The location of the scan can be determined on the basis of anatomical radiological landmarks. The angulation angle can be chosen from the lateral scanogram (fig. 2.1) in order to avoid dental fillings

Figure 2.1. Registration of the slice positions. A. In the axial plane, supine position. B. In the coronal plane, prone position. Figure 2.2. A. Position for direct coronal CT of the head and neck. The patient is sealed at the rear of ihe gantry. A silaslic shei prevents slipping. (Courtesy: P.F.G.M. van Waes and F. Zonneveld. J. Comput. Assist. Tomogr. 6 (l):55-68,1982). B. Direct coron; CT scan in a patient with a large ameloblastoma of the right mandible (see also Chapter 5. figure 5.8).

Figure. 2.3. Position for direct sagittal scanning. (Courtesy: R. Bluemm: Neuroradiology (1982) 22:199-201). 5

or metal prostheses and to approach the optimal in- The prone position can be impossible for pa- clination of the coronal plane. tients suffering from a pathologic process com- pressing the airway. In these patients, and in pa- 2.2.1.2 Registration of slice-positions tients with pathologic changes caudal to the hyoid Since slice positions are known with respect to bone I therefore recommend, direct coronal CT ac- the scanogram, use can be made of this information cording to the technique described by Van Waes to mark these positions on the scanogram. This is (9). The patient is positioned sitting in the cone on relevant for the recognition of anatomical details the rear of the gantry, while reclining slightly back- on the scans and for repositioning of the patient for wards. In this way the head, neck and upper part of a follow-up examination. In planning radiation the chest can be positioned in the scan plane (fig. therapy, this can also be used to document the pa- 2.2). This is possible only with equipment which has tient mould or cast (10). This is achieved by taping a large and wide patient aperture cone. pieces of angiographic catheter, or other radio- Direct sagittal scanning (1.2.3.6.7) proves to opaque material to the skin, connecting the tatoo- be useful for demonstrating all anatomical struc- marks. The catheter will show up as small white tures in the sagittal plane. This is especially impor- dots on the skin in the CT image. tant in hypophyseal and posterior fossa pathology. In our material, it was helpful in determining the 2.2.2.3 Diagnostic use of the scanogram extent of tumor of hard and soft palate, orbital In special cases, the advantages of the scano- floor, floor of mouth and tongue. Bluemm (3) con- gram can be put to diagnostic use: i.e. examination cludes that direct sagittal scanning has a number of requiring a low dose or to avoid further examina- advantages over reconstructed views, for example: tion when the patient has to be scanned anyway. fewer number of scans, smaller overall radiation dose to the patient, total information of one section available immediately after the examination with- 2.3 Positioning out additional processing, better understanding of the topography since the entire skull is imaged. The patient is first placed in the supine posi- Very important is the better image quality due to tion. For scans in the axial plane the gantry is tilted the lack of partial volume averaging and lack of in such a way that the scan plane becomes parallel misregistration artefacts which patient movement to the orbito-meatal line (Reids base-line). This is a causes in multiplanar reformated images. In sagit- line joining the outer canthus of the eye to the cen- tal scanning we used the procedure as described by tral point of the external auditory meatus. Some Bluemm (fig. 2.3). The patient is positioned in a authors prefer the neuro-ocular plane: that is, 10 to semi-prone/semi-left or right decubitus position on 15 degrees to the orbito-meatal line. This plane par- an inclined plane at the back of a fast whole body allels the optic nerve and is defined by the line join- scanner with the arms extended backwards close to ing, the attachment point of the superior part of the the body. The head lies on a device fixed to the auricle to the scalp with the inferior orbital margin. head-rest of the table top which brings the sagittal plane of the head parallel to the scan plane and al- In patients with a pathologic process, images lows for scan plane indexing. Both the gantry and in the coronal plane are indispensable. The patient sagittal head holding device are tilted 20 degrees is positioned prone, and the gantry is tilted in such forward in order to minimize the sideways flexion a way that the scan-plane becomes about perpendi- of the neck. cular to the plane of the orbito-meatal line. As this is not always possible, for instance in case of a stiff neck, we try to adjust the plane. Adjusting the plane is also necessary in patients with dental fil- 2.4 Field of view and diameter of scanned area lings to avoid artefacts. Prone positioning for direct coronal CT is not useful for pathologic pro- It is preferable that the scanned area be adjust- cesses beyond the hyoid bone. Due to flexion of the ed to the field of interest. This provides optimal neck more or less axial views will be obtained. spatial resolution with a minimum dose to the pa- B

Figure 2.4. Direct geometrical magnification technique. Coronal scan at the level of paranasal sinuses. A. Field of View (FOV) 32(1 cm. B. Field of View I FOV) 240 cm.

Figure 2.5. Intravenous contrast medium administration. Axial scan at the level of the alveolar process of the maxilla (two different patients). A. Without contrast medium. B. With intravenous contrast administration. Note numerous liny vessels, internal carotid a. (arrow) and internal jugular v. (arrow head). tient. This can be achieved by making use of the so- used. However, for interesting details in the body, called direct geometrical magnification technique such as the spinal column, small fields of view can (Target-CT): i.e. moving the X-ray tube as near as also be applied (Target scan). possible to the patient and always making full use Short scan times are used for uncooperative of the total detector array (fig. 2.4). patients and long scan times when a high dose is re- In order to make full use of the available spa- quired and the part of the patient to be examined tial resolution, the size of the reconstructed image can be easily immobilized. (Field of View: FOV) should be adapted to the ma- Many different kinds of convolution filters are trix size (pixel-size limitation). This can be achieved available, some have edge enhancement character- by using zoom reconstructions, i.e. after defining istics (special type of bony details) and some have the region of interest by means of a square, an im- smoothing characteristics (soft tissues with small age can be reconstructed based on the original raw contrasts). The exact degree of smoothing or edge data. The pixel-size may not limit the spatial resolu- enhancement is often a matter of personal taste: it tion, therefore the most optimal pixel-size is half is therefore important to be able to choose from a the spatial resolution. Suppose that the spatial reso- large number of possibilities. In our application the lution is 0.5 mm (T 310) then for optimal spatial standard "ramp" (random accessed memory pro- resolution a pixel-size of 0.3 mm is suggested. Elec- cedure) filter which has neither smoothing nor edge tronic enlargement on the viewing console does not enhancement, fulfilled our needs best. The proto- add more information but may facilitate pattern cols which we have applied are described in the rele- recognition. vant chapters.

2.5 Technique factor selection 2.6 Contrast media

Selecting the optimal technique from a series Intravenous bolus injection of water-soluble of available combinations is a difficult procedure contrast media can be applied to differentiate small that must be performed carefully. We have chosen lymph nodes from blood vessels and in this way for grouping of technique factors in protocols, in- blood vessels encased in infiltrating growth can be cluding patient preparation, handling and position- highlighted (fig. 2.5). The use of rapid sequence ing. The protocols were designed to suit different scanning (6-10 slices per minute) reduces the clinical requests. The radiologist can select a certain amount of contrast medium needed. Enhancement combination of protocols according to the clinical of tumor parenchyma and metastases might occur data and his own findings. Such a clinical situation even when a considerable amount of time has could be a carcinoma of the maxillary sinus with ex- elapsed after the injection of the contrast medium. tensive infiltration of the orbit, neck and lymph More recently, we use a rapid-drip infusion or i.v. node involvement of the upper mediastinum. For bolus injection to detect pathological lymph nodes bony details, thin slices are selected and the images (4.5.8). are viewed using wide windows. For soft tissues, the slice-thickness depends on the size of anatomical detail to be visualized (partial volume averaging), References and for reconstruction of perpendicular slices over- lapping or consecutive thin slices are used, or, when 1. Anderson RE: Third panel discussion. The ideal head scan- possible, the patient should be scanned directly in ner. V-360-CT scanner (Varian): Direct (positional) sagittal the desired plane. Nowadays we find that a slice scanning. Neurology 16: 535, 1978 thickness of 1.5 and 6 mm slice increments com- 2. Anderson RE, Koehler RR: An accessory table for multidi- bined with i.v. bolus injection is optimal. rectional CT scanning. Radiology 130: 802-803. 1979 3. Bluemm R: Direct sagittal (positional) computed tomogra- The field of view is adapted to the object size phy of the head. Neuroradiology 22: 199-201, 1982 and this also applies to the focal spot size. For high 4. Mancuso AA, Maceri D, Rice D, Hanafee W: CT of cervical resolution in small objects, a small focal spot is lymph node cancer. AJR 136: 381-385, 1985 5. Mancuso AA, Harnsberger MD, Muraki AS: Computed to- 129: 81-87, 1978 mography of cervical and retropharyngeal lymph nodes: 8. Reede DL, Bergeron RT: CT of cervical lymph nodes. Th( normal anatomy, variants of normal application in staging J. of Otolaryngol. 11:6, 1982 head and neck cancer. Radiology 148: 709-714, 1983 9. Waes van PFGM, Zonneveld FW: Direct coronal bod; 6. Mondello E, Savin A: Technical note. Direct sagittal com- computed tomography. J. Comput. Assist. Tomogr. 6 puted tomography of the brain. J: Comput. Assist. 58-68, 1982 Tomogr. 3: 706-708, 1979 10. Zonneveld FW: Computed Tomography. Published bj 7. Osborn AG, Anderson AE: Direct sagittal computed tomo- Philips Medical Systems. 1983 publication nr. 4322984534 graphic scans of the face and paranasal sinuses. Radiology 41 Chapter 3.

ANATOMY

3.1 Introduction the sphenoid, and inferiorly by the horizontal plate of the palatine bone. A brief description of the anatomy of the nasal The nasopharynx is the upper part of a U- cavity, paranasal sinuses, pharynx and neighboring shaped or semi-cylindrical cavity with a muscular subdivisions is given to support the interpretation wall. This cranial subdivision is continuous caudal- of the CT-images (1,2,3,4). ly with the oropharynx behind the oral cavity and The major part of the viscero-cranium is with the hypopharynx behind the larynx. The phar- formed by the bones constituting the nasal cavity ynx is continuous with the esophagus. The nasal and paranasal sinuses. The latter are air-containing cavity is divided into right and left halves by the na- cavities in bones such as the frontal, maxillary, sal septum. This septum consists of three parts: the sphenoid and ethmoid bones. They all drain into septal cartilage anteriorly, vomer and perpendicu- the nasal cavity. lar plate of ethmoid posteriorly. Anteriorly, the nasal cavity extends into the nostrils which are bounded medially by the nasal septum and laterally by the 3.2 Nasal cavity alae of the nose. The upper part of the nose is sup- ported by the nasal bone and frontal process of the The nasal cavity is topographically situated be- maxilla. The lower part has a hyaline cartilagenous low the anterior cranial fossa, between the orbits framework, consisting of a septal cartilage and the and the large maxillary sinuses, and lying cranial to lateral cartilages. A greater alar cartilage, often ac- the oral cavity. The nasal cavity is bordered lateral- companied by several smaller ones, lies below the ly by the maxilla with its sinus. The upper part of lateral alar cartilages (fig. 3.1). the lateral wall is completed by the ethmoid laby- Three shell-shaped structures, the conchae, are rinth which is situated above the maxilla. It con- situated on the lateral wall of the nasal cavity with tains the ethmoid sinuses as well as the frontonasal their meat uses below them. The superior and mid- duct of the frontal sinus. Its roof is formed by the dle conchae are portions of the ethmoid bone, cribriform plate of the ethmoid bone, which separ- whereas the inferior concha is a separate bone for ates it from the anterior cranial fossa, which is con- the most part attached to the maxilla. To assist the tinuous with the body of the sphenoid bone (fig. understanding of CT-scans, it should be mentioned 3.1). The floor consists mainly of the hard paiate. that they also have a ventro-dorsal orientation Posteriorly, the nasal cavity is separated from the whereby the superior concha lies most dorsally. The oral cavity by the soft palate. Cranioposteriorly, most cranially situated olfactory region of the nose the body of the sphenoid, with its sinuses, forms is supplied by fibers of the olfactory nerve (II). The part of the roof of the nasal cavity. This is contin- main, sensible innervation derives from the oph- ued by the anterior part of the occipital bone, which thalmic and maxillary nerves, the latter by way of proceeds to the roof of the pharynx. The connec- the pterygopalatine ganglion. The arterial supply is tion to the pharynx is formed by two oval openings: provided mainly from the sphenopalatine artery, the choanae. They are limited laterally by the me- which is a branch of the maxillary a. and gives rise dial pterygoid plate of the pterygoid process and to rr. nasales post., sup., med. and inf. and ante- medially by the vomer, superiorly by the body of riorly the ethmoidal arteries. The veins form a 10

frontal bone frontal sinus

perpendicular plate of ethmoid frontal process of maxilla lacrimal bone superior concha nasal bone inferior concha middle concha lateral nasal cartilage hiatus semilunaris; inferior concha -alar cartilage medial pterygoid anterior nasal spine

pterygoid hamulus maxilla

Figure 3.1. Lateral wall of nasal cavity.

frontal sinus nasal bone ethmoid sinus

maxillary sinus

Figure 3.2. Diagram of paranasal sinuses. 11

plexus beneath the mucosa and, in general, accom- 3.3.3 Maxillary sinus pany the arteries. The maxillary sinus is part of the maxilla. The tuber maxillae separates the maxillary sinus from 3.3 Paranasal sinuses the pterygopalatine fossa and infratemporal fossa. The sphenopalatine opening with the greater pala- At birth, the paranasal sinuses are small or un- tine artery and nerve is located posterior to the max- developed: the frontal sinuses invade the frontal illary sinus. Anteriorly, the sinus wall is formed by bone after birth, and become visible radiographi- the facies anterior maxillae and a part of the face, cally between 3 and 7 years of age; by the age of fif- with the infra-orbital opening for the nerve and ves- teen, they reach the roof of the orbit. sels. The medial wall forms the main part of the lateral wall of the nasal cavity. The lateral wall consists of the tuber maxillae. The roof of the maxillary 3.3.1 Frontal sinus sinus corresponds with the floor of the orbit. The floor of the maxillary sinus is partly located above The frontal sinuses are present between the in- the alveolar processes of the maxilla, about 1 cm be- ner and outer tables of the frontal bone, above and low the level of the hard palate (= floor of the na- behind the superior orbital margin and the nasal sal cavity). bone. These sinuses are paired structures and separated by a central bony septum (fig. 3.2). They vary greatly in size and shape. The communication 3.3.4 Sphenoid sinus of the frontal sinus with the nasal cavity is realized by the frontonasal duct and its extension, the eth- The sphenoid sinuses, located in the body of moidal infundibulum, which drain into the hiatus the sphenoid bone, are surrounded by important semilunaris of the middle meatus (fig. 3.1). Supe- structures such as brain, vessels, nerves and the pit- riorly, the frontal sinus may be closely related to the uitary gland. The sphenoid sinus varies in size and orbit and anterior cranial fossa, depending on its is divided into a right and a left portion by a bony pneumatization. The upper margin has a wavey ap- septum, which usually deviates to one side. At pearance, which may become smooth if pressure, birth, the sphenoid sinuses are present as minute for example from a mucocele, develops. cavities. The main development takes place at puberty. The sphenoid sinus is bounded laterally by the dura enclosed cavernous sinus, containing the 3.3.2 Ethmoid sinus internal carotid artery, with its sympathetic plexus, the oculomotor, trochlear, abducens, ophthalmic The ethmoid sinuses are located in the eth- and maxillary nerves (III, IV, VI and VI nerves). moidal labyrinth, which lies between the orbit and Superiorly, the sphenoid sinus is bounded by the the nasal cavity, above the maxilla and in front of sella, containing the pituitary gland surrounded by the palatine bones. The ethmoid sinus is divided in- dura, and the optic chiasma anteriorly. In front,'the to small parts by thin bony septae, forming the eth- sphenoid sinus forms the superior border of the an- moidal cells. The division into anterior and poste- terior cranial fossa. In front and below lie the nasal rior ethmoidal cells is based on their openings into cavity and nasopharynx. In the frontal wall, the the middle and superior meatus respectively. The sphenoid sinus opens through an orifice into the vulnerability of the orbit in pathological processes spheno-ethmoidal recess of the nasal cavity. Behind of the ethmoid sinus results from the fact that these the sphenoid sinus lies the basal part of the occipital structures are separated only by a thin wall (lamina bone. papyracea). The openings of the frontal, sphenoid, ethmoid and maxillary sinuses and lacrimal duct are located in the lateral wall of the nasal cavity. The opening of the sphenoid sinus can be found in the 12

right choana ,salpingopalatinc fold orifice of Eustachian tube middle concha torus tubarius salpingo pharyngeal fold . pharyngeal tonsil .pharyngeal recess

nasal vestibule

uvula

palatoglossal arch palatine tonsil retropharyngcal palatopharyn geal arch space atlantooccipital genioglossus m. ligament geniohyoid m mylohyoid m hyoid bone hyospiglottic ligament

Figure 3.3. Pharynx: nasal and oral cavity. Median Section. (Modified after Pernkopf).

Pharyngeal tubercle foramen lacerum Pharyngobasilar membrane carotid canal

petrosal bone

spine of sphenoid temporal m. pharyngeal recess lateral pterygoid m. styloid process Eustachian process orifice of Eustachian tube tensor palati m pharyngobasilar membrane salpingopharyngeal m. stylohyoid m palatopharyngeal m. medial pterygoidm. superior constrictor m. styloglossus m uvula hamulus of pterygoid levator pharyngeal m medial pterygoid m middle constrictor m. palatoglossus m tongue and lingual tonsils pharyngoeptglottic m. hyoid bone stylohoid ligament hyoepiglottic ligament thyroid cartilage thyrohyoid ligament inferior constrictor m.

Figure 3.4. Posterior view of pharyngeal and palatine muscles. Note the presence of pharyngobasilar membrane, which has been partially reflected. (Modified after Pernkopf). 13

spheno-ethmoidal recess, which is located above yngeal m. (fig. 3.3). The torus levatorius is pro- and behind the superior concha. The superior mea • duced by the levator palati m. and descends from tus receives the openings of the posterior group of the mouth of the auditory tube to the soft palate. ethmoidal cells, since it lies more dorsally. The eth- The salpingo-palatine fold is located in front of the moidal bulla is located in the middle meatus, with torus levatorius. The auditory tube, which connects the hiatus semilunaris below and in front of it. The the tympanic cavity with the nasopharynx, de- hiatus semiluminaris receives the openings of the scends from the tympanic cavity posterolaterally to maxillary and frontal sinus and anterior ethmoidal the nasopharynx inferomedially, and consists of an cells (fig. 3.1). The long, narrow frontonasal duct osseous posterior third and a cartilagenous and may open into the ethmoidal infundibulum, or di- membranous anterior two thirds. This cartilage- rectly into the inferior meatus. The nasolacrimal nous part of the tube remains closed except during duct drains into the middle meatus. The bony can- swallowing or yawning. Posteriorly, the nasophar- al, in which the duct lies, is formed by the maxilla, ynx is related to the longus capitis and longus colli lacrimal bone and inferior concha. m., lying in front of the upper cervical vertebrae. The paranasal sinuses are supplied by branches The pharynx is lined by a mucous membrane, which of the ophthalmic and maxillary arteries and is continuous with the mucous membranes of nasal, nerves. The lymphatic drainage occurs through the oral and laryngeal cavities and the auditory tubes. smaller lymphatic stations in the retropharyngeal The muscular layer is enveloped in a fibrous coat and parapharyngeal spaces, the parotid area and which separates it from the mucosa internally and submandibular space and flows to the deep cervical from deeper structures externally. The pharyngo- lymphatic system, which in turn drains into the ju- basilar fascia or membrane is a thickened part of gular trunk. this fibrous coat. The fascia is attached to the base of the skull and the auditory tube (fig. 3.4). The pharyngobasilar fascia serves to limit deformation of the nasopharynx. The fibrous coats of the phar- 3.4 Pharynx ynx consist posteriorly of a median raphe, which is anchored above to the pharyngeal tubercle on the basilar part of the occipital bone. The muscular 3.4.1 Nasopharynx coat consists of the levator and constrictor muscles (fig. 3.4), and two inner and one outer levator m. The nasopharynx and nasal cavity are both The external fascial coat covers the buccinator and components of the respiratory system. The roof pharyngeal muscles and is therefore named the buc- and posterior boundary of the nasopharynx is copharyngeal fascia. formed by the posterior part of the sphenoid body and the basal part of the occipital bone. The pha- Other important fasciae are the cervical fas- ryngeal tonsil is embedded in the mucous mem- ciae, which can be divided into a superficial layer, brane on the posterior wall (fig. 3.3). The opening a pretracheal layer and a prevertebral layer. The su- of the auditory tube is visible in the lateral wall of perficial layer surrounds the trapezius m., covers the nasopharynx above the soft palate. This open- the posterior triangle of the neck, surrounds the ing is located behind the level of the inferior concha sternocleidomastoid and roofs the anterior tri- and the torus tubarius or tubal elevation, which is angle. The prctracheal layer is limited to the front produced by the cartilagenous part of the auditory of the neck and extends between the omohyoid tube, and which forms the upper border. The phar- muscles. The prevertebral layer covers the vertebral yngeal recess is located behind and above the torus muscles and partly covers the superior cervical tubarius and is bounded medio-posteriorly by the ganglion (sumpathetic), which lies behind the inter- longus capitis m. and latero-anteriorly by the leva- nal carotid a. and in front of the longus capitis m. tor palati m. The salpingo-pharyngeal fold de- at the level of the transverse processes of C2 and scends from the posterior part of the torus to the C3. The prevertebral layer is attached to the base of pharyngeal wall and is produced by the salpingo- the skull and to the transverse processes of the cer- pharyngeal m., which in turn joins the palatophar- vical vertebrae. 14

tensor palati M levator palati spine of sphenoid pharyngobasilar membrane styloid process superior constrictor m digastric m palatine tonsil (posterior belly] styloglossus m stylohyoid ligament hyoglossus m stylopharyngeal m middle constrictor m genioglossus m slylohyoid and digastric m geniohyoid m inferior constrictor m

digastric m (anterior belly) oesophagus mylohyold m

Figure 3.5. Muscles of the tongue, floor of the mouth and pharynx. Lateral view. (Modified after Pernkopf). 15

3.4.2 Oropharynx 3.5.1 Floor of the mouth

The oropharynx which is the middle part of the The tongue has a tip, a dorsum, an inferior sur- pharynx, extends from the junction of the hard and face and a root. Part of the dorsum is in the oral soft palate to the level of the floor of the valleculae. cavity, while the posterior part extends into the The anterior wall, the glosso-epiglottic area, is oropharynx. This is the base of the tongue. The formed by the base of the tongue, valleculae, and tongue consists of intrinsic and extrinsic muscles anterior lingual surface of the epiglottis. Tonsillar (fig. 3.5) (table 3.1). The latter are bilateral and di- fossa, tonsils, palatoglossal and palatopharyngeal vided by the medial Fibrous lingual septum. These arches and glossotonsillar sulci form the lateral wall extrinsic muscles original? outside the tongue in (fig. 3.3). The superior wall includes the inferior contrast to the intrinsic muscles. The tongue rests surface of the soft palate and uvula. Posteriorly the on the floor of the mouth, which is formed by the oropharynx is limited by the mucosal lining of the mylohyoid and geniohyoid muscles and the anterior pharyngeal wall. The retropharyngeal space, the belly of the digastric muscles (table 3.1) (page 17). prevertebral muscles and the cervical vertebra can The mylohyoid m. forms the oral diaphragm and is be seen behind the pharynx. the most important structure of the floor of the mouth (fig. 3.5). The genioglossus m. are paired and separated by the fibrous lingual septum. They 3.4.3 Hypopharynx form the main bulk of the tongue and originate from the inner side of the mandible (mental spine) The hypopharynx is located between the pha- and insert in the dorsum of the tongue. The hyo- ryngoepiglottic folds and the lower level of the cri- glossus and styloglossus muscles are paired struc- coid cartilage, where the cervical part of the eso- tures lateral to the genioglossus. phagus begins. The piriform sinuses (or recesses) are part of the hypopharyngeal cavity and are situated between the quadrangular membrane. They 3.6 Spaces extend vertically from the level of the pharyngo- epiglottic fold to the beginning of the cervical part As well as cavities such as the nasal and oral of the esophagus. cavities and their adnexa, and the pharyngeal cavity, spaces or spatia can be distinguished, which contain important structures, for example, the internal 3.5 Oral cavity carotid artery and internal jugular vein. Important spaces are the parapharyngeal space, the retromax- The oral cavity is divided into two parts: the illary space, and the submandibular space. vestibule and the oral cavity proper. The vestibule is the cleft between the lips and cheeks externally, and teeth and gums internally. The roof and floor 3.6.1 Parapharyngeal space are formed by the mucous membrane of the bucco- alveolar sulci. The oral cavity proper is bounded The parapharyngeal space presents as a funnel- laterally by the teeth, while the tongue and floor of shaped space with its base located at the base of the the mouth form the inferior border. The roof is skull, enclosing the jugular foramen and carotid formed by the hard palate. Posteriorly, the oral foramen and with its apex at the level of the greater cavity is limited by the oropharyngeal isthmus, horn of the hyoid bone (5,6,2). The medial bound- which is bounded laterally by the palatoglossal ar- ary is formed by the wall of the pharynx. Posterior- ches, inferiorly by the posterior part of the tongue ly, the space is limited by the prevertebral fascia. and superiorly by the soft palate. Anterolaterally, the space is bounded by the medial pterygoid m. and posterolaterally by the deep part of the parotid gland. The styloid process divides the space into a prestyloid and a retrostyloid compart- 16

Figure 3,6. Retro-maxillary space. Lateral view of skull (slightly rotated), infratemporal fossa (large arrow), pterygoid fossa (sm arrow), inferior orbital fissure (arrow head), pterygopalatine fossa (small arrow head). Clivus (C). 17

Table 3.1. cally, it is advisable to consider thes e three regions as one (9). Origin Insertion A. Floor of the mouth 3.6.2.1 Infratemporal fossa diagastric m. - posterior belly mastoid notch on hyoid bone The infratemporal fossa is located behind the temporal bone maxilla and below the infratemporal surface and crest of the greater wing of the sphenoid. The me- - anterior belly body and greater digastric fossa dial boundary is formed mainly by the lateral ptery- horn of hyoid mandible goid plate of the sphenoid and the maxilla. Lateral- ly, the infratemporal space is limited by the coro- mylohyoid m. mylohyoid line of median tendinous mandible raphe noid process and the ramus of the mandible and the (internal surface) hyoid bone deep part of the parotid gland. Cranially, there is communication with the temporal fossa. The tem- geniohyoid m. mental spine body of hyoid bone poral m. and deep temporal vessels and nerves tra- B. Extrinsic muscles of the tongue verse these two spaces. Posteriorly the infratempor- genioglossus m. mental spine inferior aspect of al space extends into the parapharyngeal space. tongue/body of Lateral from it the parotid gland is situated. Cau- hyoid bone dally its contents join the parapharyngeal space. hyoglossus m. greater horn and inferior aspect of Medially the pterygopalatine fossa is connected body of hyoid the tongue with the infratemporal fossa via the pterygomaxil- bone Iary fissure. Anteriorly it extends along the maxilla and buccinator m. into the buccal space. The infra- stylogtossus m. front of styloid side and inferior temporal fossa contains the pterygoid muscles, the process and aspect of tongue pterygoid venous plexus, the mandibular nerve (i.e. stylomandibular ligament lingual nerve) with the chorda tympani, the inferior alveolar n. and the motor branches for the muscles palatoglossus m. palatine side of tongue of mastication, and the otic ganglion. The maxil- aponeurosis lary artery crosses the infratemporal fossa and en- C. Intrinsic muscles of the tongue No bony attachment ters the pterygopalatine fossa through the pterygomaxillary fissure. The inferior orbital fissure provides a pathway for the infra-orbital nerve and vessels, the inferior orbital vein and zygomatic nerve. ment. The retrostyloid compartment contains the carotid sheath and Xth nerve. The prestyloid compartment contains connective and adipose tissue. 3.6.2.2 Pterygopalatine fossa The pterygopalatine fossa is located posterior to the maxilla with its sinus, and anterior to the pte- 3.6.2 Retromaxillary space rygoid process of the sphenoid bone, medial to the infratemporal fossa and lateral to the nasal cavity. The retromaxillary space is situated posterior The space is bounded laterally by the pterygomaxil- to the maxilla, caudal to the sphenoid bone, lateral lary fissure through which it communicates with the to the pharynx and medial to the mandible (fig. infratemporal fossa (fig. 3.S). The medial wall is 3.6). The space includes three closely related re- formed by the perpendicular plate of the palatine gions: bone, since the pyramidal process of the palatine - infratemporal fossa bone lies between the pterygoid process and maxilla - pterygopalatine fossa more oralwards. The sphenopalatine foramen is lo- - ptsrygoid fossa cated in the medial wall. The foramen provides They are related to the pharynx medially, the communication between the pterygopalatine fossa maxilla anteriorly, the mandible laterally and the and the nasal cavity. The superior boundary is greater wing of the sphenoid bone superiorly. Clini- formed by the body of the sphenoid bone. Inferior- 18

anterior lingual gland carunculasublim submandibular duct sublingual gland mylohyoidm — digastric m s ubmandibular submandibular gland

Figure 3.7. Major salivary glands: Parotid, submandibular and sublingual gland. Lateral view. (Modified after Pernkopf). 19

Table 3.ff. bends around the hamulus to pass medially to the Openings Connected with Structures soft palate. The medial pterygoid plate gives attach- pterygopalatine ment to the pharyngobasilar fascia and superior fossa constrictor, and to the cartilagenous part of the infra-orbital orbit infra-orbital n. auditory tube, which rests in a groove on the medial fissure and vessels, zy- pterygoid plate. Portions of the medial and lateral gomatic n., inf. pterygoid muscles arise from the fossa and from the ophthalmic lateral surface of the lateral pterygoid plates. The vein medial pterygoid m. inserts into the medial surface for. rotundum + middle cranial maxillary nerve of the angle of the mandible. The lateral pterygoid can. rot. fossa m. inserts partly into the capsula of the temporomandibular joint and partly into the anterior part pterygoid or middle cranial major and prof, of the mandibular neck. Vidian canal fossa via petros n. and foramen artery lacerum 3.6.3 Submandibular space lesser and greater oral cavity palatine palatine canals nerves + arteries The submandibular triangle is bounded by the pterygo-maxillary infra-temporal maxillary artery inferior border of the mandible and the two bellies fissure fossa and veins of the digastric m. The submandibular space, bounded by the posterior bellies of the digastric m., spheno-palatine nasal cavity rr. nasales post., the hyoid bone, the inferior border of the mandible foramen sup., lat., and and mylohyoid m., is situated medial to this tri- med.; sphenopalatine art. angle. The submandibular space contains the submandibular gland, some supra-hyoid muscles, the lingual and facial a. and lymph nodes. The subnian- ly the space narrows into the palatine canals. The dibular gland consists of a superficial part or body pterygopalatine fossa contains the parasympalhetic and a deep process, which is the smallest part of the pterygopalatine ganglion and the maxillary nerve, gland. The superficial part is located in the digastric which enters the fossa via the foramen rotundum, triangle below the mylohyoid m. and is continuous whereas the maxillary artery enters laterally. They with the deep process, which lies upon this muscle supply the deep facial structures and the nose via (fig. 3.7) after curving around the posterior border the sphenopalatine foramen. The pterygopalatine of the mylohyoid m. The superficial part is covered fossa is an important communication center (9,6). inferiorly by the skin, platysma and fascia colli su- It communicates with the middle cerebral fossa, the perficialis, and is closely related to the facial vein orbit, the infratemporal fossa, the nasal and oral and submandibular lymph nodes. The deep part is cavities, and the pharynx by way of foramina, bony bounded laterally by the mandible. Medially it is re- canals and/or fissures (table 3.II). lated to the mylohyoid and hyoglossus m. The submandibular duct, which emerges from the deep 3.6.2.3 Pterygoid fossa process of the gland has a nearly horizontal course, and is located between the mylohyoid and hyoglos- The pterygoid fossa is located between the lat- sus m. It extends anteriorly and opens into the oral eral and medial pterygoid plate of the pterygoid cavity, lateral to the frenulum, producing the sub- process. These plates extend downwards from the lingual papilla. The duct is crossed by the lingual n. greater sphenoid wings. The lower end of the me- The suprahyoid muscles, i.e. digastric, mylohyoid, dial pterygoid plate is prolonged and forms the stylohyoid and geniohyoid muscles have been de- pterygoid hamulus. The scaphoid fossa is a depres- scribed earlier. They connect the hyoid bone to the sion in the medial pterygoid plate and gives origin base of the skull and the mandible. to a part of the tensor palati m. This muscle descends sagittally along the pterygoid plate and 20

3.7 Parotid gland Table 3.111. Lymph node groups of the head and neck Classification according to Rouviere The parotid gland is closely related to the in- 1. Occipital fratemporal and temporal spaces. It is located ante- 2. Mastoid rior to the external acoustic meatus and the mastoid 3. Parotid process, and inferior to the zygomatic arch (fig. 4. Submandibular 5. Facial 3.7.) Part of the gland lies posterior to the mandible 6. Submemal and masseter muscle, and part is located lateral to 7. Sublingual these structures. The parotid gland is bounded me- 8. Retropharyngeal dially by the styloid process and its muscles. The ca- 9. Anterior cervical rotid sheath, containing the internal carotid a., in- 10. Lateral cervical ternal jugular v. and Xth nerve is located posteromedial to the gland. The postero-lateral part of the gland curves round the sternocleidomastoid m., Table 3.1V. Lymphatic drainage from superficial tissues of tl whereas the anterior lateral part extends outside the head and neck mandible. Important structures which lie partly in the parotid gland are the facial nerve, the superfi- Area Lymph node group cial temporal a. and v., the external carotid a. and 1. scalp occipital the retromandibular vein. The facial nerve enters mastoid the posterior part of the parotid gland, coming 2. auricle mastoid from the stylomastoid foramen, and forms the parotid parotid plexus between the two anatomically separated parts of the gland. The parotid duct is 5 cm in 3. eye lids and cheeks parotid length, proceeds forward on the masseter m. and submandibular turns medially to pierce the buccal pad of fat and buccinator m. It ends in the oral cavity where it pro- 4. external nose submandibular duces a slight elevation of the mucosal membrane, 5. lips submandibular 1 cm inferior to the zygomatic arch: the parotid pa- submental pilla. The superficial parotid lymph nodes are located under the superficial layer of the parotid fascia, embedded in the gland. A few small, deep pa- lymph nodes into 10 principal groups (table 3.Ill] rotid lymph nodes lie on the deep aspect of the The regional submental, sublingual, submandibu gland, or are embedded in it. The parotid gland is lar, facial, mastoid, parotid and occipital lymp covered by a resiliant fascia. node groups form the pericervical collar. The su perficial tissues of the head and neck drain int these lymph node groups (table 3.1V). 3.8 Lymphatic drainage of the head and neck The retropharyngeal lymph nodes consist o two groups: the lateral and medial retropharyngea The lymphatic drainage of the head and neck nodes. The lateral nodes are situated lateral to th is rather extensive (10). Knowledge of the location longus capitis m. at the level of the second cervica of lymph node groups and the lymphatic drainage vertebra. The medial retropharyngeal lymph node of the different regions of the head and neck facili- are situated in the midline, directly behind the pos tates the interpretation of CT-scans and the staging terior pharyngeal wall, at the level of the soft palat of tumors. All the lymphatic vessels of the head and and superior aspect of the palatine tonsils. Thes neck drain directly or indirectly into the deep cervi- nodes receive afferent vessels from the posterior na cal lymph nodes, after traversing the regional sal cavity, nasopharynx, hard and soft palate lymph node groups (fig. 3.8). In 1938, the lymphat- middle ear, Eustachian tube and posterior pharyn ic drainage of the head and neck was described by geal wall and drain into the superior lateral jugula the French anatomist Rouviere. He classified the lymph nodes. 21

preauncular nodes

facial vein submandibular nodes occipital nodes " y: rctroauricular, nodes subauricular nodes superior cervical nodes (jugulo digastric nodes)

superior deep cervical nodes superior laryngeal vein internal jugular vein infernal deep cervical nodes (jugulo-omohyoid nodes) anterior jugular vein externa jugular vein jugular trunk supraclavicular nodes

infraclavicular. nodes

Figure 3.8. Lymphatic drainage of the head and neck. Arrows indicate direction of lymph flow of several areas to the lymph node stations. (Modified after Pernkopf). 22

The anterior cervical lymph node group is lo- the internal jugular lymphatic chain, lateral to this cated in the anterior triangles of the neck bordered vein. by the carotid sheaths, hyoid bone and sternoclavi- The lateral division of the internal jugular cular border, and covered by the superficial cervical lymph node chain runs from the digastric m. to the fascia, with the prevertebral fascia limiting the subclavian v. The nodes vary greatly in pattern and depth. This lymph node group can be divided into number. The upper lymph nodes lie just lateral to two subgroups: the anterior jugular chain and the the internal jugular vein. The afferent lymphatics juxtavisceral chain. The anterior jugular chain is of the internal jugular nodes come both from the re- superficial to the sternohyoid and sternothyroid gional nodes and directly from organs or regions. muscles and receives its name from its relationship The nodes connected to and draining into this chain to the corresponding vein. The nodes occur infre- are the spinal accessory and transverse cervical quently and are very small. They receive lymphatics nodes, the entire anterior cervical group, as well as from the skin and muscles of the anterior neck. the submandibular, submental, parotid, postauri- The juxtavisceral subgroup (or anterior deep cular, occipital, sublingual and retropharyngeal cervical lymph nodes) includes the prelaryngeal, nodes. The direct afferent vessels draining into this prethyroid, pretracheal and laterotracheal lymph chain may come from the entire nasal cavity, phar- nodes. They receive their afferent vessels from larynx, tonsils, external and middle ear, Eustachian ynx, thyroid, epiglottis, piriform sinuses, trachea tube, tongue, hard and soft palate, hypopharynx and esophagus. The efferent vessels run to the and larynx. All the major salivary glands may have lower internal jugular nodes, but may also termi- direct lymphatic vessels draining into the internal nate in the main jugular trunk at the jugulosubcla- jugular lymph node group. The important jugulo- vian junction. digastric node lies on the internal jugular vein at the The lateral cervical lymph node group has su- level of the greater horn of the hyoid bone, and just perficial and deep components. The lymph nodes below the posterior belly of the digastric m. The of the superficial group are small and usually elon- posterior third of the tongue and the palatine ton- gated and are most often found higher up along the sils drain into this node. It derives its importance external jugular vein, close to the parotid group. from the fact that it is frequently enlarged in carci- The deep lateral cervical lymph nodes of the neck noma of either of these organs. A second important are divided into three chains: lymph node of the internal jugular chain is the - spinal accessory juguto-omohyoid node, which lies on the internal jugular v., just above the middle tendon of the - transverse cervical omohyoid m. This node receives afferent vessels - internal jugular. from the tongue directly and indirectly by way of The internal jugular chain is the chief collec- the submental, submandibular and upper deep cer- ting trunk of the neck. Rouviere subdivided this vical nodes. chain into anterior and lateral divisions. The anterior nodes are those located anterior to the internal The spinal accessory chain runs along the Xlth jugular vein. They can be subdivided into digastric cranial nerve, crossing the posterior triangle of the and thyroid levels. The lymph nodes of the digastric neck. The upper portion of the chain blends in with level are arranged in ladder fashion, paralleling the the upper part of the internal jugular chain and the internal vein from the subdigastric area to the com- lower end joins the lateral part of the transverse cer- mon facial bifurcation of the internal jugular vein. vical chain, which follows the course of the trans- They are closely related to the internal jugular vein, verse cervical a. and runs forward to the lower end hypoglossus n. and internal carotid n. and more of the internal jugular chain, thus forming a tri- caudally they lie superficial to the external carotid angle. These transverse cervical lymph nodes, also a. and branches until the common facial vein is termed supraclavicular lymph nodes, may be in- reached. The anterior internal jugular lymph nodes volved in carcinoma in the thorax or the abdomen. receive vessels from the occipital, postauricular, pa- The efferent vessels from the deep cervical rotid and submandibular nodes. The efferent ves- nodes form the jugular trunk located in front of the sels take a backward course over the vein and enter anterior scalenus muscle and internal jugular vein, 23 and are covered by the omohyoid fascia. The left 4. Hafferl A: Lehrbuch der topographischen Anatomie. jugular trunk joins the thoracic duct; the right jugu- Springer Verlag. 1957. zweite Auflage. lar trunk usually ends at the junction of the subcla- 5. Lawson VG, Leliever WC, Makerewich LA et al.: Unusual vian vein with the internal jugular vein. parapharyngeal lesior s. J. Otolaryngol. 8(3): 241-249.1979 6. Mancuso AA, Bohma.; L, Hanafee W, Maxwell D: Com- puted Tomography of the nasopharynx: Normal and Vari- ants of Normal. Radiology 137: 113-121. 1980 7. Osborn AG: Radiology of the pterygoid plates and pterygo- References palatine fossa. A.J.R. 132: 389-394. 1979 8. Pernkopf E: Atlas of topographical and applied human 1. Gardner E, Grav DJ, O'Rahilly R: Anatomy. A regional anatomy. Edited by Helmut Farner. Vol. I Head and Neck. study of human structures. W.B. Saunders Company. 1963. 2nd revised edition. Urban and Schwarzenberg. Baltimore 2nd Edition. and Munich. 1980 2. Grant JCB: An atlas of anatomy. The Williams and Wilkins 9. Reissner K. Gosepath J: Craniotomography. An atlas and Co., Baltimore. 1983. 8th Edition. guide. George Thieme Publishers. Stuttgart. 1977 3. Haagensen DC, Feind CR, Herter FP, Stanetz CA, Wein- 10. Silver JA, Mawad ME, Hilal SK et al: Computed Tomogra- berg JA: The lymphatics in cancer. 1st Edition. Philadel- phy of the nasopharynx and related spaces Part I: Anatomy. phia. WB Saunders. 1972 (60-208). Radiology 147: 725-731. 1983 25

Chapter 4.

CT-IDENTIFICATION

4.1 Axial sections tal artery can be identified anteriorly, the occipital artery posteriorly. 4.1.1 Nose, nasal cavity, nasopharynx, paranasal sinus 4.1.1.2 Level of nasal bone and orbit Several axial sections are obtained at the level As described in Chapter 2, scans of the para- of nasal bone and orbit: upper axial, mid-axial and nasal sinus and oro- and nasopharynx are obtained lower axial orbital views (figs. 4.1-4.5). As dis- in the axial and coronal plane with a usual thickness cussed in Chapter 2 (Technique), the bony struc- of 1.5-6 mm and, if necessary, with intravenous tures are best seen with a higher window width and contrast enhancement (300 ml of 14% iodinated level (3200 and 300 HU respectively). Eye, extra- contrast medium, diatrizoate meglumine). Patients ocular muscles and other structures in the orbit can are scanned from the level of the superior border of be better visualized with a window width of 400 HU the frontal sinus to the level of the floor of the and a level of 40 HU. In daily practice, our scans mouth, depending on the extension of pathology. were generally viewed with a 400/40 window width Sixteen sections in the axial plane are obtained par- and - level. The bone setting was used when neces- allel to the infra-orbito-meatal line. Thirteen sec- sary. Tadmor and New (1978) gave a clear descrip- tions in the coronal plane are obtained perpendicu- tion of the orbital structures and stressed the value lar to the infra-orbito-meatal line. AH sections 4.5 of the coronal sections (14). Extraocular muscles, mm interspaced and with a thickness of 1.5 mm. orbital fat, bony orbit, eyeball and lens, optic nerve and ophthalmic vein were demonstrated. Later, 4.1.1.1 Level of frontal sinus Weinstein et al. (15) applied the technique of CT The first section is made above the orbital sector scanning (zoom reconstruction technique) to roof. The frontal sinuses can be identified as low- the orbit. This technique improved the spatial reso- density, air-containing cavities situated in the fron- lution (15). Weinstein was then able to observe the tal bone and separated by a bony septum. Depend- ophthalmic artery and superior ophthalmic vein ing on its pneumatization, the frontal sinus may ex- and their branches and the intraorbital branches of the III, V and VI nerves. Zonneveld and Van Waes tend above the roof of the orbit. Thus, part of the (16) were able to identify 67 structures in and orbital roof may become visible on the axial scan. around the orbit. The orbital structures are beyond The parietal and occipital bones can also be identi- the scope of this work. They are used to facilitate fied, as can the intracranial structures which are not orientation of the axial and coronal scans. discussed here. The frontal bone is covered by a muscle layer, subcutaneous fat and cutis. The fron- 26

frontal a. orbicularis oculi m. trochlea- frontal sinus lacrimal gland frontal bone (zygomatic proo levator palpebrae and sphenoid bone (greater wing) superior rectus m. temporal fascia temporal m. temporal bone

mastoid external ear

Figure 4.1. Upper orbital axial section.

On the upper orbital axial section the uppes nus, the zygomatic process of the frontal bone, the part of the globe (eyeball) becomes visible at the lev- parietal and occipital bones and the thin wall be- el of the superior part of the orbit on both sides. tween orbit and ethmoid sinus (lamina papyracea) The lower part of the frontal sinus, the ethmoid si- can also be identified (fig. 4.1). 27

"igure 4.1. Upper orbital axial section. 28

proeerus m. orbicularis oculi m globe -ethmoid sinus zygomat ic bone. lamina papyracea lacrimal gland -superior oblique m. lacrimal n. medial rectus m. orbital fat >ptic n. lateral rectus m. iphthalmic a. temporal fascia optic canal temporal m. superior ophthalmic v. temporal v. temporal bone •superficial temporal a. and basilar a. •pituitary gland mastoid

Figure 4.2. Mid-orbital axial section.

The mid-orbital axial section through the orbit and optic canal are demonstrated as is the su- middle of the orbit shows the globe, the lateral and perior orbital fissure lateral to the optic canal. The medial rectus muscles, the optic nerve and intra- frontal process of the zygomatic bone, the greater orbital fat, and ophthalmic artery (figs. 4.2 and wing of the sphenoid, the temporal bone, parietal 4.3). The nasal bone, ethmoid sinus and sphenoid and occipital bones and the proximal part of the sinus, and the close relationship to the apex of the temporal muscle can be identified. 29

Figure 4.2. Mid-orbital axial section. 30

lens nasal bone globe lamina papyracea optic n. ethmoid sinus zygomatic bone rbicularis oculi m. lateral rectus m. superior orbital fissure medial rectus m. inferior rectus m. temporal m. temporal fascia temporal bone sphenoid sinus medial temporal vein mastoid superficial temporal a. and v.

occipital bone occipital m.

Figure 4.3. Mid-orbital axial section. 31

nasal cavity uperior orbital flssure

ethmoid sinus sphenoid sinus internal auditory canal

Figure 4.3. Same section with bone window setting. 32

nasal boni nasal cavity lacrimal sac globe thmoid sinus orbital fat zygomat ic bone rbicularis oculi m.

inferior rectus m. temporal m. inferior orbital fissure temporal fascia superficial temporal a. and v. foramen rotundum iphenoid sinus xternal auditory me masloid •sternocleidomastoid iplenius capitis m. rapezius m.

external ear occipital bone

Figure 4.4. Lower orbital axial section.

The lower orbital axial section, through the as a small round hypodense area. The first part < lower part of the orbit and nasal bone, demon- the zygomatic arch can also be identified. Part < strates the inferior part of the globe and orbit, the the temporal muscle and the lateral pterygoid a upper part of the maxillary sinus, the nasal cavity situated behind the zygomatic bone, lateral to il divided by the nasal septum, the ethmoid sinus and temporal bone. Part of the temporal lobe and t\ the frontal process of the zygomatic bone (figs. 4.4 mastoid are visible. The inferior orbital fissure ca and 4.S). The nasolacrimal duct can sometimes be be identified in the posterior part of the orbit as identified in the anterior part of the maxillary sinus slit-like low density area surrounded by bony ma 33

Ihmoid sinus maxillary sinus •sphenoid sinus nasal cavity inferior orbital fissure clivus. inner ear. mandibular condyle arotid canal internal auditory canal

Figure 4.4. Lower orbital axial section with bone window setting. Note that in the axial section recognition of skull base defects is difficult.

gins and directed anterolaterally. This fissure pro- age. The cartilagenous part of the external nose vides the passage for the infraorbital nerve and ves- cannot be separated from the muscles of the exter- sels, the zygomatic nerve and the inferior ophthal- nal nose: they both present as a soft tissue structure mic vein. with the density of muscle. The various external na- The ophthalmic veins can be identified by ad- sal muscles cannot be identified separately. ministering an intravenous bolus injection of con- The base of the skull is best seen in the coronal trast medium. The upper part of the maxillary sinus scans and invasion of tumor into the skull base is visible anteromedial to the inferior orbital fis- and/or brain can be easily recognized. It is impor- sure, located posterolateral to the inferior part of tant to use a special window setting to detect lesions the ethmoidal cells. Parts of the external ear are of the skull base caused by extracranial pathology. shown lateral to mastoid and temporal bone. Part A window width of +1600 HU and a window level of the external nose consists of muscles and cartil- of + 50 HU can be employed. 34

nasal bone nasal cavity middle concha nasolacrimal duct inferior rectus m. perpendicular plate of orbicular; oculi m. ethmoid bone zygomatic arch maxillary sinus pterygopalatine fossa with temporal m. ganglion and blood vessel vomer sphenopalatine foramen masseter m. pterygopalatine fossa lateral pterygoid m. mandibular condyle deep temporal a. and v. superficial temporal a. and carotid canal external auditory meatus occipital bone (basilar part

sternocleidomastoid m. splenius capitis m. posterior rectus capitis m. semispinalis capitis m.

Figure 4.5. Lower orbital axial section. Upper axial section through maxilla.

4.1.1.3 Level of maxillary sinus, retromaxillary bone-density structures in the nasal cavity between space, upper part of nasopharynx and the sinuses, with the nasal bone and external nose parapharyngeal space in front. The nasolacrimal duct is shown as a round The upper axial section through the maxillary low density area in the anteromedial part of the sinus sometimes shows part of the lower orbit with maxillary sinus wall. the inferior oblique muscle as a slightly denser area The nasopharynx, sphenoid, occipital and in fatty tissue (fig. 4.5). Posterior to this lower part temporal bones and sometimes the infratemporal of the orbit, the maxillary sinuses can be identified fossa become visible posterolateral to the nasal cav- as two triangular shaped bony structures surround- ity and maxillary sinus. The mastoid cells, jugular ing an air-containing cavity. The bony nasal septum foramen, and carotid canal can be identified in the and superior conchae can be located as almost temporal bone (special window setting) (fig. 4.SB). 35

pterygoid canal foramen ovale pterygopalatine fossa foramen lacerum foramen spinosum carotid canal mandibular condyle clivus jugular canal carotid canal

Figure 4.5. Lower orbital axial section. Upper axial section through maxilla.

The foramen lacerum is located between the apex of the external meatus is visible posterior to this ring. the petrous bone, the sphenoid, and the occipital Lateral to the maxillary sinus and sphenoid bone bone. The oval foramen is shown in the sphenoid the infratemporal space is shown in which the tem- bone, and slightly posterior to it, the foramen spi- poral and lateral pterygoid muscles can be identi- nosum can be identified as a pin-point air-density fied. Lateral to the mandibular condyle, and in area in tY- bone. Lateroposteriorly, the greater front of the external meatus, the temporal artery wing of the sphenoid bone continues in the tempor- and vein and auriculotemporal nerve can be identi- al bone, where the mandibular fossa and mandibu- fied as tiny dots in the subcutaneous fat. The other lar condyle can be identified. The mandibular con- arteries and veins are only visible if contrast me- dyle presents as an oval bone-density structure sur- dium has been injected. rounded by a low-density ring. The anterior wall of 36

nasal bone septal cartilage nasoJacrimal duct infraorbital foramen orbicularis oculi m. middle concha zygomatic bone zygomatic arch maxillary sinus ronoid process of mandible uperior alveolar a. and v. temporal m. pterygopalatine fossa maxillary a. and v. internal maxillary a. masseter m. ial pterygoid m. lateral pterygoid m. •levator and tensor palati m medial pterygoid m. parapharyngeal space ;vator and tensor palati m. leep lobe of parotid gland longus capitis m. internal carotid a. rectus capitis m. ityloid process ternal jugular v. sternocleidomastoid m. facial n. occipital v mastoid tip >bliquus capitis superior m. digastric m. (posterior bellj rectus capitis posterior m. •posterior vertebral venous | spinalis capitis m. semispinalis capitis m.

Figure 4.6. A. Mid-axial section through maxillary sinus. Pterygoid process of sphenoid bone becomes visible (arrow head). Noie the presence of facial nerve as a tiny white dot surrounded by tissue of lower density.

The longus capitis and rectus capitis anterior can be identified between the paranasal sinus and muscles are present anterior to the basi-occipital pterygoid process. Sometimes the maxillary artery bone. The nasopharynx and nasal cavity with mid- can be seen entering the pterygopalatine fossa in dle concha, external nose including the cartilage- this section. The upper head of the lateral pterygoid nous part of the nasal septum, and paranasal sinus muscle and the temporal muscle lateral to it, are can be identified anteriorly. At this level, the slit- shown in the reiromaxillary space. The thin line in like low density area of the pterygopalatine fossa front of the maxillary sinus and lateral to the zygo- 37

Figure 4.6. Mid-axial section through maxillary sinus.

matic bone represents the facial muscles. The ptery- anterior to the temporal bone, and can be identified goid process and pterygoid plates, dorsal to the as an oblong bony structure. The levator palati is maxillary sinus become visible on the mid-axial sec- visible medial to it. tion of the maxillary sinus (figs. 4.6 and 4.7). The The masseter, temporal, pterygoid, palato- zygomatic bone, the mandibular condyle and part pharyngeus, levator and tensor palati, and neck of the temporal bone are still present, as are the oc- muscles can also be identified. The parotid gland is cipital bone (basi-occipital part), the mastoid cells, located between the mandibular ramus and the the J ^ular foramen and carotid canal. The external mastoid on both sides and has a slightly lower den- meatus can also be identified. The styloid process sity than the surrounding muscles. of the temporal bone also becomes visible, located 38

septal cartilagi orbicularis oculi m. infraorbital a. maxillary sinus, inferior concha zygomatic bone, inferior meatus coronoid process of mandible nasal cavity temporal m. pterygopalatine canal masseter m. pterygoid fossa lateral pterygoid m. nasopharynx medial pterygoid m. torus tubarius Eustachian tube orifice, mandibular condyle pharyngeal recess mandibular n. (fossa of Rosenmueller) external carotid a. parapharyngeal space longus capitis m. deep lobe of parotid gland parotid gland styloid process internal carotid a. internal jugular vein digastric m. mastoid tip- lateral rectus capitis m. digastric m. occipital condyle sternocleidomastoid m. bliquus capitis superior r longissimus capitis m. ledulla oblongata rectus capitis posterior major m. posterior arch of C, rectus capitis posterior minor m. semispinalis capiiis m. splenius capitis m. rapezius m.

Figure 4.7. Mid-axial section through maxillary sinus. Note the perpendicular plates of pterygoid process (small arrow heads). The parotid gland and parapharyngeal space become visible at this level.

Lateral to the pterygoid and temporal muscles, front of the lateral pterygoid inserting into the me- the upper part of the masseter becomes visible, lo- dial part of the coronoid process of the mandible. cated medial to the zygomatic arch. More inferior- The orbicularis oculi muscle can be identified ante- ly, the masseter presents as a muscular band lateral rior to the zygoma as a thin line in the subcutaneous to the mandible. The lower head of the lateral pter- fat tissue. Parts of the external ear are also shown. ygoid muscle is shown, as is the medial pterygoid, The nasolacrimal duct presents again in the anterior which is situated on the medial side of the lateral part of the medial wall of the maxillary sinus. pterygoid plate and inserts into it the angle of the Slightly inferiorly, the nasolacrimal duct drains be- mandible. Part of the temporal muscle is visible in low the inferior concha into the inferior meatus. 39

Figure 4.7. Mid-axial section through maxillary sinus.

4.1.1.4 Nasopharynx ator palati and posteriorly by the longus capitis The nasopharynx can be identified on the mid- muscie. The auditory tube orifice is visible anterior and lower axial scans of the maxillary sinus as an al- to the torus tubarius. It also presents as a small slit- most quadrangular air-density cavity. The lateral like air-density cavity. wall of the cavity shows the torus tubarius, pro- Mancuso (5) and Silver (12) described the nor- duced by the cartilagenous part of the auditory tube mal nasopharynx and variants of normal. They and partly by the levator palati muscle (figs. 4.7 and concluded that the superficial landmarks (tori, 4.8) The cartilagenous part cannot usually be dis- Eustachian tube orifices and lateral pharyngeal re- tinguished from the surrounding levator palati and cesses) of the nasopharynx are often asymmetrical, tensor palati muscles. These muscles are also al- whilst the deep tissue planes are symmetrical. most impossible to identify separately in the axial In the case of asymmetrical superficial land- planes. The pharyngeal recess or fossa of Rosen- marks, they conclude that it is useful to rescan with mueller can be seen anterior to the torus tubarius. a widely opened mouth, or during a "pinched The recess can be identified as a slit-like air- nose" modified Valsaiva maneuver. The lateral re- density cavity directed posterolateral and located in cesses distend during the open-mouth procedure, the posterior part of the nasopharynx. It is bounded and the Eustachian tube orifices contain more air. anteriorly by the torus tubarius, laterally by the lev- The pharyngobasilar membrane is usually not visible on CT. 40

nasal m. septal cartilage asolacrimal duct nasal cavity axillary sinus levator labii sup.in. ygomatic bone facial v. ygomatic m. inferior concha axilla inferior meatus asseter m. terygoid fossa lateral pterygoid m. ledial pterygoid m. deep lobe of parotid gland ensor and levator pale parapharyngeal space superior constrictor m. superficial lobe of parotid gland idible longus and rectus capitis m. ternal carotid a. styloid process 'etromandibular v. internal jugular vein nternal carotid a. dens axis parotid gland transverse ligament of Ci 'digastric m. sternocleidomastoid m. 'transverse process of C longissimus capitis m. obliquus capitis inferio spinal cord isterior vertrebral splenius capitis m. venous plexus rectus capitis posterior major m. minor occipital n. semispinalis capitis m. trapezius m.

Figure 4.8. Mid- to lower axial section through maxillary sinus. The posterior belly of the digastric muscle indicates the postero-medial border of the superficial lobe of the parotid gland.

The inferior concha is a separate bone and its 4.1.1.5 Parapharyngeal space upper border is connected with the lateral wall of The parapharyngeal space can be identified as the nasal cavity. The lower border of the inferior a low-density structure between the lateral ptery- concha is free. The more superior part of the infe- goid muscle anterolaterally, the maxillary artery rior meatus is shown as an oval shaped air-density and vein anteriorly, the styloid process and its three area surrounded by a thin bony lining. The lower muscles laterally, the internal carotid artery and in- part is more slit-like and covered by a thicker part ternal jugular vein posteriorly and the superior of the lower concha which extends to the posterior constrictor muscle and levator and tensor palati part of the nasal cavity. The nasopharynx is situat- medially. The parapharyngeal space is visible on ed posterior to it (fig. 4.7). The superior constrictor the axial scans at the level of the nasopharynx and muscle can hardly be distinguished from palatal extends to the lower oropharynx (figs. 4.7-4.12). muscles, longus capitis and rectus capitis muscles. The parapharyngeal space is always symmetrical unless a pathologic process invades it. 41

Figure. 4.8. Mid- to lower axial section through maxillary sinus.

4.1.1.6 Parotid gland ary impression of the deep lobe parotid tissue (13). The parotid gland can be identified as a trian- The position of the facial nerve (VII) is important. gular area behind the mandible and in front of the This can only be predicted indirectly from charac- mastoid process with a lower attenuation coeffi- teristic landmarks such as the styloid process, the cient than muscle, due to the amount of fat in the posterior belly of the digastric muscle and the ster- gland (figs. 4.7-4.10). The gland is visible on the nocleidomastoid muscle. Recently, Curtin (3) re- axial scans, from base of skull to the angle of the ported that he could identify the part of the facial mandible or slightly below (6). If intravenous con- nerve between its exit from the stylomastoid fora- trast is used, several landmarks facilitate the locali- men and its entrance into the parotid gland. He zation of the gland: for instance the retromandib- identified this part of the facial nerve as a small dot ular vein and the external carotid artery which are in the fatty tissue between the mastoid tip and sty- located in the front part of the gland and the inter- loid process. Curtin calls it "a bull's eye". After re- nal carotid artery lying posteromedial to the gland. viewing some of our high-resolution scans, we The sternocleidomastoid muscle, digastric muscle could also identify this part of the facial nerve (fig. and mastoid tip can be identified posterior to the 4.6). gland. The administration of watersoluble contrast The facial nerve enters the posterior part of the medium by direct injection into the parotid gland parotid gland between the sternocleido-mastoid through a plastic cannula (CT-sialography) proved muscle and the posterior belly of the digastric mus- to be very useful to determine whether a para- cle and proceeds anteriorly through the gland, lat- pharyngeal mass arises from the deep lobe of the eral to the external carotid artery and retromandib- parotid gland or from adjacent tissue with second- ular vein and divides into several branches lateral to the mandible (3). 42

septal cartilage nasal cavity levator labii superioris m. maxilla maxillary sinus lasal m. and cartilage buccinator m. facial v. tuberosity of maxilla •zygomatic m. lateral pterygoid m. mandible medial pterygoid m. soft palate mandibular canal parapharyngeal space inferior alveolar n. and a. pharynx masseter m. internal carotid a. retromandibular v. •parotid gland external carotid a. longus capitis m. styloid process internal jugular v. transverse process of C, •digastric m. dens of axis ternocleidomastoid m. transverse ligament of C, longissimus capitis m. spinal cord bliquus capitis inferior m. spinous process of C iplenius capitis m. trapezius m •minor occipital n. deep cervical v. semispinalis m.

Figure 4.9. Lower axial section through maxillary sinus.

The lower axial section of the maxilla shows occipital condyles and part of the foramen magnum part of the hard palate, the inferior part of the si- are visible with the medulla oblongata inside. The nus, the alveolar process and inferior part of the mastoids are also visible on both sides. pterygoid process (figs. 4.8 and 4.9). The two The muscular and cartilagenous parts of the branches of the mandible, the dens of axis, and the nose are visible. Slightly lower, the soft palate pre- anterior tubercle of the first cervical vertebra, the sents as a structure with muscular density (fig. 4.9). 43

Figure 4.9. Lower axial section through maxillary sinus. 44

maxilla orbicularis oris m. facial v. levator labii superioris m zygomatic m. tongu buccinator m. masseter m. mandible mandibular cana medial pterygoid m. inferior alveolar a. and n pharyngopalatine m. parapharyngeal space external carotid a. soft palate pharynx external carotid a. internal carotid a. styloid process superior constrictor m. parotid gland longus colli and capitis m. internal jugular v. vertebral a. and v. digastric m. obliquus capitis inferior m. rectus capitis lateralis m. deep cervical v. sternocleidomastoid m. trapezius m. 2nd cervical vertebra posterior vertebral venous pie* splenius capitis m. semispinalis capitis m.

Figure 4.10. Axial section at the level of oropharynx and oral cavity.

4.1.2 Oropharynx, oral cavity, tongue and pharyngeal muscle also cannot be identified separ- floor of the mouth ately from the longus capitis and rectus capitis muscles. Silver (5) stressed the fact that the deglutitional The soft palate, which forms the junction be- muscles (constrictor and palatals) could be distin- tween naso- and oropharynx, can be identified in guished from the masticatory muscles (pterygoids front of the pharynx as a soft tissue mass with mus- and masseters) because they are separated by the cular density (fig. 5A) (figs. 4.9-4.11). The various fatty plane of the parapharyngeal space. Part of the muscles of the soft palate are not easy to identify inferior parotid gland can be seen posterior to the separately at this level (palatoglossus, uvula, leva- digastric muscles and anterior to the sternocleido- tor and tensor palati). The slight prominence of mastoid muscle as a structure of slightly lower at- muscular tissue lateral in the pharynx is caused by tenuation than muscle. the salpingopharyngeal muscle. The constrictor 45

Figure 4.10. Axial section at the level of oropharynx and oral cavity. 46

nasal m. and cartilage' orbicularis oris m. maxilla levator labii sup. m. tongue facial v. •zygomatic m. buccinator m. mandible masseter m. uvula medial pterygoid m. .external carotid a. mandibular canal pharynx inferior alveolar a. and n. digastric m. parapharyngeal space longus colli and capitis m. retromandibular v. internal jugular v. stylopharyngeal m. lymph nodes styloid process .obliquus capitis inferior m. internal carotid a. longissimus capitis m. internal jugular v. minor occipital n. sternocleidomastoid m. rectus capitis posterior major i vertebral a. and v. •mispinalis capitis m. deep cervical v. trapezius m.

Figure 4.11. Axial section at the level of oropharynx and oral cavity.

The parapharyngeal space can be identified a thin line indicates the presence of the zygomatic lateral to the constrictor muscles and medial to the muscle. The anterior facial vein is visible lateral to lateral and medial pterygoid muscles, which at this the buccinator muscle and in front of the masseter level are not clearly separated. The bony structures muscle (fig. 4.10). The buccinator muscle is visible of the mandible and the masseter muscle are visible on both sides, directly lateral to the alveolar ridges lateral to the pterygoids. In front of these muscles, of the maxilla. 47

Figure 4.11. Axial section at the level of oropharynx and oral cavity. 48

orbicularis oris m. buccinator m. maxilla facial •zygomatic m. tongu mandible lingual septum superficial lingual v. masseter m. stylopharyngeal m. medial pterygoid m. parotid gland parapharyngeal spa pharyngeal v. retromandibular v. external carotid a. parotid gland digastric m. pharynx constrictor pharyngeus rr internal carotid a longus colli and capitis n internal jugular v. sternocleidomastoid m. vertebral a. and v.

obliquus capitis inferior i minor occipital n. splenius capitis m. splenius capitis m. trapezius m. rectus capitis posterior major m. semispinalis capitis m.

Figure 4.12. Axial section at the level of oropharynx and oral cavity. 49

Figure 4.12. Axial section at the level of oropharynx and oral cavity. 50

lower lip orbicularis oris m. platysma tongu facial v. buccinator m mylohyoid m. .hyoglossus m. masseter m. .genioglossus m. mandible medial pterygoid m. lingual septum styloglossus m. intrinsic muscles stylohyoid m. submandibular gland ternal jugular v. digastric m. tonsillar fossa pharyngopalatine and igastrie m. constrictor pharyngis m. longus colli and internal carotid a. splenius cervicis m. internal jugular v. scalennus médius m. levator scapulae m. Iongissimus capitis m. longissimus capitis m. deep cervical v. 'sternotfeidomastoid m. trapezius m. minor occipital n. splenius capitis m. semispinalis capitis m.

Figure 4.13. Axial section at the level of lower oropharynx, tongue and floor of the mouth.

At the level of the lower oropharynx, tongue submandibular duct, lingual salivary glands, lin- and floor of the mouth, the various muscles of the gual and hypoglossal nerves are found. The lingual tongue, such as the genioglossus, can be identified, artery is located at the posteromedial side of the hy- separated by the fibrous lingual septum which pre- oglossus. The mylohyoid muscle can be identified sents as a low-density line. (figs. 4.13 and 4.14) The lateral to these hyoglossus and styloglossus mus- hyoglossus and styloglossus are located lateral to cles, and medial to the mandible (figs. 4.13-4.15). the genioglossus. They are slightly curved postero- Only the posterior part of the tongue shows a mus- medially and separated from the genioglossus by a cular mass without any structure: the intrinsic mus- fat containing space with low density in which the cles. 51

Figure 4.13. Axial section at the level of the lower oropharynx, tongue and floor of the mouth. 52

platysma mentalis m. mandible igastric m. (anterior belly) depressor anguli oris m. eniohyoid m. mandibular canal lingual vessels inferior alveolar n. lylohyoid m. masseter m. yoglossus m. ingual septum 'acial v. intrinsic m. of tongue ubmandibular gland tonsillar region iharyngopalatine and external jugular v. stylopharyngeal m. external carotid a. piglottis internal carotid a. harynx internal jugular v. reater horn of hyoid bone sternocleidomastoid m. longus capitis m. scalenus medius m. accessory n. longissimus capitis m. rd cervical vertebra (C3) minor occipital n. longissimus capitis m. deep cervical v. plenius capitis m. semispinalis cervicis m. ispinalis capitis m. trapezius m.

Figure 4.14, Axial section at the level of tongue and floor of the mouth. Note the presence of anterior belly of digastric muscle on the left.

Posterolateral to the mylohyoid muscle, the jugular vein is visible anterior to the sternocleodo- submandibular glands present as round structures mastoid muscle, located below the parotid gland. with the density of muscle since they contain less fat On the lower sections the external jugular vein is lo- than the parotid gland (figs. 4.14 and 4.15). cated lateral to the sternocleidomastoid muscle. The pharyngeal musculature and the palatine The platysma can be seen on these axial sections as tonsils form a homogeneous mass in which the vari- a sheet of muscle, located subcutaneously in front ous structures cannot be identified. The internal of the mandible extending laterally around it into carotid artery and jugular vein, the external carotid the sternocleidomastoid muscle and extending artery and stylohyoid muscle, lateral maxillary ar- downwards to the level of the clavicles. It is ex- tery and the digastric muscles can be identified pos- tremely variable in its degree of development. terior and lateral to these muscles. The external- 53

Figure 4.14. Axial section at the level of tongue and floor of the mouth. 54

platysma mentalis m. mandibli digastric m. •mylohyoid m. .submental v. geniohyoid m. lingual septum superficial fascia hyoglossus m. submandibular gland pre-epiglottic space hyoid bone. vallecula epiglottica external carotid a. -epiglottis internal carotid a. -facial v. internal jugular v. •oropharynx sternocleidomastoid m. longus colli and scalenus anterior m. longus capitis m. scalenus médius m. levator scapulae m. longissimus colli m. deep cervical v. multifidus m. semispinalis cervicis m. splenius capitis m. trapezius m .semispinalis capitis m.

Figure 4.15. Axial section at the level of lower oropharynx, tongue and floor of the mouth.

There is only a very small muscular band visi- below the mandible (figs. 4.14 and 4.15). The ante- ble anterior to the second vertebra consisting of the rior belly of the digastric muscle and the lowest part longus colli and longus capitis and the constrictor of the mandible are sometimes seen in this section, muscle, which usually cannot be identified separa- depending on the position of the patient's head. tely. The splenius and scalenus médius muscles are The valleculae and epiglottis can be identified di- visible directly lateral to the vertebra on both sides. rectly posterior to the hyoid bone. The valleculae More posterior the semispinatus capitis, longissi- are bounded posteriorly by the epiglottis and are mus capitis, semispinalis cervicis muscles and the separated from each other by the median glosso- deep cervical vein can be identified as posterior epiglottic fold which can be identified as a thin line, neck structures separated by the ligamentum nu- perpendicular to the body of the hyoid bone. The chae. The tortuous structure on both sides of the epiglottis is connected to the lateral pharyngeal spinous process might be the longitudinal vertebral walls by the pharyngo-epiglottic folds, also visible venous sinus. The hyoid bone, with the body and as thin curved lines on the axial sections. the two greater horns is visible in the section slightly Figure 4.15. Axial section at the level of the lower oropharynx, tongue and floor of the mouth. mentalis m. depressor labii inferioris m. platysma depressor anguli oris m. mandible mylohyoid m.

pre-epiglottic space- hyoid bone vallecula epiglottis submandibular gland epiglottis .greater horn of hyoid bon< pharynx xternal carotid a. external carotid a. internal jugular v. internal carotid a. sternocleidomastoid m. internal jugular v. longus colli and longus capitis m. 'scalenus medius m. scalenus medius and tongissimus capitis m. levator scapulae m. mispinalis capitis m. longissimus capitis m. .trapezius m. obliquus capitis inf. m. deep cervical v. rectus posterior major m. semispinalis cervicis m.

Figure 4.16. Axial section at the level of hypopharynx.

The inlet of the larynx (aditus laryngis or vesti- also be identified in this section as a low-density bule) is visible as an air-filled area behind the valle- area due to the fat content. The internal carotid ar- culae and the epiglottis (fig. 4.16). The superior tery and internal jugular vein accompanied by the portions of the piriform sinus present on the lateral vagus nerve (not visible) is shown posterolaterally. part of the laryngeal vestibule. The cervical sympathetic plexus is present posterior The stylopharyngeal and pharyngopalatine to the internal carotid artery. The longus colli mus- muscles are visible as a muscular band anterior to cle and constrictor muscle cannot usually be distin- the piriform sinus. The superior part of the aryepi- guished. Inferiorly, the submandibular glands can glottic fold is shown in this section through the infe- be identified as fairly round structures lateral to the rior part of the hyoid. The pre-epiglottic space can hyoid bone. 57

Figure 4.16. Axial section at the level of the hypopharynx.

The sternocleidomastoid muscle and the exter- nius capitis, levator scapulae, and the anterior sca- nal jugular vein can be identified as can the pla- lenus muscle (fig. 4.15). The glomus caroticum and tysma (fig. 4.16). The important neck muscles superior laryngeal nerve are located posteromedial which can be distinguished are the semispinalis cer- to the external carotid artery which is located in vicis, the semispinalis capitis, trapezius and sple- front of the internal carotid artery. B

Figure 4.17. A. Spinal accessory lymph node on the righl, medial lo the slernocleidomaMoid m. (arrow head). B. Enlarged internal jugular lymph node on (he left (arrow), closely related lo an enlarged spinal accessory lymph node (arrow head).

4.1.3 Identification of lymph nodes the nodes varied from 3 to 10 mm. We could con- on the axial sections (figs. 4.17 and 4.18) firm these findings in our material. To identify pathological lymph nodes it is nec- It is important to be aware of the position of essary to obtain contrast enhanced scans [150 ml of lymph nodes in the axial sections. Mancuso (7, 8) 60% meglumine iothalamate (Conray 60) (Mancu- and Reede (10,11) gave a clear description of the lo- so) or 300 ml Reno-M-drip over a 15-minute pe- cation of important groups of lymph nodes on CT. riod.] Scans are started after 150 ml of contrast The lateral retropharyngeal lymph nodes, the sub- have been infused (Reede)(8). mental, submandibular, superior, middle and infe- The spinal accessory nodes can be identified in rior jugular lymph nodes and the spinal accessory the posterior triangle of the neck along the course lymph nodes could be identified. The parotid of the spinal accessory nerve. In the axial scans, lymph nodes were visualized in only 7 out of 30 they can be seen at the level of the hyoid bone in the cases. Mancuso observed that normal lymph nodes fatty tissue of the triangle directly medial to the pos- are usually homogeneous and have attenuation terior inner border of the sternocleidomastoid mus- values about 10 to 20 Hounsfield Units. The size of cle. 59

Figure 4.18. A. Enlarged lateral retropharyngeal lymph node o~ the left (curved arrow). B. Post-glandular submandibular lymph node on the right (small arrow).

The anterior and lateral internal jugular nodes jugular vein, and the spinal accessory nodes, which can also be identified at this level surrounding the are located in the posterior triangle, posteromedial jugular vein and carotid artery. Slightly superiorly, to the stenocleidomastoid and anterolateral to the at the level of the inferior part of the mandible, the levator scapulae (fig. 6B). superior internal jugular nodes can be identified an- The retropharyngeal nodes are divided into the terior to the internal carotid artery and internal jug- medial retropharyngeal and lateral pharyngeal ular vein and posterior to the submandibular gland. nodes. Only the lateral pharyngeal nodes can be At this level, the spinal accessory lymph nodes can identified, directly lateral to the longus colli muscle be seen posteromedial to the sternocleidomastoid and medial to the internal carotid artery. The paro- muscle in the posterior triangle of the neck. In the tid lymph nodes could be identified by Mancuso in section of the mandible, the posterior belly of the 7 out of 30 scans. As described by Mancuso, they digastric muscle is visible anterolateral to the inter- were located between the tail of the parotid and the nal carotid artery and internal jugular vein. Lymph upper edge of the sternocleidomastoid muscle, nodes can also be identified (jugular-digastric closely related to the retromandibular vein. nodes) lateral to this digastric muscle. It is not al- The submandibular nodes can be seen ante- ways possible to distinguish the posterior deep jug- rior, lateral and posterior to the submandibular ular nodes from the spinal accessory nodes at this gland. level. Inferior to the hyoid bone, at the level of the The submental nodes are visible between the thyroid cartilage, it is possible to identify the mid- anterior bellies of the digastric muscles and the dle internal jugular nodes, located posterior to the hyoid. 60

superior sagittal sinus frontal bone falx cerebri

supra-orbital a. levator palpebrae and superior rectus m. orbital septum globe lens frontal sinus nasal cavity nasal bone anterior nasal spine

Figure 4.19. Coronal section of anterior part of the face. Lens and globe can be identified.

This section, the most frontal, shows part of the frontal sinus, orbit, nasal cavity and anterior nasal spine.

4.2 Corona] sections neck, the tilting plane of the gantry is changed. The tilting plane is also changed when there are artefacts To obtain coronal sections the patient should due to metallic dental fillings. be positioned prone with the neck maximally ex- The anatomy in the coronal sections is des- tended. The gantry is tilted such that it is almost cribed from the most anterior part of the face to the perpendicular to the orbitomeatal line. This is not section through the temporomandibular joint. always possible or useful. With older people, who Scans are taken with a slice-thickness of 1.5 mm, cannot extend their heads due to stiffness of the 4.5 mm intervals and 4.8 seconds scan-time. 61

Figure 4.19. Coronal section of anterior part of the face. Lens and globe can be identified. 62

supra-orbital a., levator palpebrae sup. m. and crista galli superior rectus m. frontal sinus lacrimal gland- zygomatic process of globe. frontal bone medial rectus m. superior oblique m. ethmoid sinus lamina papyracea orbicularis oculi m. inferior oblique m. middle concha maxillary sinus nasal cavity zygomatic m. nasal septum facial v. inferior concha levator labii superioris m anterior nasal spine levator anguli oris m. maxilla

Figure 4.20. Coronal section of anterior part of the face. The maxillary sinuses become visible.

The inferior nasal concha presents in the nasal bony structure shaped like an inverted question cavity as a soft tissue swelling in the most anterior mark. Superior to it, the middle nasal concha pre- part of the cavity. In the next section it can be seen sents as a curved structure. slightly more posteriorly and containing a thin 63

Figure 4.20. Coronal section of anterior part of the face. The maxillary sinuses become visible. 64

levator palpebrae and temporal m. superior rectus m. olfactory bulb superior oblique m. zygomatic bone medial rectus m. lacrimal gland and lamina papyracea lateral rectus m. ethmoid sinus globe middle concha rectus inferioi m. •inferior rectus m. inferior oblique m. •inferior oblique m. infra-orbital foramen •zygomatic m. nasal cavity inferior concha inferior meatus •levator labii maxillary sinus superioris m. facial v. facial v. nasal septum orbicularis oris m.

Figure 4.21. Coronal section through orbits, maxilla and anterior cranial fossa. The olfactory bulb is visible.

Directly superior to the ethmoidal cells, and lying on both sides of the crista galli, the olfactory bulb is visible as a small round structure (fig. 4.21). 65

Figure 4.21. Coronal section through orbits, maxilla and anterior cranial fossa. 66

temporal fascia temporal m. levator palpebrae and cribiform plate superior rectus m. olfactory bulb superior oblique m. zygomatic bone ophthalmic a. lamina papyracea medial rectus m. ethmoid sinus optic n. nasal septum lateral rectus m. middle concha acrimal n. nasal cavity hiatus semilunaris inferior concha middle meatus hard palate 'zygomatic m. buccinator m. maxillary sinus alveolar process inferior meatus tongue facial v. mental protuberance

Figure 4.22. Coronal section through orbit with muscles and optic n., ethmoid sinus, maxillary sinus and anterior part of the body of the mandible. The zygomatic bone is visible.

The globe is visible anteriorly, surrounded by a round structure. Tiny dots represent vessels and the orbital fat and medial, lateral, superior and in- nerves (figs. 4.20-4.25). The posterior part of the ferior rectus muscles, the superior and inferior obli- orbit (apex) presents as a triangular area in which que muscles and ophthalmic vein. Directly poste- muscles, optic nerve, arteries and veins converge rior to the globe, the optic nerve becomes visible as (fig. 4.25). 67

Figure 4.22. Coronal section through orbit with muscles and optic n., ethmoid sinus, maxillary sinus and anterior part of the body of the mandible. 68

temporal m levator palpebrae and temporal fascia superior rectus m. cribriform plat ophthalmic a. ethmoid sinus medial rectus m. and zygomatic arch superior oblique m. opening of maxillary sinus optic n. superior meatus lateral rectus m. middle concha inferior rectus m. nasal cavity orbital fat inferior meatus maxillary sinus nasal septum zygomatic m. hard palate facial v. alveolar process buccinator m. tongue mandible

Figure 4.23. Coronal section through orbit, maxillary sinus, tongue, and mandible. Note the opening of maxillary sinus into nasal cavity.

The maxilla, hard palate, alveolar arch and also be identified. The muscles of the tongue separ- zygoma present as the bony structures of the face ated by the fibrous lingual septum present as rather (figs. 4.21-4.26). Part of the anterior mandible can symmetrical structures (figs. 4.23-4.31). 69

Figure 4.23. Coronal section through orbit, maxillary sinus, tongue and mandible. 70

ophthalmic v. levator palpebrae m. temporal m. and superior rectus m. temporal fascii superior oblique m. ethmoid sinus and medial rectus m. lamina papyracea optic n. superior concha lateral rectus m. middle meatus inferior rectus m. middle concha inferior orbital fissure nasal septum 'zygomatic arch inferior concha :ygomatic bone inferior meatus maxillary sinus zygomatic m. facial v. hard palate andible alveolar process mucosal lining of hard palate

Figure 4.24. Coronal section through orbit, nasal cavity, maxillary sinus and mandible. Note the presence of superior concha.

The superior concha can be identified as a small tween the superior nasal concha and the roof of the soft tissue mass, located in the superior part of the nasal cavity. The zygomatic muscles can also be nasal cavity in close proximity to the ethmoidal cells identified on the anterior sections (figs. 4.23 and which are best seen if a bone-window setting is 4.24). used. The spheno-ethmoidal recess is located be- 71

Figure 4.24. Coronal section through orbit, nasal cavity, maxillary sinus and mandible. 72

superficial temporal a. phenoid sinus ophthalmic a. and v. lesser wing of sphenoid superior concha •superior orbital fissure superior meatus iptic n. middle concha emporal lobe middle meatus greater wing of sphenoi. temporal m. inferior orbital fissure coronoid process of mandible temporal m. nasal septum zygomatic arch inferior concha asseter m. inferior meatus Iveolar process of maxi maxillary sinus buccinator m. hard palate facial v. facial v. tongue lingual septum mandible geniohyoid m. mylohyoid m. digastric m. (anterior belly)

Figure 4.25. Coronal section through posterior part of orbit and maxillary sinus. Note the superior and inferior orbital fissure, superior concha and meatus. Buccal fat pad (arrow).

The muscles of the floor of the mouth are the the geniohyoid are also visible, the hyoglossus lyinfc digastric, mylohyoid and geniohyoid muscles. The lateral to the genioglossus. The buccinator muscle inferior muscles are the digastric muscles, separated is visible lateral to the tongue and medial to the from the geniohyoid muscle by the mylohyoid mandible and slightly posteriorly, the masseter can muscle (figs. 4.25-4.29). Inferior to the digastric be seen. The facial vein is visible lateral to the mus- muscle, the platysma can be seen as a thin line em- cle (fig. 4.20-4.28). The buccal fat pad presents in bedded in the subcutaneous fat (figs. 4.27-4.31). the coronal scan between the masseter and buccina- The genioglossus and hyoglossus, situated above tor as an oblong low-density area. 73

Figure 4.25. Coronal section through posterior part of orbit and maxillary sinus. 74

greater wing of sphenoid lesser wing of sphenoid pterygopalatine fossa optic canal middle concha superior orbital fissure maxillary a. temporal lobe zygomatic arch temporal m. middle meatus sphenoid sinus nasal cavity inferior orbital fissure inferior concha alveolar a. nasal septum maxillary sinus coronoid process of mandible inferior meatus alveolar process of max hard palate masseter m. tongue buccinator m. genioglossus m. facial v. mylohyoid m. mandible submental a. and v. lingual a. and v. glossopharyngeal n. digastric m. geniohyoid m. (anterior belly) mylohyoid m.

Figure 4.26. Coronal section through optic canal, sphenoid sinus, infratemporal fossa, coronoid process of mandible and nasal cavity. Pterygopalatine fossa and ganglion are visible.

The sinus has a different shape in sections identified in these coronal sections, as can the infe- through the posterior part of the maxillary sinus. rior orbital fissure. Sometimes the superior orbital The sinus is more oval-shaped in the supero- fissure is also visible in the same section. inferior direction. The pterygopalatine space can be 75

Figure 4.26. Coronal section through optic canal, sphenoid sinus, infratemporal fossa, coronoid process of mandble and nasal cavity. 76

optic canal temporal m. maxillary a. sphenoid sinus sphenoid bone pterygopalatine fossa zygomatic process of sphenoid middle concha nasal cavity vomer lateral pterygoid m. posterior part of maxil lingual septum hard palate tuberosity of maxilla masseter m. genioglossus m. and buccinator m. geniohyoid m. ongue mylohyoid m. mandible platysma facial v. digastric m. submental a. and v. (anterior belly)

Figure 4.27. Coronal section through posterior part of maxilla, sphenoid sinus and mandible. Note the presence of tuher maxillae. 77

Figure 4.27. Coronal section through posterior part of maxilla, sphenoid sinus and mandible. 78

ella temporal m. and fascia phenoid sinus superficial temporal a. foramen rotundum zygomatic process of reater wing of sphenoi temporal bone Vidian canal pterygoid process of sphenoid lateral pterygoid m. sphenoidal keel (rostrum) iterygoid fossa choana ledial pterygoid plate medial pterygoid m. lateral pterygoid plate soft palate masseter m. pterygoid hamulus submemal a. and v. mandible facial v. tongue mylohyoid m. genioglossus m. and lingual a. and v. geniohyoid m. platysma digastric m. (anterior belly)

Figure 4.28. Coronal section through sphenoid sinus, pterygoid fossa, tongue and ramus of the mandible.

The pterygoid process, with the two laminae, The temporal muscle is visible lateral to these mus- becomes visible directly posterior to the maxillary cles and sometimes the temporal fascia can also be sinus. The foramen rotundum, the Vidian canal identified. Part of the facial artery can be identified and the anterior clinoid process can be identified in in the coronal section at the level of the pterygoid this section (fig. 4.28). The foramen lacerum is visi- plates (12). This is the horizontal part, or second ble directly posterior to the foramen rotundum. segment, of the facial artery. The facial artery can The pterygoid hamulus is well shown at the inferior be identified better if a bolus injection of medium part of the medial pterygoid plate as a thin vertical is administered: a horizontal course over the ante- line, slightly thickened distally. The medial ptery- rior part of the lateral pterygoid muscle just below goid muscle can also be identified running from the the base of the skull. pterygoid fossa inferolateral to the angle of the The soft palate and uvula present as muscular mandible. The lateral pterygoid muscles are shown structures and the soft palate as a horizontal struc- superior to the medial pterygoid, running from the ture, the uvula perpendicular to it (figs. 4.28-4.31). lateral pterygoid plate to the mandibular condyle. The soft palate delineates the boundary between naso- and oropharynx. 79

Figure 4.28. Coronal section through sphenoid sinus, pterygoid fossa, tongue and ramus of mandible. 80

cavernous sinus posterior clinoid process pituitary gland sphenoid sinus zygomatic process of sphenoid bone temporal bone pharynx lateral pharyngeal recess (fossa of Rosenmueller) torus tubarius lateral pterygoid m. orifice of Eustachian tube palatoglossus m. soft palate tongue medial pterygoid m. genioglossus and masseter m. geniohyoid m. mandible lingual septum submentai a. and v. and •mylohyoid m. submentai lymph nodes digastric m. platysma

Figure 4.29. Coronal section through posterior sphenoid sinus, nasopharynx, soft palate, tongue and mandibular branches.

The nasopharynx is bounded by the levator pa- scans. The torus tubarius presents as a prominent lati and lateral to it, the tensor palati muscle, both soft tissue mass, comprising the salpingopharyn- inserting into the soft palate; the levator produces geal muscle and cartilagenous part of the auditory the main bulk of the middle segment of the palate, tube. The Eustachian tube orifice is located direct the tensor palati inserts into the anterior (lateral) below it. (fig. 4.30) part of the soft palate. They elevate the soft palate The lateral recess or fossa of Rosenmueller is against the superior constrictor and palatopharyn- situated above the torus tubarius. The fossa of Ro- geal arch muscles allowing the passage of food senmueller often greatly varies in size in different through the oropharynx (deglutition). The relation- patients. The superior constrictor is not visible in ship between levator and tensor palati is better dem- the nasopharynx since its superior margin extends onstrated in the coronal scans than in the axial to the level of the floor of the nasal cavity. 81

sphenoid sinus sphenoid bone (greater wing

pharyngeal tubercli pterygoid canal

Figure 4.29. Coronal section through poslerior sphenoid sinus, nasopharynx, soft palate, tongue and mandibular branches (bone window setting). 82

basilar a. sphenoid sinus

cavernous sinus clivu: cavernous sinus, trigeminal cave temporomandibular joint

lateral pharyngeal recess torus tubarius petro-occipital synchondrosis lateral pterygoid m. scaphoid fossa parotid gland iharynx (superficial lobe) ft palate levator and tensor palati m. medial pterygoid m. maxillary a. mandible parapharyngeal space masseter m. palatopharyngeal m. tongue lingual septum submental a. and v. mylohyoid m. plalysma

Figure 4.30. Coronal section through clivus, nasopharynx, soft palate, tongue and ramus of the mandible. Note the lateral pharyngeal recess, torus tubarius, temporomandibiJar joint, cavernous sinus and trigeminal cave.

The parapharyngeal space, the sublingual gual space can be identified between mylohyoid space and submandibular space can easily be identi- muscle on the lateral side, and the genioglossus on fied in the coronal sections (figs. 4.30-4.31). Later- the medial side. They can always be identified on al to the levator palati, and medial to the styloglos- CT (Muraki, 1983) (9). The sublingual space sus and pterygoid muscles, an area of fat-density proved to be symmetrical in all of the 35 scans Mu- can be seen which represents the parapharyngeal raki studied. He also concluded that the deep mus- space. The submandibular space is located latero- culature of oropharynx and floor of the mouth inferior to the mylohyoid muscle, and the sublin- were symmetrical in the majority of cases. 83

internal carotid artery sphenoid sinus

trigeminal cave temporotnandibular joint

Figure 4.30. Coronal section through clivus, nasopharynx, soft palate, tongue and ramus of the mandible (bone window setting). clivus carotid syphon trigeminal cave Eustachian tube (auditory tube) temporo-mandibular joint petro-occipital synchondrosi levator palati m. tensor palati m. temporal bone pharyngotubarius m. spine of sphenoid lateral pterygoid m. parotid gland parapharyngeal spao longus colli and levator and tensor palati m. longus capitis m. lateral pharyngeal recess mandible pharynx medial pterygoid m. masseter m. soft palate palatoglossus and palatopharyngeus m. 'styloglossus m. facial a. and v. tongue platysma lingual septum digastric m. mylohyoid m.

Figure 4.31. Coronal section through clivus, nasopharynx, soft palate and tongue. Note the levator and tensor palati m. and parapharyngeal space.

In this coronal section, the extension of the are best seen in the more posterior sections, at the parapharyngeal space can be seen over its full level of the external meat us and external ear, 1st length extending from the level of the skull base to and 2nd cervical vertebra. The parotid and sub- the level of the lower oropharynx. The parapharyn- mandibular glands can also be identified in the co- geal space lies posteromedially between the naso- ronal scans. Their identification can be facilitated pharynx and the infratemporal fossa (pterygoid if CT-sialography is performed. The parotid gland muscles). The styloid process and styloglossus, sty- becomes visible posterior and superior to the mas- lopharyngeal and stylohyoid muscles are situated seter. If no contrast is administered, the gland has posterolaterally. The styloid process and muscles a slightly lower density than muscle. 85

carotid canal Eustachian tube temporomandibular joint

spine of sphenoid petro-occipital synchondrosis

Figure 4.31. Coronal section through clivus, nasopharynx, soft palate and tongue (bone window setting). 86

References Normal Anatomy. Radiology 148: 709-714.1983 9. Muraki AS, Mancuso AA, Harnsberger HR, Parkin JL: 1. Bryan RN, Miller RH, Ferreyro RI, Sessions RB: Com- CT of the oropharynx, tongue base and floor of the mouth: puted Tomography of the major salvary glands. AJR 139: Normal Anatomy and range of variation in staging carcino- 544-547. 1982 ma. Radiology 148: 725-731. 1983 2. Carter BL, Karmody CS, Blickman JR, Panders AK: Com- 10. Reede DL, Bergeron RT: CT of cervical lymph nodes. J. puted Tomography and Sialography I: Normal Anatomy. Otolaryngol. II. 1982 J. Comput. Assist. Tomogr. 5(1): 42-45. 1981 11. Reede DL, Whelan MA, Bergeron RT: Computed Tomo- 3. Curtin HD, Wolfe P, Snijderman N: The facial nerve graphy of the Infrahyoid Neck. Part I: Normal Anatomy. between the stylomastoid foramen and the parotid: Com- Radiology 145: 389-395. 1982 puted Tomographic Imaging. Radiology 147: 165-169. 12. Silver AJ, Mawad ME, Hilal SK et al: Computed 1983 Tomography of the nasopharynx and related spaces. Part 4. Hesselink JR, New PFJ, Davis KR et al.: Computed tomo- I: Anatomy. Radiology 147: 725-731. 1983 graphy of the paranasal sinuses and face. Part I: Normal 13. Som PM, Biller HF: The combined CT-sialogram. Anatomy. J. Comput. Assist. Tomogr. 2: 559-567. 1978 Radiology 135: 387-390. 1980 5. Mancuso AA, Bohman L, Hanafc: W, Maxwell D: Com- 14. Tadmor R, New PFJ: Computed Tomography of the orbit puted Tomography of the nasopharynx. Normal and vari- with special emphasis on coronal sections. Part I: Normal ants of normal. Radiology 137: 113-121. 1980 Anatomy. J. Comput. Assist. Tomography 2: 24-34. 1978 6. Mancuso AA, Hanafee WN: Computed Tomography of 15. Weinstein MA, Modic MT, Risius B et al: Visualization of the head and neck. Williams and Wilkins 1982. 168-169 the arteries, veins, and nerves of the orbit by sector 7. Mancuso AA, Maceri D, Dale R, Hanafee, W: CT of cervi- computed tomography. Radiology 138: 83-87. 1981 cal lymph node cancer. AJR 136: 381-385. 1981 16. Zonneveld FW, Van Waes PFGM, Damsma H, Rabi- 8. Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH: schong P, Vignaud J: CT of the temporal bone. Head and Computed Tomography of cervical and retropharyngeal Neck Imaging. Excluding the brain. Edited by R. Thomas lymph nodes: Normal Anatomy. Variants of Normal, and Bergeron, Anne G. Osborn and Peter M. Som. The CV Applications in staging head and neck cancer. Part I: Mosby Company. St. Louis / Toronto 1984 87

Chapter 5.

PATHOLOGY OF PARANASAL SINUSES

5.1 Introduction tients. Weber's early conclusion was that bony structures are best evaluated by polytomography, One of the first applications of CT in otorhino- while soft structures are best outlined by CT. CT laryngology was examination of the paranasal si- demonstrates extension into the orbit, intracranial nuses. The possibilities offered by CT in detecting cavity, pterygopalatine fossa, temporal fossa and pathology in the soft tissues surrounding the para- soft tissue structures of the face. A mass with lytic nasal sinuses proved to be an especially valuable ad- bone destruction is the most frequent radiologic junct in obtaining diagnostic information. In this finding in malignant lesions. Thawley (29) conclud- study, we have attempted to answer the following ed that bone destruction was equally well demon- questions: strated by CT and polytomography. Becker (7, 8) - In the review of the literature, what are the indi- concluded that CT, compared with conventional cations for CT-examination, and how have these tomography, was superior in 40%, equivalent in changed with increased experience and improve- 40% and inferior in 20% of cases in assessing path- ment in technique? ological findings involving the bony structures of - What is the impact of CT on diagnostic under- the skull base. It proved to be difficult to distin- standing in a group of patients? guish between inflammatory and malignant condi- - What is the influence of CT on patient manage- tions in ethmoid sinus pathology. Mancuso (50) ment? compared CT and pluridirectional tomography for their ability to show the extent of paranasal sinus tumor, or benign aggressive processes in 31 pa- 5.2 Review of the literature tients. He concluded that CT was superior to pluridirectional tomography in showing spread of tumor to all clinically important areas, including the infra- General experiences: temporal fossa, nasopharynx, orbit and intracran- CT versus conventional X-ray. ial compartment. CT not only consistently allowed less equivocal interpretation but also allowed better The first studies on CT-examination in oto- qualification of orbital involvement and both brain rhinolaryngology were published by Wortzmann in and infratemporal fossa involvement. Forbes (29) 1976 (97). Later Carter (15, 16), Tadmor (85), reached the same conclusion. Nehen (59) also com- Thawley (89), Mancuso (55), Dubois (27), Claussen pared computerized tomography and hypocyclo- (20), Moedder (57), Noyek (60), Lohkamp (48, 50, tomography in lesions of the nose, paranasai si- 51), Gould (33), Schindler (76), Palacios (63), Pul- nuses and nasopharynx. The conclusion was that len (68), Keane (46) and Forbes (29) described their CT generally produces better representation of early experiences with CT in otorhinolaryngology. both the bony structures and the soft tissue, and An extensive description of the normal anatomy of that only CT has the capacity of evaluating intra- the paranasal sinuses was given by Hesselink (40, cranial extension. 41). Weber (93) analyzed the clinical and pathological features of carcinoma of the sinuses and des- The value of CT in trauma has been stressed by cribed the different radiological modalities and several authors (15, 20, 23, 30, 34, 36, 74). It is in- their value in the diagnosis and treatment of 100 pa- teresting to see that the technical development of

Figure 5.1. Road accident. Complex fraclurcs of orbit, frontal and nasal bone, ethmoid sinus and maxillary sinus. 89

CT equipment led to almost complete replacement ma of the base of the tongue, larynx and hypo- of conventional equipment by CT (14, 43, 74, 77). pharynx, who had undergone radical neck dissec- CT fully evaluates complex fractures of the parana- tion. The clinical efficacy of CT, relative to diagno- sal sinuses and orbits (fig. 5.1). Important is the rec- sis and treatment of lymph node metastasis to the ognition of fractures of the frontal process of the neck, was evaluated using a modification of the maxilla and the anterior wall of the antrum since questionnaire on "Overall contribution of CT", they constitute major support to the mid face. If developed by Wittenberg (95). The clinical efficacy these fractures are unrecognized, serious facial de- evaluations of this prospective group showed im- formities may result (44). proved diagnostic understanding in seven patients, Alford et al. (1) demonstrated the value of CT and little or no effect on diagnostic understanding in delineating a soft-density foreign body in a child in three patients. Therapeutic implications were in whom all other modalities, including surgical ex- more significant. The surgeon reported that CT in- ploration, had failed to locate this foreign body. creased his confidence in the treatment chosen in seven patients, and that data available only from CT would have altered therapy in three patients. In Staging a later two-part study, Mancuso (53) described the range of normal variation in size, morphology and Lohkamp and Claussen (1977) (49) described pathology of the nodes in the head and neck region. the interpretation of CT in connection with the His CT-findings on size and location of normal TNM classification. They suggest that CT can de- lymph nodes correlate well with pathological, ana- termine T3/T4 and T2 tumors more precisely, but tomical and surgical literature. The diameter of that it is probably of no diagnostic value, since neck nodes, as seen on CT, varies from 3-10 mm in lymph nodes cannot be distinguished from the sur- the internal jugular chains, to l-10mm in the spinal rounding soft tissue structures. This is only possible accessory chains. The findings also indicate a ten- with direct or indirect lymphographic opacifica- dency for the nodes in the upper neck to be larger tion. Even then, their small-size reproduction on than those in the lower neck. It is not possible to CT scans brings the value of this mode of investiga- evaluate the internal architecture of normal lymph tion into some doubt. Mancuso (52, 53), Baehren nodes. Microscopic changes in small lymph nodes (3) and Reede (70) reported better results in their cannot be identified by CT. Neither is it possible to more recent studies (1981, 1982, 1983). Baehren differentiate between reactively enlarged nodes and concluded that the fraction of false-negative evalu- those enlarged by metastasis. It is interesting to ation of lymph nodes by palpation was 21% and note that CT may indicate enlargement of retro- that this high error in judgement could be reduced pharyngeal lymph nodes: nodes which are beyond to 7.5% by using CT. the reach of palpation. This is also true for the highest of the deep cervical nodes. Many authors con- Recent CT-studies have evaluated the effect of cluded that CT is of particular value in assessing CT-scanning on staging of tumors of the paranasal radical operability and the adequacy of radiothera- sinuses and the role of CT in otorhinologic practice py fields. (12, 43; 67, 84). Jeans (43) studied 30 patients with paranasal sinus tumors and concluded that CT advanced the staging in 57%. This resulted in larger volumes being treated by radiotherapy. Tissue density and contrast medium

It appeared that measurements of tissue densi- Lymph node metastasis ties were not helpful in distinguishing malignant tumor from benign disease. Parsons (64) found that Mancuso (52) suggested diagnostic criteria for in 15 out of 32 patients, CT demonstrated a signifi- evaluating cervical nodal metastasis. He also stud- cantly greater tumor extent than the convention ied the pathological correlation of CT and surgery methods did. The additional tumor most common- in a prospective group of ten patients with carcino- ly involved the pterygoid region or orbit. He con- yo

eluded that intravenous injection of contrast mate- tion are infections and allergic diseases. The sinus rial is useful when the blood-brain barrier is in- cavity fills completely and becomes airless, in con- volved but that it is of no value in facial neoplasm trast to the retention cyst. The sinus mucosa contin- proper. Bilaniuk (12) found that contrast enhance- ues to secrete and an increased pressure on the rigid ment is only useful in some specific lesions such as sinus walls develops. This may lead to expansion of vascular malformation, chemodectoma or juvenile the sinus, thinning of the walls or even pressure nec- angiofibroma and in determining whether there is rosis and bone erosion. In general, a mucocele is intracrania! extension of the lesion. She also de- sterile. If infected, it is referred to as a pyocele. scribed the advantage of i.v. contrast administra- Symptoms of mucoceles depend on their location. tion in differentiating between fluid and solid tissue Mucoceles in eihmoidal cells commonly cause dip- within a sinus, as in demonstrating inhomogeneity lopia and proptosis; in the maxillary sinus, painless of a mass resulting from necrosis, or formation of bulging of the cheek, diplopia or ipsilateral dental i cyst or abcess. Intravenous contrast administra- problems may occur. The CT-findings in mucoceles tion can also improve delineation of the normal or- consist of thinning and expansion of the sinus walls bital structures when they are displaced and distort- and a lack of enhancement after the administration ed, and can demonstrate mucocele walls. Som (79) of contrast material (42). The majority of muco- now routinely uses intravenous contrast material, celes show a homogeneous aspect. In pyoceles, en- since it enhances inflammation, thereby allowing its hancement at the periphery occurs after the admin- detection. Squamous cell carcinoma and fibrous istration of contrast, giving a rim-effect to the mucosal scarring were not enhanced by i.v. contrast mass. Mucoceles of the ethmoidal cells may expand injection. into the medial orbit. Even though the lamina papyracea is destroyed, a thin fatly plane is often preserved between the mucocele and the rectus muscle Coronal plane (36). There is displacement of soft tissue structures but no invasion. Price (65, 66) concludes that the The value of the coronal scans is stressed in appearance of mucocele may permit a definitive di- many studies. Especially when caudocranial extent agnosis. The location in the frontal and ethmoid si- is suspected (35, 40, 41, 55, 62, 64, 73, 86, 87, 88). nuses, with the expansile and destructive nature of Coronal scans are essential for evaluating the crib- the lesion, is characteristic, and CT is of value in the riform plate, the roof of the ethmoid sinuses, the determination of infra-orbital and intracranial ex- ethmoidomaxillary plate, the olfactory fossa, the tension. Mucoceles in the maxillary sinuses are orbital margins, the hard palate, floor of the maxil- rare. Gilsanz and Stanley (31) described an antral lary and frontal sinuses and the parasellar area. mucocele, which caused upward displacement of More detailed studies about different pathological the globe and swelling of the cheek due to displace- eniities followed these studies, in which the possi- ment of the lateral wall. The differential diagnosis bilities of CT in otorhinolaryngology were demon- included malignant tumor. strated. In 1983, Carter (16) described computed tomographic detection of sinusitis responsible for intracranial and extracranial infection. Carter demon- Disease entities strated several cases which illustrated the advantage of CT in the evaluation of the presenting symptoms Complications of sinusitis, such as mucoceles and the identification of an underlying sinusitis. and pyoceles, were extensively studied and their The presenting symptoms were secondary to the characteristics on CT were described by many au- complications. These complications included intra- thors (13, 32, 42, 61, 65, 66, 75, 80, 81). orbital and intracranial complications. Intraorbitai A paranasal sinus mucocele can be defined as complications are inflammation and edema, orbital the progressive accumulation of mucoid secretions cellulitis, osteitis, subperiostal abscess, intraorbitai within the sinus cavity initiated by an obstruction at abscess, arterial occlusion of the central retinal ar- the sinus ostium. Most common causes of obstruc- tery, optic neuritis, and hematoma (5, 19, 37, 38, Figure 5.2. Giant cell tumor of left maxilla. Destruction of alveolar process (arrows) and lateral antral wall (arrow heads). 39, 78). Intracranial complications include osteitis, reditary fibrous dysplasia) and the aneurysmal bo- osteomyelitis, subdural abscess, subdural empy- ne cyst also belong to this group of giant cell lesions ema, epidural abscess, meningitis, intracerebral ab- (fig. 5.2). The giant cell granuloma is usually visual- scess, cavernous sinus thrombosis, superior sagittal ized in the anterior portion of the mandible and sinus thrombosis and fungal infection (4, 11, 21, maxilla. Radiographically, a lytic lesion, someiimes 45, 56, 69, 71, 94). The spread of infection is con- multilocular, is visible. There may be areas of in- sidered to be venous spread (i.e. via the ophthalmic creased density within the lucency, due to the pro- vein and ethmoid veins), by continguous spread duction of osteoid and/or calcification. Bone de- and by extension via the perineural spaces and vari- struction may occur with and without calcification. ous canals, by the dehiseence of bone due to infec- It may then be impossible to distinguish this lesion tion, tumor or trauma, and via the congenital open- from a malignant process (72). When bone expan- ings in sphenoid and lamina papyracea. In such sion occurs, the giant cell granuloma is difficult to complicated intracranial and intraorbital diseases, differentiate from other benign tumors or muco- CT scan can quickly provide a correct diagnosis and celes. It may be impossible to differentiate from knowledge of the total extent of the disease, thus other fibro-osseous lesions such as fibrous dyspla- enabling proper patient management. The radio- sia (92), from sarcoidosis (93) and Wegener's gran- graphic manifestations of mycotic infections of the ulomatosis. Som (82) described the radiological ap- paranasal sinuses, one of the causes of severe intra- pearance of giant cell (reparative) granuloma, cranial complications, have been described by brown tumor and giant cell tumor as a lytic defect Becker (9), Centeno(18)and Kilpatrick (47). Cente- that may expand or perforate the bony cortex. In no discussed the role of CT in the early diagnosis of cherubism, an expansive, multilocular lytic mass, rhinocerebral fungal disease, i.e. mucormycosis may perforate the cortex and cause disturbance of and aspergillosis. This disease, which begins as a dentition, often bilateral, whereas the aneurysmal disease of the sinuses and nose, may extend into the bone cyst shows an expansive cystic mass, often orbital apex and cavernous sinus causing death by trabeculated or honeycombed. occlusion, rupture or thrombosis of arteries due to In an earlier study, Som (83) described the vasculitis, or by extension into the brain. CT coexistence of a malignant tumor and a mucocele in proved to be especially valuable in diagnosing the the paranasal sinuses. Such multiple lesions may intraorbital involvement of the disease causing dis- create a false impression of tumor size. Radiother- placement and thickening of medial uctus muscle apy fields may erroneously be set too large and the and optic nerve, leading to indistinct outlines of the tumor response may be underestimated. As most of nerve as it entered the orbital apex, this structure the malignant paranasal sinus tumors are character- having a higher density than normal. Mild propto- ized by a soft tissue mass with aggressive bone sis, which was evident in half of the cases, could destruction of the adjacent walls, the radiographic also be diagnosed. finding of an expansile mass is unlikely to be caused solely by carcinoma. The coexistence of a mucocele or even an alternative diagnosis of a select group of Benign lesions tumors, should then be considered.

Benign lesions such as retention cysts, polyps and inverted papilloma can easily be assessed by Malignancies plain films with conventional tomography, although antrochoanal polyps may mimic a malig- Malignant paranasal sinus tumor occurs in nant lesion, since they often lead to destruction of 0.2-0.3% of all human cancers and in 3(ro of malig- the medial sinus wall (15). One of the uncommon nant tumors of the head and neck (6.25). In malig- benign bone lesions of the paranasal sinus, the giant nant paranasal sinus tumors symptoms often take cell granuloma is included in the group of giant cell the form of recurrent chronic rhinosinusitis in the lesions (72, 81). The brown tumor of hyperparathy- early course of the disease and are often trivial (93). roidism, the true giant cell tumor, cherubism (he- The average delay is about 6 months from the onset A

Figure 5.3. Recurrent iidcnocurcinonia of ethmoid sinus (wiiitv arrow). Simmth liniiij! ot the posini;i\illccn>niy caviu. A. Axial section. B. Coronal section. of symptoms to the diagnosis. These symptoms are Extension of cancer of the paranasal sinuses dependent on the site and extension of the tumor. may occur through the innumerable foramina and There may be symptoms of unilateral nasal ob- fissures of the bones making up the sinus complex. struction and pain, with serosanguinous or puru- Extension into the adjacent structures may be peri- lent discharge. There may be specific localizing neural, vascular or lymphatic, or per continuita- signs secondary to tumor invasion, e.g. swelling of tum. the palate or the face. When a tumor invades the Som (79) studied 43 patients who had under- infra-orbital canal or foramen rotundum, paraes- gone either a partial or total maxillectomy for an thesia may develop. Eye symptoms can also occur, antral malignancy, and advised a six to eight week as can trismus when the tumor extends into the pter- post-operative baseline scan, with routine follow- ygopalatine fossa. Neurological involvement often up CT-examinations at four to six month intervals occurs in otorhinology due to extension of tumor for at least the first three years after surgery. In 18 into the orbit, an rior, middle and posterior cran- patients who underwent a combined clinical and ial fossa. Palsies of cranial nerves III, IV, VI, V-l CT-evaluation, there proved to be 4 recurrences of and V-2 suggest cavernous sinus involvement by tumor. In 3 patients, the recurrence of tumor was thrombosis or direct tumor invasion. A paresis of clinically occult and the clinically suspected recur- V-3 may indicate a lesion at the base of the skull in- rence in the fourth patient was confirmed by CT- volving the oval foramen, or a more peripherally lo- scan. The lining of the postmaxillectomy cavity cated lesion in the infratemporal fossa. Multiple should normally appear smooth on the CT-scan palsies of nerves IX, X, XI and XII may suggest in- (fig. 5.3). Any nodularity probably represents tu- vasion of the skull at the basiocciput, or more com- mor. When there is diffuse thickening of the overly- monly, an infratemporal mass around the internal ing skin of the cheek, tumor recurrence of inflam- carotid artery, just below the skull base. If VII or matory reaction should be suspected. With the im- VIII nerve lesions are observed, pathology of the provement of spatia! resolution (77), smaller recur- petrous bone must be considered. Destruction of rences of tumor may be detected more clearly. the foramen magnum may result in invasion of the Biopsy, however, is indispensable. IX, X, XI and XII cranial nerves. Lymph node metastasis of a paranasal sinus tumor occurs mainly to the retropharyngeal, upper 5.3 Patients and methods deep cervical and submandibular lymph nodes. Squamous cell carcinoma is the most frequent type In order to evaluate the impact of CT-exami- of carcinoma in the paranasal sinuses. The other nations in case of diseases affecting the paranasal common types of tumor are adenocarcinoma, ad- sinuses, 81 patients were reviewed. These 81 pa- enoid cystic carcinoma and melanoma. They are all tients were selected on the basis of the presence of epithelial tumors. Rare tumors are those arising pathologic changes affecting the paranasal sinuses from the supporting structures: i.e. rhabdomyosar- as demonstrated by CT-examiiiation. These pa- coraa, osteogenic sarcoma, chondrosarcoma, his- tients were discussed with the referring clinician. In tiocytoma and lymphoma (10.24). However, the this retrospective analysis, all the data of the pa- histology of the tumor has no impact on the inter- tients, as recorded in the patient's history, were pretation of CT-examination. Tumors originating studied and the following aspects have been dis- from bone, are not included in the group of soft tis- cussed: sue tumors. 1. Did CT contribute to the diagnostic under- Downey (26) described the CT-appearance in standing of the patient's disease, i.e. did CT pro- two patients with a chondrosarcoma. He concludes vide more, the same, less or confusing information that when CT reveals a relatively large mass with than was already available by conventional X-ray calcification, evidence of bone expansion rather studies and clinical examination, including inspec- than destruction, minimal symptoms and no evi- tion, palpation and endoscopy? (Table 5.1). dence of metastasis, the diagnosis of chondrosar- 2. Did CT contribute to a change in the originally coma should be seriously considered. planned therapeutic approach? Table 5.1. Diagnostic understanding (Wittenberg, 95, 96) Table 5.11. Standards for review of physicians' diagnostic and therapeutic ratings (Fineberg, 28) Value rating Dg Diagnostic ratings: Dl vs. D2 Final diagnosis differs from CT radiol- - CT confused my understanding of this ogist's diagnosis. If, prompted by CT paiient's disease and led to investigations I results, diagnostic tests in addition lo would not otherwise have done. Dgl those planned prior to CT are under- - CT con/used my understanding of this taken, then rate Dl. patient's disease but did not lead lo any IW vs. U4 Final diagnosis concurs with CT radiol- additional investigation. 0g2 ogist's diagnosis. If final diagnosis - CT had no effect or little effect on my shows >25°/« change compared with understanding of this patient's disease. Dg3 pre-CT probability, then rate D4. -CT provided information, which substantial- 04 VS. 05 If no other radiographic test did or ly improved my understanding of this could have been expected to reveal patient's disease. Dg4 the diagnosis, then rate D5. -My understanding of this patient's disease depended upon diagnostic information Therapeutic ratings: provided only by CT (unavailable from any Tl vs. T2 If therapeutic measures prompted by non-surgical procedure). Dg5 CT are subsequently found to be inappropriate, then rate Tl. T3 vs. T4 If final therapy differs from pre-CT Thirty-eight patients referred by the depart- therapy and review of abstracted rec- ment of E.N.T.-surgery (Head Prof, dr E.H. Hui- ord corroborates CT's contribution zing) have been evalualed with Dr John A.M. de to the change, then rate T4. T4 is. T5 If no other test report or information Groot, E.N.T.-speda'.ist. in the medical record contributes to a Eighteen patients referred from the depart- change in treatment and CT does, ment of Radiotherapy (Head: Prof, dr H. van Pe- then rate T5. perzeel) were discussed with Prof, dr L.A. Ravasz. Fourteen patients referred from the department of dental surgery (Former Head: Prof, dr P. Table 5.III. Modification of Wittenberg's Method Egyedi) were discussed with Prof, dr P. Egyedi and Choice of therapy Value rating with dr H. Mueller. - CT led me to choose therapy which in retro- Eleven patients were referred from Centres spect was not in the best interest of the outside the University Hospital. patient. Thl These referring clinicians provided their re- - CT was of no influence in my choice of marks in writing. therapy. Th2 - CT did not alter my choice of therapy, but This approach harbors a triple bias. A retro- did increase my confidence in the chosen spective study implies an inherent bias. A further treatment. Th3 bias is the fact that only patients whose clinicians - CT contributed to a change in therapy. Th4.5 elected to pursue the diagnosis with CT were studied. The third bias is caused by the fact that patients were selected on basis of pathologic processes described by Fineberg (28) (Table 5.II). The thera- evident in the CT images. It was not the aim of this peutic rating as described by Wittenberg et al. was study to determine the sensitivity or the specificity not applied. Since, in our opinion, there is an im- of this method. This requires an unbiased ap- portant subjective factor in the different Nation be- proach. tween T4 and T5 (Wittenberg) - the impression of In contrast to the prospective approach of Wit- the referring clinician and the extent of the disease tenberg and Fineberg (28) who questioned the refer- being such that precise staging is no longer of any ring clinician before and after the CT-examination, great significance - it is sometimes impossible to our study was performed retrospectively. The stan- make this differentiation. It is, however, possible dards for review of Physicians' Diagnostic and accurately to assess if CT had a positive effect on Therapeutic Ratings have parallelled the method as the choice of therapy. We therefore decided to sim- plif'y Wittenberg's method by considering T4 and 2. to detect lymph node metastases and inflam- T5 together as one positive group (Table 5. III). mation by enhancement; If CT provided a higher stage of tumor, or a 3. to delineate fascial planes (fig.)- change in the radiotherapy field (e.g. palliative or Initially our scans were done with a slice thick- curative radiation), than we concluded that CT ness of 6 mm at 6 or 9 mm intervals; scan time 4.2 contributed to a change in therapy. seconds. Later, we found that a slice thickness of The review of the CT-examinations was per- 1.5 mm at 6 mm intervals, combined with intraven- formed by the author and Prof. dr. P.F.G.M. van ous bolus-technique, was optimal. The new ceramic Waes after an interview with the referring clinician, tube of the present CT scan (Tomoscan 350. Phil- and analysis of the clinical results. In order to give ips) accepts a higher heat load, allowing consecu- a belter impression of the state of the art of multi- tive scanning of ] .5 mm slices svilhoul cooling time. planar high resolution CT we have included CT- In patients with biopsy-proven pathological proces- images from patients of the evaluated series, as well ses, only scans with intravenous contrast medium as interesting, more recent, patients. The evaluated administration are done: intravenous rapid se- 81 patients were examined in the period from 1978 quence scanning up to 20 slices during injection of until the end of 1984. 50 to 100 ml contrast medium (440 mg J/ml) ap- Intravenous contrast medium was adminis- plied in a batch mode. [Isopaque 440. Nyegaard tered in most of the patients examined. Mancuso Oslo]. Patients are examined routinely in the trans- (54) uses a rapid drip infusion by placing a 19 gauge verse axial plane. In cases of complicated patholog- needle into a good sized antecubital vein. The con- ical process, and when evaluation of structures trast bottle is then raised as high as possible. A dose orientated in the transverse plane is required, addi- of 150cc.sof'60% meolumine iothalamateis usual- tional direct scans are made in the coronal and/or ly sufficient. If not, an additional 75 ml of rapid sagittal plane. By selecting planes perpendicular to drip infusion, or a bolus injection, may be used. the basic transverse plane, the sections are no lon- Mancuso states that the use of intravenous contrast ger influenced by the same partial volume effect. material is justified in nearly all instances of malignancies which involve the head and neck, although it is possible to evaluate both the primary and re- 5.4 Results gional nodal disease without contrast infusion. The intravenous administration of contrast The value rating in diagnostic understanding medium is necessary: (Dg) and choice of therapy (Th) in a group of 81 un- 1. to demonstrate encasement of blood vessels by selected patients is listed in table 5.IV. The patho- tumor and to distinguish numerous branching ves- logic findings in these 81 patients are summarized sels within the neck from lymph nodes; in table 5.V.

Table 5.1V. Paranasal sinuses

Patient No. Site of lesion or Histology Value Rating primary lumor Dg Th

A. Skull and face 42 fibrous dysplasia Dg4 Th3 B. Frontal sinus 49 chronic sinusitis Dg5 Th4.5 54 chronic sinusitis DgS Th3 53 pyocele Dg5 Th3 68 pyoccle Dg5 TV. 5 75 trauma Dg5 Th4.5 52 hyperostosis (leontiasis ossea) DgS Th2 76 ossifying fibroma Dg5 Th3 50 fibrous dvsplasia DgS Th4.5 Table 5.1V. iCimiimted)

Patient No. Site of lesion or Histology Value Rating primary tumor Dg Th

C. Elhmoicl sinus 55 chronic sinusitis Dg5 Th4.5 27 mucocele Dg5 Th4.5 45 pyocele Dg5 Th4.5 9 polyps Dg3 Th2 69 polyp Dg2 Thl 34 infected polypoid tissue Dg5 Th4.5 72 inverted papilluma Dg5 Th3 13 adenocarcinoma Dg5 Th4.5 37 adenocarcinoma Dg5 Th4.5 80 adenocarcinoma Dg5 Th4.5 3 non-Hodgkin lymphoma £>g5 Th3 21 non-Hodgkin lymphoma Dg5 Tl)4.5 40 non-Hogdkin lymphoma Dg5 Th2 35 osteogenic sarcoma Dg5 Th4.5 51 papillary carcinoma Dg5 Th2 8 squamous cell carcinoma Dg5 Th3 23 squamous cell carcinoma Dg5 Th4.5 25 squamous cell carcinoma Dg5 Th4.5 38 squamous cell carcinoma Ug4 Th3 67 squamous cell carcinoma Dt-" Th3 5 undifferentiated carcinoma Dgi Th3 12 undil'fercntiatcd carcinoma »g4 Th3 19 undiffcrentiiUcd carcinoma DgJ Th2 26 undifferentiatcd carcinoma Dg5 Th3 39 undifferentialed carcinoma Dg5 Th4.5 46 undit'fcrcniiatcd carcinoma Dg5 Th4.5 D. Maxillary sinus 29 chronic sinusitis Dg.l Th3 74 chronic sinusitis Og3 Th3 43 chronic sinusitis/polyp* Dg3 Th3 36 inverted papilloma Og5 Th4.5 70 inverted papilloma Og3 Th3 71 inverted papilloma and squamous cell carcinoma Dg5 Th4.5 48 ossifying fibroma Og5 Th4.5 15 adenocarcinoma Dg5 Th4.5 20 adenocarcinoma Dg3 Th3 2 adenoid cystic carcinoma Dg5 Th3 28 adenoid cystic carcinoma Dg5 Th3 59 adenoid cystic carcinoma Dg5 Th4.5 79 adenoid cystic carcinoma Dg5 Th4.5 10 anaplastic carcinoma Dg5 Th4.5 I colloid carcinoma Dg5 Th2 7 extramedullary plasmacytoma Dg5 Th4.5 18 extramedullary plasmacytoma Dg5 Th3 31 extramedullary plasmacytoma Dg5 Th3 14 fibrosarcoma Dg5 Th4.5 81 fibrosarcoma Dg5 Th4.5 78 malignant melanoma Dg5 Th3 11 squamous cell carcinoma Dg5 Th4.5 16 squamous cell carcinoma Dg5 Th4.5 17 squamous cell carcinoma Dg3 Th2 32 squamous cell carcinoma Dg5 Th4.5 33 squamous cell carcinoma Dg5 Th4.5 Table 5. IV. (Cimtinut'if)

Patient No. Site of lesion or Histology Value Rating primary tumor Dg Th 77 squamous cell carcinoma Dg5 Th3 4 undifferentiated carcinoma Dg5 Th4.5 6 undifferentiated carcinoma Dg5 Th4.5 44 undifferentiated carcinoma Dg5 Th4.5 E. Maxilla 47 nasolabial cyst Dg5 Th4.5 62 ameloblastoma Dg5 Th4.5 56 adenoid cystic carcinoma Dg4 Th3 63 ? carcinoma Dg5 Th4.5 30 osteogenic sarcoma Dg5 Th2 60 osleogenic sarcoma Dg5 Th3 F. Hard palate 61 adenocarcinoma Dg5 Th4.5 57 adenoid cystic carcinoma Dg4 Th3 58 mucoepidermoid carcinoma (benign type) Dg5 Th3 64 squamous cell carcinoma Dg5 Th4.5 G. Mandible 22 ameloblastoma Dg4 Th3 24 non-Hodgkin lymphoma Dg5 Th3 41 osteogenic sarcoma Dg5 Th4.5 H. Cheek 65 acinic cell carcinoma Dg3 Th2 I. Ndsopalutine duct 66 cyst Dg5 Th4.5 i. Parotid gland 73 cyst Dg5 Th4.5

The contribution of CT to diagnostic un- ment. This is a positive effect (Dg3 Th3). Only in 3 derstanding (Dg) and choice of therapy (Th) is pre- of these patients did CT fail to provide essential sented in table 5.VI. new diagnostic information and fail to influence the choice of therapy (Dg3 Th2 combination). This can be graded as a negative result. The overall con- S.5 Discussion tribution of CT can be considered negative in only 5 patients (6%). In 7 out of 81 patients CT provided In none of the patients was CT confusing nor information which significantly improved under- did it lead to superfluous investigations. In 2 pa- standing of the patient's disease (Dg4). In this patients, CT was confusing but did not lead to any ad- tient material all patients with Dg4 occurred in ditional investigation. Moreover, the choice of combination with Th3 (table 5.VI and 5.VII). This therapy was not influenced in one patient (Dg2 constituted a positive result for these patients. In 63 Th2), but in the other patient it led to inappropriate patients CT provided information which could not therapy (Dg2 Thl). CT had little or no effect on di- be obtained from any other non-surgical procedure agnostic understanding in 9 cut of 81 patients (table (Dg5). CT had no influence on the choice of thera- 5. VI). We are inclined to consider not only the Dgl py (Dg5 Th2) in only 3 of these patients. There are and Dg2, but also the Dg3 group as a negative re- 2 basic reasons why CT may not influence patient sult. However, by relating the results of this group management (Th2): (Dg3) to the results on the impact on patient man- 1. Host factor. The patient is not able to be treat- agement, we found that in 6 patients, the CT exami- ed. nation increased confidence in the chosen treat- 2. Tumor factor, a. The primary tumor is too Table 5. V. Pathological findings in 81 patients Table 5. VII. Combined results of diagnostic and therapeutic impact in 81 patients malignant tumors - squamojs cell carcinoma 12 Dg Th No. of -adenoid cystic carcinoma 6 patients - adenocarcinoma 7 Dg2 Thl 1 -undifferentiated carcinoma 9 I Dg2 Th2 1 > negative results of - anaplastic carcinoma 1 Dg3 Th2 3 CT in 5 patients -colloid carcinoma 1 - acinic cell carcinoma 1 Dg3 Th3 6 - osteogenic sarcoma 4 Dg4 Th3 7 - fibrosarcoma 2 Dg5 Th2 5 ' positive results of -non-Hodgkin lymphoma 4 Dg5 Th3 17 CT in 76 patients - mucoepidermoid carcinoma I Dg5 Th4.5 41 - extramedullary plasmacytoma 3 - papillary carcinoma 1 - malignant melanoma 1 - ? carcinoma 1 therapy (Dg5 Th3). In half of the patients (41 out benign tumors of 81 patients, or about 50%) CT not only provided - inverted papilloma 3 unique information but also contributed to a major - polyps 4 change in therapy. The overall positive result of the - cysts 3 - hyperostosis (leontiasis ossea) 1 CT examination is 76 out of 8i patients. - ossifying fibroma 2 - fibrous dysplasia 2 - ameloblastotna 2 5.6 Illustrative patients and pathology infections - sinusitis 5 CT confused the understanding of the patient's - mucocele 1 disease (Dgl, Dg2) - pyocele 3 trauma I Confusing CT findings occurred in a minority of patients. In one patient this resulted in inappropriate therapy. It concerned a 31-year old man who large: the loco-regional extension is so large that has exophthalmus (patient no. 69). A radiograph of planned curative radiotherapy becomes impossible, the paranasal sinuses in the occipito-mental (Wat- b. There is a second malignant tumor or there ers') and postero-anterior view (Caldwell) showed are distant metastases. blurring of the left ethmoid sinus and thickening of Another reason is that the clinician's thera- the lining mucosal membrane of the left maxillary peutic choice is predominantly based on the histo- sinus. CT showed a tumor in the left ethmoid sinu., logical report, without taking the CT-findings into and in the apex of the orbit. The posterior part of account. the bony wall of the orbit could not be adequately In 19 patients, the unique information of CT delineated. Invasion of tumor from the left eth- examination contributed to a definite choice of moid sinus into the apex of the orbit was suspected (fig. 5.4). At surgery, no tumor in the orbit could be demonstrated. The orbital fat proved to be Table 5.VI. Contribution of CT in 81 patients edematous and the orbital muscles swollen and Diagnostic- No. of Choice of No. of pale. The final diagnosis was infectious pseudotu- understanding patients therapy patients mor of the orbit. The process in the ethmoid sinus (Dg) (Th> proved to be a polyp. No signs of malignancy were Dgl 0 Thl 1 found (Dg2 Th 1). Since the CT examination was of 6 Dg2 2 Th2 poor quality (second generation scanner, wrong Dg3 9 Th3 33 Dg4 7 Th4.5 41 window setting), we believe that this false negative Dg5 63 finding is an exception. 101)

Figure 5.4. Pseudotumor of lefl orbi! due to elhmoid polyp (2nd generation CT scan). 101

^igure 5.5. Chronic sinusitis of the led maxillary sinus. Situaiion after surgery. Nole the calcified rim (small arrow) and defects in ateral and medial antral wall. 1(12

itti

'^MMHMMJtt itfBBKKBSatA.

I'liiuri' ?.f>. Remnants ol infected pohpoid tissue in ethmoid MIIII- altci Miiiicr*. \. \\i.il M.,HIN. Dt-liM^ m cihinoul ;IIK1 nut\illar\ sintiSL's (arrou hauls). M<>lh cfhinoiii UIHI sphenoid sinuses ..oniiiin puKpttiil IISMII.1 .nul i:\iic. M I oion.il MMIOMV liul^ini: ol poKpoid tissue into ihi.1 nasal ca\tt> on bolh sitics. 1 he nppei pan ot itn; nasal scptuni (petpeiulMilat plate ol ethmoid) is deMioved t;irrouI. (.'. Direet sai-'illal seelions. I he deteet in Ihe ethmoid sums ||,ioi is shown as is Minimi: ot the sphenoid MIIIH. 103

Figure 5.6. Remnants of infected polypoid (issue in ethmoid sinus al'ler surgery. A. Axial scans. Defects in ethmoid and maxillary sinuses (arrow heads). Both ethmoid anJ sphenoid sinuses contain polypoid tissue and glue. B. Coronal sections. Bulging of polypoid tissue into (he nasal cavity on both sides. The upper part of the nasal septum (perpendicular plate of ethmoid) is destroyed (arrow). C. Direct sagittal sections. The defect in the ethmoid sinus floor is shown as is the blurring of the sphenoid sinus. 104

Figure 5.7. Acinic cell carcinoma in left check surrounded by fatty tissue on the lateral side. The minor approaches the niucosa on the medial side. A. Coronal section. B. Electronic enlargement of same section. 10?

Figure 5.8. Amclohlasioma olthc mandihle. the tuimir is nell delineated. ;md SIIOH s arc.is of dillereiii densiu. I lie mandible shows extensive destruction and is displaced anterolateralK. 1 he inlialcitiporal space is occupied b\ the minor, and the paiapharvngeal space is compressed (arrow head). Anterior now ing ol posterior antral wall rel'lects s|o« prouiii ol ilie minor. 106

CT had little or no effect on the understanding of side of the left cheek (patient no. 65). On the coro- the patient's disease (Dg3) nal scan, a rather well defined tumor was seen lateral to the tuber maxillae. There was no evidence of In 9 patients, the results of the CT examination bone destruction, but there was invasion of tumor agreed with the clinical findings and the findings of into the fatty tissue of the cheek (fig. 5.7). After conventional radiographs. CT provided no essen- surgery, the tumor proved to be an acinic cell carci- tial new diagnostic information. In 2 of these pa- noma, a very rare tumor, with a high degree of ma- tients, CT was of no influence on the choice of ther- lignancy. Since the surgical excision proved not to apy. However, in 7 patients, CT did not alter the be radical, radiotherapy was done. CT had little or choice of therapy, but did increase confidence in not effect on the understanding of the patient's dis- the chosen treatment. One of these patients was an ease and did not alter the choice of therapy (Dg3 81-year old man with an adenocarcinoma of the left Th2). maxillary sinus (patient no. 20). Conventional tomography demonstrated a tumor of the left maxil- CT provided information, which substantially lary sinus invading the left ethmoid sinus, medial improved the understanding of the patient's disease orbital wall, the nose and the hard palate. CT con- (Dg4) firmed these findings (DgT TM). A 54-year old woman had recurrent infections In 7 patients, CT provided information which of the left maxillary sinus after surgery (patient no. substantially improved the understanding of the pa- 74). Endoscopic examination revealed thickened, tient's disease (Dg4). A 63-year old woman had a granulating mucosa and pus in the left maxillary si- recurrent undifferentiated carcinoma in the left eth- nus. An infectious process outside the left maxillary moid sinus and nasal cavity (patient no. 12). CT sinus was suspected. This could not be demonstrat- examination showed tumor and evidence of deed by CT (Dg3 Th3). CT showed calcification of the struction of the left ethmoid sinus, tumor in both chronic inflamed granulation tissue. This calcified nasal cavities and displacement of the nasal septum rim paralleled the skeletal structures (fig. 5.5). (Dg4). A 46-year old woman suffered from recurrent A 79-year old woman had recurrent amelo- nasal polyps and sinusitis (patient no. 43). A CT blastoma of the mandible (patient no. 22). Amelo- scan was done to exclude orbital wall involvement. blastomas are benign epithelial odontogenic tumors CT did not show destruction or expansion of the or- and constitute a small percentage (1%) of all tu- bital walls. A tumor mass was seen in the nasal cavi- mors and cysts of the jaws (6). The classic roentgen ty on both sides, along with surgical defects in the appearance of an ameloblastoma is that of a multi- lateral walls and partially filled maxillary and eth- locular radiolucency. Recently, Mueller (58) con- moid sinuses. Polyps and glue were found at sur- cluded that more radical surgery is advisable in gery. CT had no effect on the understanding of the multilocular ameloblastoma, and that in unilocular patient's disease and did not alter the choice of ther- ameloblastoma, a more conservative approach is apy (Dg3 Th3). This is in contrast to a second pa- justified. In our patient, histological examination tient with infected polypoid tissue (patient no. 34). revealed the multilocuisr pattern. CT showed a Here, CT clearly demonstrated that remnants of fairly well delineated tumor, with well defined, less the disease were present after surgery (Dg5. Th4.5) dense, round areas (fig. 5.8). The tumor had a par- (fig. 5.6). tially ossified capsula, produced by the outermost A 31-year old man complained of recurrent cells which resemble those of the ameloblastic layer headaches (patient no. 54). A thickened and scler- or inner enamel epithelium. There was also a pres- otic left frontal sinus was noticed on CT. No intra- sure deformity of the right maxillary sinus. The pa- cranial enhancement or pathology was seen after rapharyngeal space was compressed but not invad- intravenous contrast administration. There proved ed. The mandible was destroyed. to be a chronic frontal sinusitis. This was also seen Since the tumor could be inspected and palpat- on plain radiographs (Dg3 Th3). ed rather well, and destruction of the mandible was A 44-year old man noticed a tumor in the inner shown on conventional radiographs, (he only con- Figure 5.9. Fibrous dysplasia (Albright syndrome). A. Axial section at the level of paranasal sinuses. Encroachment on pterygopalatine fossa (arrows). Cyst-like changes in maxilla as well as mandible (arrow heads). B. Coronal sections. Mottled appearanr..- of left frontal bone and maxilla on both sides. IDS

figure 5.10. fibrous dvsplasia. Ifnlargement of right I'romal bone with mottled appearance- 109

Figure 5.11. Adenoid cystic carcinoma of hard palate. Extension of tumor into soft palate, pterygoid process (small arrow), nasal cavity and maxillary sinus. The infra-orbital wall is also involved. Bulging of the hard palate (arrow head), due to the slowly growing tumor. 110

Figure 5.12. Squamous cell carcinoma of the ethmoid sinus. Invasion of tumor into base of skull (arrow head), nasopharynx, posterior maxillary sinuses, pterygopalatine fossa, superior orbital fissures, and right parapharyngeal space. Coronal scans. Ill

tribution of CT was the demonstration of tumor in dency of this tumor to invade nerves. CT examina- the infratemporal space with compression of the tion did not alter the choice of therapy (Dg4 Th3). parapharyngeal space. This did not alter patient On clinical and CT examination, the adenoid cystic management. (Dg 4 Th3) carcinoma sometimes appears as a rather well cir- A 31 -year old woman was known with the Al- cumscribed tumor. Microscopically, a highly in- bright syndrome (patient no. 42). This syndrome vasive pattern with neural invasion is seen. This ex- includes skeletal lesions, skin pigmentation and plains the need for wide excision of this tumor. precocious puberty (6). The skeletal lesions belong Bulging of the hard palate (patient no. 57, fig. 5.11) to the group of fibro-osseous lesions, i.e. fibrous reflects the slow expansion of this malignant tu- dysplasia. These lesions show replacement of nor- mor. This pattern is not pathognomic for adenoid mal bone architecture by tissue composed of col- cystic carcinoma. lagen, fibroblasts and varying amounts of osteoid or calcified tissue. CT examination showed expansion of the bony walls of the paranasal sinus, mot- The understanding of the patient's disease tled cyst-like lesions of the enlarged mandible, and depended upon diagnostic information provided involvement of the skull base and temporal and oc- only by CT (Dg5) cipital bone (fig. 5.9 and 5.10). On the axial scan, the pterygopalatine fossa proved to be narrowed by Most of the patients examined belong to the the bone expansion. There was no invasion of tu- Dg5 group. A number of patients in this group will mor into the soft tissues. As plain radiographs be described, along with remarks on the influence showed the cyst-like lesions well, the major contri- of the CT examination on therapy. bution of CT was the demonstration of pathologi- A 56-year old man had severe headache for 7 cal changes in the skull base (Dg4). This, however, months (patient no. 23). He also suffered from loss was of no influence on patient management (Th2). of taste and smell, and he complained of diplopia. In this patient, Th2 resulted from the fact that Anterior rhinoscopy had revealed a large ulcerating therapy had been determined from the outset. tumor. This tumor almost entirely filled the left na- There is also no influence on therapy when the con- sal cavity. A polypoid lesion was seen, attached to dition of a patient precludes radiotherapy, surgery the right medial concha and posteriorly, a tumor- or chemotherapy. When the CT findings are useless ous mass was reported. Two deep ulcerations of the or incomplete, there is also no influence on therapy. junction of the soft and hard palate were seen on in- Th2 will also result when the clinician ignores the spection of the oral cavity. Endoscopic examina- findings of the CT examination (patient no. 20). tion showed the tumor in both nasal cavities. The A 70-year old man had a swelling of his right nasopharynx could not be inspected. Biopsy re- cheek and an ill-fitting dental prosthesis due to an vealed that the tumor was a well differentiated adenoid cystic carcinoma of the left part of the hard squamous cell carcinoma. CT showed the presence palate (patient no. 56). Conventional tomography of tumor in both ethmoid sinuses and invading the showed destruction of the hard palate, alveolar base of the skull i.e. clivus, nasopharynx, posterior process, right anterior and posterior wall of the part of both maxillary sinuses, both conchae, ptery- maxillary sinus. The tumor reached the orbital gopalatine fossa, superior orbital fissures and the floor; destruction of this floor was not obvious. CT superior part of the parapharyngeal space on the examination confirmed these findings and also right-hand side (fig. 5.12). The bony framework of demonstrated invasion of tumor into the infratem- the posterior maxillary sinuses, the hard palate, the poral space. Involvement of the temporal muscle superior and posterior part of the pterygoid pro- was suspected. At surgery, the orbital floor did not cesses and the posterior parts of both medial orbital show macroscopically recognizable tumor. The or- walls, was destroyed (Dg5). The destruction of the bital floor therefore was resected and the orbital clivus, which was demonstrated on CT, was espe- contents were saved. Histological examination, cially important for further patient management however, showed involvement of the orbital floor (Th4,5). Another patient with a squamous cell car- and infraorbital nerve. This resulted from the ten- cinoma of the ethmoid sinus had extension of the 12

Figure 5.13. Inverted papilloma and squamous cell carcinoma. A. Coronal sections. Infiltration of tumor into ihe orbit (small arrow head), parapharyngeal. infratemporal and temporal space (arrow). Enlargement of masseter muscle. B. Avial sections. Infiltration of tumor into the cheek (arrow head). le\alor lahii superior muscle (small arrow) and pterygopalatine fossa (large arrow). Note the enlarged pre-auricular lymph nodes. Figures. 13. Inverted papilloma and squamous cell carcinoma. Axial sections. Infiltration of tumor into the cheek (anow headl. le\ator labii superior muscle (small arrow), and pterygopalatine fossa (large arrow). Note the enlarged pre-auricular lymph node* f small iijrov\ heads).

Figure 5.14. Colloid carcinoma. There is destruction of the cribriform plate (small arrow heads) and mtracranial spread ol lumor (arrows). Lateral displacement of the left medial orbital wall (small arrows). 14

/•mure 5./5. \denocarcinoma o! ilu1 ethmoid Mini- (I I. C oronal sections. Intracrainal extension ol minor. The cnhriiorm plaic is desinned. rhcrc i- also dc-iriuiuui ot the medial and nilenor orbital "all. clhnioul sinus, nasal septum and medial antral s,all on the left The nasal cawu is also occupied h\ ihis tumor on both sides. 115

Figure 5.16. Undil'lcreniiaicd carcinoma of right ma\illar\ sinus. A. Direct sagittal section. I:\tension of minor into nasopharwiv B. Coronal section, t:\tension of tiimor into right orbit and nasal auity. Displacement of nasal septum to the iett.

[•'inure 5.17. Situation after resection of an adenocarcinoma of the hard palate. I he detect has been closed with .i buccal lui pad<»null arrows). A. Second generation scanner image (197X1. B. Third generation scunner image (I*>S 1). Die lateral picrvgoid plate lu- been resected (arrow head) as has tiie medial pterygoid muscle (small arrow head) and pan ot the latetal picrveoid muscle. 116

tumor into the nasal cavity, maxillary sinus, sphen- 58). This patient had a low-grade mucoepidermoid oid sinus, anterior and middle cranial fossa and carcinoma of the hard palate. This carcinoma was pterygopalatine fossa (Dg5 Th4,5) (patient no. 25). completely resected. The resection borders were Invasive squamous cell carcinoma arising in free of tumor. The remaining cavity was closed with the same anatomical area as the inverted papilloma, the buccal fat pad in order to facilitate prosthetic is not unusual (83). In our study it occurred in a supply (91). 79-year old man, who had undergone surgery in the The aim of postoperative CT-examination was past for an inverted papilloma. Invasion of the left to record the status quo and to allow follow-up of ma.xillary sinus tumor into the cheek, orbit, parap- the patient after a certain period of time. Only CT haryngeal space and infratemporal fossa was well could provide this information (Dg5). This was of shown (fig. 5.13). no influence on immediate therapy (Th3). Another case of carcinoma with involvement A second patient, who had an adenocarcinoma of the cranium was seen in a 74-year old man (pa- of the hard palate, underwent the same procedure tient no. 1). Although CT provided unique infor- (patient no. 61). We were able to review the patient mation which was unavailable from any other non- after two years. The CT scans all showed the same, surgical procedure (Dg5), this was of no influence well-delineated defect on axial and coronal scans, on therapy, since this colloid carcinoma was re- located directly posterior to the right maxilla (fig. sistent to radiotherapy and not sensitive to chemo- 5.17). Patients 58 and 61 are still alive after more therapy (Th2) (fig. 5.14). Adenocarcinoma in the than 5 years. (Compare the difference in technique ethmoid sinus, due to wood-dust exposure, is a of the first examination with a 2nd generation scan- well-known entity (6) (patient no. 80, fig. 5.15). An ner, and the second examination with a 3rd genera- undifferentiated carcinoma occurred in a patient tion scanner.) who was a furniture worker (patient no. 26). There Osteogenic sarcoma, which is the most com- was no intracranial extension of tumor. This was mon primary malignant tumor of bone, is relatively confirmed at surgery (Dg5 Th3). rare in the oral and facial region. Two patients in An undifferentiated carcinoma of the right our material had an osteogenic sarcoma of the maxillary sinus occurred in an 82-year old woman maxilla (patients nos. 30 and 60) and one of them (patient no. 44). The patient was examined in the had a lov, -grade osteogenic sarcoma (patient no. axial, coronal and sagittal plane (fig. 5.16). The 30) (fig. :S.1N). One patient had an osieogcnic sar- coronal and sagittal sections showed extension of coni;i of the mandible. The CT examination of this tumor into the nasal cavity and right frontal sinus. patient (no. 41) showed involvement of the right The coronal sections showed invasion of tumor into mandible from the coronoid process to the mental the medial orbit on the right. The ethmoidal cells protuberance (fig. 5.19). The tumor extended to the were destroyed, the sphenoid walls were intact on buccal and lingual side of the mandible. The poste- the right and were opacified, probably due to the rior part of 'he mandibular ramus was normal on presence of glue. The extensive findings of the CT CT. The tumor had a 'sunray' appearance, which examination demonstrated that only palliative ra- implies that the cortex is affected and new bone has diotherapy was possible (Dg5 Th4,5). developed. This new bone forms striations which Mucoepidermoid carcinomas can be divided extend perpendicular to the surface. The paraphar- into low-grade and high-grade carcinomas. The yngeal space was compressed by the tumor which high-grade carcinomas require radical surgery be- invaded the medial pterygoid muscle and masseter. cause of their high recurrence rate (20-50%) and The findings of the CT examination were con- the propensity for regional lymph node metastasis. firmed at surgery and by histological examination. Since the low-grade mucoepidermoid carcinomas If the tumor had invaded the parapharyngeal space, usually have signs and symptoms similar to benign patient management would have been different. CT mixed tumors, they may be adequately treated by therefore provided unique information which influ- local excision without adverse results, particularly enced patient management (Dg5 Th4,5). recurrences. A mucoepidermoid carcinoma was In the patient with the low-grade osteogenic present in one of the patients examined (patient no. sarcoma of the maxilla (patient no. 30), the first /•t,uun> *.IX. (Kk-o na of left rna villa. 1 VwriJt/linn n) ol luinoi uilo mlr 1 IN

f iiiun- 5.19. (Ki \iiv,om.i n! the ndii in.uulihic IneiMiL n.dke .>! liL'h' ni.iiuiihiLl.ir KIMIIU .HK! N>J\ luiil'i.iiii'ii ol

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120

ii^urv 5.20.11. ï\n;imedullar\ plasmacytoma and annlokl ot hoth paianasal sinusev 'Iho anicrioi aiui nicdtal \IIHI1* walK are destroyed on both Mdov The posterioi wall ol the liiiln ma\ill;ir> sum- ah» shows destruction, the tumor imades Uie nil'ratemporal space (arrow|. 1 "he nasal eaiiti is panialK l'ilied »ilh mmor. 121

Figure 5.21 Ossifying I'ifrroniii. Axial scclions. I ulerul displiicomcni nl lijihl Uimina pap>i;n.va (small arums). I he iiinuii t'Mcnds m the orbilal scpluni (arrows), occupies the nasal ca\il>, tlesirovini^ \x\x\ ol Ihe nasal lione at the riiihi {arritw head).

Figure 5.22. l.eonliasis ossea or oMcrnal Inperostosis. Note the hroacleninu and hulginu of sclerotic occipital and Irorn.il Urne (.nial and /'ronlal sections).

123

histological diagnosis was a desmoplastic fibroma. fibroma appears as a well demarcated radiolucen- Initially, it was thought therefore that the tumor cy, later it becomes more mineralized. When the le- was relatively benign. CT examination, however, sion expands, the sinus mueoperiosteum can appear showed invasion of tumor into the temporal muscle as a more or less calcified rim. Ossifying fibroma and tendon, in the lateral and medial part of the was present in two of the patients examined (pa- pterygoid muscle, destruction of the pterygoid pro- tients nos. 48 and 76). Both patients were first recess, alveolar process and hard palate. These inva- ferred to the ophthalmologist because of a swelling sive and destructive findings on CT examination around the eye. One of these patients, a 40-year old were very suggestive of malignancy, as was con- woman, had a fluctuating swelling at the site of the cluded in the CT report. The surgeon based his plan right lacrimal sac (patient no. 48). The ophthalmol- of treatment on the first histological diagnosis of ogist suggested a cyst of the lacrimal sac. CT desmoplastic fibroma, although the CT was in dis- showed a large, well-demarcated lesion in the eth- agreement (Th2). A second histological examina- moid and frontal sinus which extended to the left tion confirmed the conclusion of the CT examina- ethmoid sinus and displaced the nasal septum to the tion: there was a low-grade osteogenic sarcoma. A left. The lamina papyracea of the right eye was dis- re-resection was performed. placed laterally. The medial rectus muscle was well A 59-year old man had an extramedullary plas- delineated. The orbital fat between lamina pa- mecytoma of his left maxillary sinus causing swel- pyracea and medial rectus muscle was preserved ling of his cheek (patient no. 7). CT showed de- (fig. 5.21). These findings on CT examination were struction of part of the anterolateral and posterior unique and very important when compared with wall of the maxillary sinus and part of the zygoma other factors in leading to a beneficial change in (fig. 5.20). The tumor invaded the anterolateral therapy (Dg5 Th4,5). The findings at surgery cor- part of the infratemporal fossa. The posterior part related well with CT examination. of the maxilla and the pterygopalatine fossa were External hyperostosis in the frontal and occip- free of tumor. The tumor was closely related to the ital bone region occurred in one patient (patient no. inferior orbital fissure. It was fairly well delineated 52). The disease is also known as leontiasis ossea and had almost smooth margins. In front and later- and is characterized by excessive formation of cor- ally the tumor approached the fascia, preserving a tical bone which may lead to great deformity of the distinct fatty interface. The tumor had a slightly in- skull. In this patient, the lesions were located in the homogeneous appearance with dense spots, prob- occipital and temporal bones, and the sphenoid and ably due to the presence of remaining bone. Since frontal bone on the left (fig. 5.22). CT showed the the tumor was well shown, the field of radiation exact extent of the disease, especially in the base of could be planned exactly (Dg5 Th4,5). Extramedul- the skull (Dg5 Th2) (fig. 5.22). lary plasmacytoma is a plasma cell tumor which is Mucoceles and pyoceles were seen in four pa- characterized by an abnormal proliferation of plas- tients (patients nos. 27, 45, 53, 68). In a 38-year old ma cells derived from progenitor cells in or outside woman, a proptosis of the right eye developed some bone marrow. TheextrameduJlary form occurs less years after ethmoidectomy (patient no. 27). CT frequently than the medullary form. The second showed a well-defined oval density in the ethmoidal patient with an extramedullary plasmocytoma had cells on the right side protruding into the right orbit been treated with radiotherapy for his tumor in the and causing protrusion of the right eye. The lamina past (patient no. 18). CT clearly showed recurrence papyracea could not be identified. The orbital fat of the tumor (Dg5 Th3). A rare combination of between medial rectus muscle and the lesion was extramedullary plasmacytoma and amyloidosis is well shown (Dg5 Th4,5). (fig. 5.23) No enhance- shown in figure 5.20 II. ment occurred after intravenous injection. A muco- Ossifying fibroma is often considered to be a cele of the ethmoid sinus was found at surgery. variant of fibrous dysplasia because of the histolog- Mucoceles are well delineated and their margins do ical similarities. It is a benign fibro-osseous lesion. not enhance with contrast. Mucoceles of the eth- The stage of maturity of the lesion is important for moid sinus are very rare. the radiographic appearance. At first, the ossifying Pyoceles show a rim enhancement after intra- 124

Figure 5.23. Mucocele of right ethmoid sinus. Amerolateral displacement of the right eye. There is no enhancement of mucocele wall after i.v. administration of contrast medium. Note the optic canal (arrow).

Figure 5.24. Pyocele of left frontal sinus. Axial sections. A. Wiihout i.v. contrast medium. B. With i.v. contrast medium. Enhancement of pyocele wall (arrow heads). Note the forward and lateral displacement of the left eye. 125

Figure 5.25. Nasopalatine cyst. A. Axial section. The anterior wall of ihe left maxilla shows destruction (small arrow). In front, a low density area with a lobulated wall is visible. The cyst protrudes into the right maxillary sinus. )2r.

1-itinrc .'.J.-\vi. A OI p;m of m;i\ill.i l.irniu lu-aiU). I .itci.il nl li^.ilm l;ihii Mipi'iun iilu-Ji.' 127

venous contrast injection. This is well demonstrat- into the left maxillary sinus. The soft tissues on the ed in a 75-year old woman who had an extreme left- left side of the nose and cheek were pushed for- sided protrusio bulbi (patient no. 68). CT showed ward. A cyst was found at operation but no defect a very large oval lesion medial to the left eye. There was seen in the anterior part of the maxilla, al- was displacement of the left eye anteriorly and lat- though this defect was quite obvious on CT. CT erally. The lesion occupied the left frontal sinus, provided unique information (Dg5) and influenced left ethmoid sinus and left part of the nasal cavity, patient management (Th4,5). probably including the ostium of the left maxillary The nasolabial cyst presented in a 24-year old sinus, which was filled with tumor or glue. As the worr.an (patient no. 47). On CT, the cyst had well- maxillary sinus walls were thickened, there was defined smooth margins (fig. 5.26). Bone resorp- probably a chronic sinusitis. The anterior wall of tion of the anterior left maxilla was shown. These the frontal sinus was destroyed (fig. 5.24). Rim en- findings are important for the resection of the cyst hancement occurred after intravenous injection of (Dg5, Th4,5). contrast medium. The anterior wall of the frontal sinus was destroyed (fig. 5.24). At surgery, the diagnosis of a pyocele was confirmed, as was the ex- 5.7 Conclusion tension of the lesion, described in the CT report. The maxillary sinus contained glue. In these pa- In 76 out of 81 patients (about 94°7o) CT tients CT provided information unavailable from proved to play a positive role in therapeutic man- other non-surgical investigations and influenced agement. In a small number of patients (4) CT ex- patient management (Dg5 Th4,5). amination provided valuable information but ther- The location of a pyocele, the well-defined apy was not influenced: the patient's condition or margins and rim enhancement after intravenous the disease was such that therapy was impossible. contrast administration, may be considered as Superfluous CT examination leading to wrong ther- pathognomonic. apy was seldom found (1 out of 81 patients). Al- Two types of non-odontogenic cysts of the though there are some diseases which have a more maxilla occurred in our patient material: a nasopa- or less specific appearance on CT, such as muco- latine duct cyst and a nasolabial (nasoalveolar)eyst. celes, non-odontogenic cysts, ameloblastomas, The cysts originate from non-odontogenic epithe- adenoid cystic carcinomas, osteosarcomas and lium. The nasopalatine duct cyst originates from chondrosarcomas, CT cannot provide a histologi- the epithelial remnants of the nasopalatine duct (2). cal diagnosis. It is the most common non-odontogenic cyst in the In general, the histology of the tumor has no oral region and is situated in or near the incisive ca- impact on the interpretation of the CT examina- nal, just behind the maxillary central incisors. On tion. Demonstration of a mass with lytic bone radiography, the cyst can be seen in close relation- destruction is the most frequent radiological find- ship to the apices of the upper teeth which may ing in malignant lesions. In these patients, thin cause confusion with apical lesions. The cyst causes needle aspiration biopsy or open biopsy is required. slow remodeling of the surrounding palate and There proved to be a good correlation between maxilla (22). CT examination and the findings at operation. In A fairly large nasopalatine duct cyst was seen only 1 out of 81 patients did the fir.-lings at surgery in a 20-year old woman (patient no. 66). The cyst conflict with CT examination. CT technique is de- presented as a nasal tumor with swelling on the left cisive in good pattern recognition. Multiplanar di- side of the nose. CT revealed a well-demarcated tu- rect CT proved to be most useful. Based on the mor with a lower density than muscle (fig. 5.25). above, we may conclude that High-Resolution This tumor occupied part of the left anterior nasal Computed Tomography is indispensable in the cavity and was located just in front of the inferior treatment of suspect and malignant lesions of the nasal concha. The anterior wall of the left maxillary paranasal sinuses. sinus was destroyed, as was the nasal bone and hard palate on the left side. Part of the tumor protruded 12S

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Jeans WD, GilaniS, BullimoreJ: The effect of CT scanning ic diagnosis of malignant tumors of the paranasal sinuses on staging of tumors of the paranasal sinus. Clinical Radiol- and related structures. J. Otolaryngol. 6 (5): 399-406. 1977 ogy 33: 173-179. 19S3 61. Osborn AG, Johnson L, RobertsTS: Sphenoidal mucoceles 44. Johnson DH Jr, Colman M, Larsson S et al: Computed To- with intracranial extension. J. Comput. Assist. Tomogr. 3: mography in Medial Maxilla-Orbital Fractures. J. Comput. 335-338. 1979 Assist. Ton.ogr. 8 (3): 416-419. 1984 62. Pagani 5i, Thompson J, Mancuso AA, Hanafee W: Lateral 45. Kaplan RJ: Neurological complications of infections of the wall of the olfactory fossa in determining inlracranial exten- head and neck. Otolaryngol. Clin. North. Am. J.: 729-749. sion of sinus carcinoma. AJR 133: 497-501. 1979 1976 63. Palacios E, Valvassori G: Computed Axial Tomography in 46. Keane WM, Bilaniuk LT, Zimmermann RA: Cranial Com- Otorhinolaryngology. Adv. Otorhinolaryngol. 24: 21-23. puted Tomography: Application to Otolaryngology. Trans. 1978 Am. Acad nphthaimol. Otolaryngol. 84 (5) ORL 859-865. 64. Parsons C, Hodson H: Computed Tomography of the para- 1977 nasal sinus tumors. Radiology 132: 641-645. 1979 47. Kilpatrick C, Tress B, King J: Computed Tomography of 65. Price HT, Danziger A: Computerized tomographic findings Rhinocerebral Mucomycosis. Neuroradiology 26: 71-73. in mucoceles of the frontal and ethmoid sinuses. Clin. '984 Radiol. 31: 169-174. 1980 48. Lohkamp F, Claussen C. Spenneberg H: Computertomo- 66. Price HT, Batnitzky S, Karlin CA et al: Case Report, Mul- graphie des Gesichtsschaedels (Teil II) Pathologische Ver- tiple pamnasal sinus mucoceles. J. Compul. Assist. To- aenderungen. Fortschr. Roenigenstrahlen 126: 513. 1977 mogr. 5 (1): 122-125. 1981 49. Lohkamp F, Claussen C: Die Bedeutung der Computer- 67. Proops DW, Phelps PD: Computed tomography in ENT tomographie fuer die TNM Klassifikation der Gesichts- practice. 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Laryngoscope 90: 1814-1824. 1980 cal lymphnode cancer. AJR 136: 381-385. 1981 72. Rhea JT, Weber AL: Giant-cell granuloma of the sinuses. 53. Mancuso AA, Harnsberger MD, Muraki AS, Stevens MH: Radiology 147: 135-137. 1983 Computed Tomography of Cervical and Retropharyngeal 73. Rothman SI.G, Allen WE, Simeone JF: Direct coronal com- Lymphnodes: Normal Anatomy, Variants of Normal and puterized tomography. Comput. Tomogr. 1: 157-165. 1977 Applications of Staging Head and Neck Cancer. Part I: 74. RoweLD, Miller E, Brnat-ZawadzkiMJ: Computed Tomo- Normal Anatomy. Radiology 148: 709-714. 1983 graphy in maxilla-facial trauma. Laryngoscope 91: 54. Mancuso AA: Cervical lymphnode metastases: Oncologic 745-757. 1981 imaging and diagnosis. Int. J. Radiation Oncology Biol. 75. Saito Y, Hasigawa M, Hinatsuka et al: Computed Tomo- Phys. Vol. 10: 411-423 graphy in the diagnosis of mucoceles of sphenoid and eth- 55. Mancuso AA, Hanafee WW, Winter J et al: Extensions of moid sinuses. Rhinology 18: 51-55. 1980 paranasal sinus tumors and inflammatory disease as eval- 76. Schindler E, Anlich A, Wende S: Value and Limits of com- uated by CT and pluridirectional tomography. Neurora- puterized axial tomography in ORL. Adv. Otorhinolaryn- diology 16: 449-453. 1978 gol. 24: 9-20. 1978 56. Maniglia AJ, Van Buren JM, Bruce WB et al: Intracranial 77. Schneider G, Sager WD, Lepuschutz H: Multidirectional abscesses secondary to ear and paranasal infections. Otolar- Tomography and High Resolution CT in lesions of the yngol. Head and Neck Surg. 88: 670-680. 1980 Paranasal Sinuses and the Pharyngeal Cavity. Acta Radiol. 57. Moedder U, Rose KG, Friedmann G et al: The efficiency of Diagn. 23: 63-69. 1982 CT and conventional tomography of processes of the skull 78. Smith AT, Spencer JT Jr: Orbital complications resulting 130

from lesions of the sinuses. Ann. Olol. Rhinol. Laryngol. phy in orbital disease. J. Comput. Assist. Tomogr. I: 4. 57: 5-27. [948 1977 79. Som PM, Shugar JMA, Biller HF: The early deteclion of 89. Thawley SE, Gado M, Fuller TR: Computerized Tomo- antral malignancy in the postmaxillectomy patient. Radiol- graphy in the evaluation of head and neck lesions. Laryngo- ogy 143: 509-512. 1982 scope 88. 1978 80. Som PM, Shugar JMA: Antral Mucoceles: A new look. J. 90. Trachtenberg SB, Wilkinson EE, Jacobson G: Sarcoidosis Comput. Assist. Tomogr 4 (4): 484-488. 1980 of the nose and paranasal sinuses. Radiology 113: 619-620. 81. Som PM, Shugar JMA: The CT classification of ethmoid 1974 mucoceles. J. Comput. Assist. Tomogr. 4 (2): 199-203. 91. Utilization of the buccal fat pad for closure of oro-antral 1980 and/or oro-nasal communication. Journal of Maxillofacial 82. Som PM, Lawson W, Cohen BA: Giant-cell lesions of the Surgery Vol. 5 No. 4. ',977 facial bones. Radiology 147: 129-134. 1983 92. Vanel D, Conanet D, Michean et al: Pseudotumoral Fibrous 83. Som PM, Shugar JMA: The significance of bone expansion Dysplasia of the Maxilla Radiological Studies and Comput- associated with the diagnosis of malignant tumors of the ed Tomography Contribution. Skeletal Radiol. 5: 99-103. paranasal sinuses. Radiology 136: 97-100. 1980 1980 84. Som PM: The role of CT in the diagnosis oil' carcinoma of 93. Weber AL, Tadmor R, Davis R, Robertson G: Malignant the paranasal sinuses and nasopharynx. J. Otolaryngol. II tumors of the sinuses. Radiologic Evaluation, including CT (5): 340-348. 1982 scanning, with clinical and methodological correlation. 85. Tadmor R, Davis KR, Weber A el al: Computed Tomogra- Neuroradiology 16: 443-448. 1978 phy of the skull and facial structures. J. Comput. Assist. 94. Whitaker CW: Imracranal complications of ear, nose and Tomogr. J: 3. 1977 Ihroat infections. Laryngoscope 81: 1375-1380. 1971 86. Tadmor R, Davis KR, Weber AL et al: Computed Tomo- 95. Wittenberg J, Fineberg H V, Black EB et al: Clinical efficacy graphy of the skull and facial structures. Preliminary evalu- of computed body tomography. AJR 131: 5-14. 1978 ation of direct coronal sections. Comput. Tomogr. I: 96. Wittenberg J, Fineberg HV, Ferrucci JT el al: Clinical effi- 211-215. 1977 cacy of computed body tomography II. AJR 134: 87. Tadmor R, New FPJ: Computed Tomography of the orbit 1111-1120. 1980 with special emphasis on the coronal sections. Part I: Anat- 97. Wortzmann G, Holgate RC: Computerized Tomography omy. J. Comput. Assist. Tomogr. 2: 35-44. 1978 (CT)inOtolaryngology. Laryngoscope 86: 1552-1562. 1976 88. Takahasi M, Tamakawa Y: Coronal Computed Tomogra- 131

Chapter 6.

PATHOLOGY OF PHARYNX, ORAL AND NASAL CAVITY

6.1 Introduction sions of the nasopharynx to the surface; only very aggressive lesions will cross this fascial plane. The Current radiological interest in detecting pa- very loose areolar arrangement of the reflections of thology in the naso- and oropharynx and in the na- the buccopharyngeal fascia in the parapharyngeal sal and oral cavity has been stimulated by computed and paranasopharyngeal space can easily be dis- tomography. One of the reasons is that convention- placed and permit benign tumor masses to assume al radiological techniques (plain radiographs and a round configuration. The fat content also demar- contrast agents) only demonstrate superficial or cates the outer limits of the tumor. The carotid bony abnormalities. This study will expand upon sheath acts as a separate space and appears as a low- previous observations and will assess the impact of density area that can only be invaded by a very ag- computed tomography on diagnostic understand- gressive process. When the sheath is obliterated, ing and therapeutic decision-making. A number of and no other masses can be demonstrated, it may be illustrative patients and their pathology will be dis- assumed that a neural lesion, or a lesion arising in cussed. the chemoreceptor organs is responsible. CT examination revealed that all the malignant tumors inves- tigated were able to invade the dense pharyngobasi- 6.2 Review of the literature lar fascia and to infiltrate to a varying extent in the paranasopharyngeal and parapharyngeal spaces Mancuso (13) was one of the first radiologists (4). The low-density fat, interspersed in the bucco- to give a clear description of the CT anatomy of the pharyngeal fascia, became obliterated. The malig- nasopharynx. One of his conclusions was that CT nant tumors were not confined by fascial planes, is the radiographic examination which best comple- but invaded the carotid sheath in a high percentage ments clinical evaluation of the nasopharynx. It of cases, either by direct extension, or by metastasis should be the radiographic examination of choice to the deep lymph node chain; they also tended to when looking for or determining the extent of naso- invade the base of the skull around the foramen la- pharyngeal disease. A malignant tumor was detect- cerum. Biopsy verification is essential for diagno- ed clinically in 24 patients; CT could confirm this sis. in all 24 cases. Also in 4 patients with benign mas- Hoover (1983) (7) studied the benefits of com- ses, CT could confirm the pathological process. In puted tomography in determining the extent of dis- this study, Mancuso did not mention if CT added ease and as an aid in differential diagnosis. This re- information to the clinical examination, or if thera- port states that endoscopic examination may be di- py was altered as a result of CT-examination. agnostic, but some limitations are frequently en- Bohman (3) reviewed the anatomical consider- countered: ations that aid in the CT differentiation of benign the determination of the extent of submucosal lesions from their malignant counterparts. The spread; spread of tumors from the nasopharynx, and their - the identification of intracranial extension; general morphology, is controlled by the re- - in some instances, the differentiation of benign straining effects of the fascial planes. The dense from malignant processes. pharyngobasilar fascia confines benign mucosal le- - the delineation of aggressive inflammatory 132

processes, such as Wegener's granulomatosis, mu- massively thickened mucosa, since the latter stains cormycosis. with intravenous contrast. Hoover studied 70 patients to determine what Silver (17) also described the normal anatomy help could be anticipated from computed tomo- and pathology of the nasopharynx and related graphic scanning. All CT-scans were evaluated for spaces, and analyzed 31 patients with malignant tu- the presence or absence of obliteration of the poste- mors involving the nasopharynx. Silver especially rior and lateral paranasopharyngeal fascial planes, describes the CT-changes in nasopharyngeal carci- and for the presence of intracranial spread. This in- nomas: su^mucosal infiltration, infiltration and/or tracranial spread from the nasopharynx occurs by obstruction of theEustachian tube orifice with pro- 4 primary pathways: duction of serous otitis media, and often, soft pal- 1. posterior lateral spread along the carotid artery ate infiltration. Infiltration of the superior para- via the foramen lacerum to the cavernous sinus and pharyngeal space with involvement of the mandib- middle cranial fossa; ular division of the trigeminal nerve, enlargement 2. posterior lateral metastasis to the highest jugu- (rarely) of the cervical lymph nodes and not infre- lar node to the jugular fossa and posterior cranial quently extension through the skull base via the fo- fossa; ramen lacerum, also belong to these changes. 3. spread laterally through the pterygoid venous Hopping (8) retrospectively reviewed 57 pa- plexus and directly through the floor of the middle tients with nasopharyngeal masses. The roles of cranial fossa; conventional radiography, polytomography and 4. anterior lateral spread through the sphenopala- computed tomography were discussed. The study tine foramen into the infratemporal fossa. This demonstrates the limitations of conventional radio- route is then continuous through the inferior orbi- graphs in distinguishing between benign and malig- tal and superior orbital fissure with the middle nant nasopharyngeal masses. Radiographs can pro- cranial fossa. vide valuable information on the presence of a mass Hoover found that intracranial spread oc- and bone erosion in advanced disease, and they are curred in 53% of the primary malignant tumors, important as survey views for planning tomogra- and in 14% of the secondary malignant neoplasms phy. Polytomography and CT-scans are helpful in of the nasopharynx. Invasion of one or more of the the accurate staging of nasopharyngeal malignan- paranasopharyngeal fascial planes was demonstrat- cies by defining the presence or absence of bony ed in 81%. changes in the skull base. In this study, there proved to be a high inci- An interesting study on CT-examination of the dence of intracranial extension in patients with ju- nasal cavity was published by Kassel (10). He venile angiofibroma (5 out of 12 patients) either to stressed the limitations of conventional films, util- middle cranial fossa via the sphenoid sinus, or via izing specific projections and soft tissue or bone the infratemporal fossa. The other benign tumors techniques, for displaying the structures of the na- tended to expand with the lateral low-density sal cavity. The conchae and lateral walls of the nas- planes, showing a rounded growth pattern, thus al cavily can be well assessed in conventional tomo- leaving some low-density, fatty margins at the pe- grams in the Caldwell-position. The assessment of riphery of tumor masses. Hoover concluded that soft tissue beyond the air-containing cavities is lim- CT-scanning is extremely useful in differentiating ited. Angiography may provide more information malignant from benign disease, as well as in evalu- about extension of tumor if a specific pattern or dis- ating the extent and aggressiveness of any inflam- placement of vessels is present. As has been de- matory process. However, malignant lesions scribed before, contrast nasopharyngograms (5, 9, proved to be indistinguishable from aggressive in- 16) only demonstrate the outline of the mass. Kassel flammatory processes such as aspergillosis, mucor- et al. concluded that: mycosis and Wegener's granulomatosis. Intra- 1. CT demonstrates nasal anatomy well. venous contrast material was helpful in determining 2. CT is not useful in diagnosing undetected carci- intracranial spread and also aided in differentiating nomas of the nasal cavity but that CT-examination obstructed sinus cavities filled with tumor from is utilized for optimal demonstration of: 133

- tumor spread, with emphasis on assessing as a result of some combination of tumor, tissue re- soft tissue areas poorly visualized by clinical or sponse and edema. The two malignant tumors other radiologic modalities; which could not be seen on CT-scans were located - a possible involvement of bony or soft tissue in the lateral free margin of the tongue. The other areas that may decide if the tumor is operable malignant tumors showed obliteration of the (nasopharynx, sphenoid sinus, cribriform plates, m.l.d.p., l.l.d.p. and intrinsic musculature in the orbital apex, pterygoid fossa); majority of cases. The authors conclude that CT- - complex nasal-facial fractures or their com- scanning gives accurate anatomical details of the plications, congenital abnormalities and lesions in base of the tongue and floor of the mouth, and may the posterior nares. serve as a valuable adjunct to physical examination In 1982, Larsson (11) presented a study on in differentiating extrinsic from intrinsic lesions, computed tomography of the tongue and floor of and in determining whether an intrinsic lesion has the mouth. At the same time, Baehren (13) de- crossed the midline. It would appear to be a reason- scribed the value of CT in the diagnosis of malig- ably reliable guide for determining whether a tumor nant oral tumors and their local metastasis. Lars- mass involves the base of the tongue. son reviewed the CT anatomy of the musculature of Baehren (I) reported 46 computed tomograph- the tongue and its relationship to the submandibu- ic examinations in 39 patients with histologically lar gland. Thirty CT-scans of the base of the tongue confirmed malignant oral cavity tumors. The value and floor of the mouth were also analyzed. Larsson of CT was compared with clinical staging in 24 et al. distinguish the lateral low-density plane operated cases. Clinical examination was superior (1.1.d.p.), seen between mylohyoid and hyoglossus to CT in determination of the T-category. The out- muscle, from the midline low-density plane line of the tumor was better demonstrateu by CT. (m.l.d.p.) which is the fibrous lingual septum, sep- Baehren used the U.I.C.C. criteria (Union Interna- arating the genioglossus and geniohyoid muscles in- tional contre le Cancer) (or the classification of tu- to two symmetrical bundles, (see figs. 4.13, 4.14) mor stage. For the determination of the T category, The fibers of the genioglossus muscle are lost poste- the widest diameter was measured. Deep infiltra- riorly in a rounded ball that constitutes the intrinsic tion of a large tumor (T4) into muscles and bone is muscles of the tongue as seen on CT-scans. The in- well shown with CT. Enlarged lymph nodes (< 1.5 terdigitating hyoglossus and styloglossus muscles cm) are also clearly demonstrated by CT. surround the intrinsic tongue musculature. These Muraki (15) studied the normal anatomy and muscles are best seen on axial scans, while the coro- range of variations of the oropharynx, tongue base nal scans assess the mylohyoid and the digastric and floor of the mouth. The results in staging carci- bundles well since their shallow obliquity to the noma in 35 patients were also reported. CT findings axial plane makes them more nearly perpendicular added unique and valuable information in 8 out of to the coronal plane. CT-scanning of the soft tissue 12 patients with carcinoma, confirmed the clinical spaces of the tongue is best accomplished in the co- impression of the extent of the lesion in four pa- ronal plane, provided dental fillings do not inter- tients, and were potentially misleading in one pa- fere. Larsson studied the behavior of benign intrin- tient. The unique and valuable information in the sic and extrinsic-malignant lesions, and the normal 8 patients resulted from the detection of: situation, with regard to the midline low-density plane (fibrous lingual septum), the lateral low- - clinically occult lesions density plane (l.l.d.p.), and the intrinsic muscula- - extension of primary tumor beyond the limits ture of the tongue. These three landmarks were expected by palpation and endoscopic examination readily visible and were consistently seen in the - the presence of lymph nodes that were not ap- tongue of the normal group. The normal m.l.d.p. preciated at the initial physical examination. serves as a useful landmark in determining spread across the midline. It proved not to be possible to determine whether the homogenous appearance of 6.3 Patients and methods the tongue occurred solely as a result of tumor, or In order to evaluate the impact of CT-exami- 134

nation in diseases affecting the pharynx, oral cavi- elected to pursue the diagnosis with CT were ty, nasal cavity and nose, 53 patients were reviewed. studied. The third bias is caused by the fact that pa- These 53 patients were selected on the basis of the tients were selected on basis of pathologic processes presence of pathologic changes affecting pharynx, evident in the CT images. It was not the aim of this oral cavity, nasal cavity and nose, as demonstrated study to determine the sensitivity or the specificity by CT-examination. These patients were discussed of this method. This requires an unbiased ap- with the referring clinician. In this retrospective proach. analysis all the patient data, as recorded in the pa- In contrast to the prospective approach of Wit- tient's history, were studied and the following tenberg and Fineberg (21, 22) who questioned the aspects were discussed: referring clinician before and after the CT-exami- 1. Did CT contribute to the diagnostic under- nation, our study was performed retrospectively. standing of the patient's disease, i.e. did CT pro- The standards for review of Physicians' Diagnostic vide more, the same, less or confusing information and Therapeulic Ratings parallelled the method as than was already available by conventional X-ray described by Fineberg (6) (Table 6.11). The thera- studies and clinical examination, including inspec- peutic rating as described by Wittenberg et al. was tion, palpation and endoscopy (Table 6.1)? not applied. Since, in our opinion, there is an im- 2. Did CT contribute to a change in the originally portant subjective factor in the differentiation be- planned therapeutic approach? tween T4 and T5 (Wittenberg) - the impression of the referring clinician and the extent of the disease Table 6.1. (Wittenberg) being such that precise staging is no longer of any Diagnostic understanding Value rating great significance - it is sometimes impossible to make this differentiation. It is, however, possible - CT confused my understanding of this patient's disease and led to investigations I accurately to assess if CT had a positive effect on would not otherwise have done. Dgl - CT confused my understanding of this patient's disease but did not lead to any Table 6.11. Standards for review of physicians' diagnostic and additional investigations. Dg2 therapeutic ratings (l-'inebcrg) - CT had no effect or little effect on my Diagnostic ratings: understanding of this patient's disease. Dg3 Dl vs. D2 Final diagnosis differs from CT radiol- -CT provided information which significantly ogist's diagnosis. If, prompted by CT improved my understanding of this patient's results, diagnostic tests in addition to disease. Dg4 those planned prior to CT arc under- - My understanding of this patient's disease taken, then rate Dl. depended upon diagnostic information Di vs. 1)4 Final diagnosis concurs with CT radiol- provided only by CT (unavailable from any ogist's diagnosis. If final diagnosis non-surgical procedure). Dg5 shows >25°''o change compared with pre-CT probability, then rale D4. D4 vs. D5 If no other radiographic test did or Thirty-six patients referred by the department could have been expected to reveal of E.N.T.-surgery (Head: Prof, dr E.H. Huizing) the diagnosis, (hen rale 1)5. were evaluated with Dr John A.M. de Groot, Therapeulic ratings: E.N.T.-specialist. Tl vs. T2 If therapeutic measures prompted by Fourteen patients referred from the depart- CT are subsequently found to be in- ment of Radiotherapy (Head: Prof, dr H. van Pe- appropriate, then rale Tl. perzeel) were discussed with Prof, dr L.A. Ravasz. T3 vs. T4 If final therapy differs from pre-CT therapy and review of abstracted rec- Three patients have been referred from Cen- ord corroborates CT's contribution tres outside the University Hospital. These refer- to the change, then rate T4. ring clinicians provided there remarks in writing. T4 vs. T5 If no other test report or information This approach harbors a triple bias. A retro- in the medical record contributes to a spective study implies an inherent bias. A further change in treatment and CT does, bias is the fact that only patients whose clinicians [hen rate T5. 135

the choice of therapy. We therefore decided to sim- planar high resolution CT we have included CT- plify Wittenberg's method by considering T4 and images from patients of the evaluated series, as well T5 together as one positive group (Table 6.1 II). as interesting, more recent, patients. The evaluated If CT provided a higher stage of tumor, or a 53 patients were examined in the period from 1978 change in the radiotherapy field (e.g. palliative or until the end of 1984. curative radiation), then we concluded that CT con- All scanning was performed with a Philips tributed to a change in therapy. Tomoscan 200, 300, 310 or 350. Scans were ob- The review of the CT-examinations was per- tained in the axial and/or coronal plane, in supine formed by the author and Prof.dr P.F.G.M. van and/or prone position. No intravenous contrast Waes after an interview with the referring clinician medium was used in the initial phase of the study. and analysis of the clinical results. In order to give Later, intravenous rapid drip infusion or bolus in- a better impression of the state of the art of multi- jections were administered. The recent protocol which is used in the examination of the pharynx and related regions, is described in Chapter 5. Table 6.III. Contribution of CT in choice of therapy Choice of Iherapy Value rating -CT led me to choose therapy which in retro- 6.4 Results spect was not in the best interest of the patient. Thl - CT was of no influence in my choice of The value rating in diagnostic understanding therapy. Th2 (Dg) and choice of therapy (Th) in a group of 53 pa- - CT did not alter my choice of therapy, but tients is listed in Table 6.1V. The pathological find- did increase my confidence in the treatment ingsin these patients are summarized in Table6.IV. chosen. Th3 The contribution of CT to diagnostic under- -CT contributed to a change in therapy. Th4.5 standing (Dg) and choice of therapy (Th) is given in Table 6.V1.

Table 6.IV. Pharynx, nasal and oral cavity

Patient No. Site of lesion or Histology Value Rating primary tumor Dg Th A. Nasopharynx 37 nasopharynx angiollbroma Dg5 Th4.5 49 nasopharynx angiofibroma Dg5 Th4.5 44 soft palate pleomorphic adenoma Dg5 Th2 48 naso- and oropharynx pleomorphic adenoma Dg? Th2 11 nasopharynx adenoid cystic carcinoma Dg4 Th3 4 nasopharynx metastasis from breast carcinoma Dg5 Tl)3 7 naso- and oropharynx non-Hodgkin lymphoma Dg4 Th3 15 naso- and oropharynx non-Hodgkin lymphoma Dg? Th2 52 naso- and oropharynx non-Hodgkin lymphoma Dg? Th2 1 nasopharynx squamous cell carcinoma Dg5 Th4.5 8 nasopharynx squamous cell carcinoma Dg5 Th3 12 nasopharynx squamous cell carcinoma Dg5 Th3 20 nasopharynx squamous cell carcinoma Dg5 Th4.5 23 soft palate squamous cell carcinoma Dg5 Th4.5 45 nasopharynx squamous cell carcinoma Dg3 Th3 50 nasopharynx squamous cell carcinoma Dg5 Th4.5 2 torus tubarius undifferentiated carcinoma Dg5 Th3 5 paryngeal recess undifferentiated carcinoma Dg3 Th3 6 nasopharynx undiffcrentiated carcinoma Dg5 Th4.5 14 nasopharynx undifferentiated carcinoma Dg5 Th4.5 19 nasopharynx undifferentiated carcinoma Dg5 Fh4.5 46 nasopharynx undifferenliatcd carcinoma Dg5 Th4.5 136

Table 6.1V. (Continual)

Patient No. Site of lesion or Histology Value Rating primary tumor Dg Th

B. Oropharynx 24 oropharynx abscess Dg5 Th2 47 oropharynx pleomorphic adenoma Dg5 Th2 22 tonsil squamous cell carcinoma Dg3 Th3 25 base of tongue squamous cell carcinoma Dg2 Th2 27 base of tongue squamous cell carcinoma Dg3 Th3 28 tonsil squamous cell carcinoma Dg5 Th4.5 31 tonsil squamous cell carcinoma Dg5 Th4.5 32 tonsil squamous cell carcinoma Dg5 Th4.5 33 oropharynx squamous cell carcinoma Dg5 Th4.5 34 base of tongue squamous cell carcinoma Dg3 Th3 35 tonsil squamous cell carcinoma Dg5 Th2 40 tonsil squamous cell carcinoma Dg5 Th4.5 42 base of tongue squamous cell carcinoma Dg2 Th2 51 base of tongue squamous cell carcinoma Dg5 Th4.5

C. Hypopharynx 41 piriform sinus squamous cell carcinoma Dg5 Th4.5 43 epiglottis squamous cell carcinoma Dg3 Th2

D. Nasal cavity and nose 17 nasal cavity hemangioma Dg4 Th3 3 nasal cavity inverted papilloma Dg5 Th3 9 nasal cavity inverted papilloma Dg3 Th3 16 nasal cavity Wegener's granulomatosis Dg3 Th2 13 middle concha hernangiopericyloma Dg5 Th4.5 39 nose non-Hodgkin lymphoma Dg3 Th3 10 nasal cavity/nasopharynx squamous cell carcinoma Dg5 Th2 21 nasal vestibule squamous cell carcinoma Dg5 Th4.5 36 middle concha squamous cell carcinoma Dg3 Th3 38 nose squanious cell carcinoma Dg5 Th4.5 18 nasal vestibule undifferentiated carcinoma Dg5 Th4.5

E. Oral cavity 26 tongue squamous cell carcinoma Dg3 Th2 29 tongue squamous cell carcinoma Dg3 Th3 30 floor of mouth squamous cell carcinoma Dg3 Th2 53 floor of mouth squamous cell carcinoma Dg4 Th4.S

The combined results of diagnostic and thera- standing in 13 out of 53 patients (Dg3). In4of these peutic impact are listed in table 6.VII. patients, therapeutic management was not influenced (Dg3, Th2), and in 9 patients CT increased confidence in the chosen treatment (Dg3, Th3). We 6.5 Discussion are inclined to consider this as a positive result. In the 4 patients in which choice of therapy was not in- In none of the patients was CT confusing, nor fluenced, this resulted from the host factor (see did it lead to superfluous investigations (Dgl). In 2 Chapter 5) in three patients, and from tumor factor patients, CT was confusing (Dg2), but in neither in one. Three patients were too ill for therapy (26, case was the choice of therapy influenced (Dg2, 30, 43), the other received systemic treatment (pa- Th2). CT had little or no effect on diagnostic under- tient no. 16). The findings of CT in this patient did 137

Table 6. V. Pathological findings in 53 patients is considered as a positive result. In 35 patients, CT malignant provided information which could not be obtained - squamous cell carcinoma 29 from any other non-surgical procedure (Dg5). In 8 - undift'erentiated carcinoma 7 of these patients, CT had no influence on the choice -adenoid cystic carcinoma 1 of therapy (Dg5, Th2). This was due to the fol- -non-Hodgkin lymphoma 4 - hemangiopericytoma 1 lowing reasons: - metastasis from breast carcinoma 1 1. Tumor factor Although CT gave more details than clinical benign -inverted papiJJoma 2 examination, the extent of tumor was such that - hemangioma 1 therapy was already determined (chemotherapy) - Wegener's granulcmatosis 1 (patient nos. 15 and 52). - angiofibroma 2 - Presence of tumor was seen with CT-exami- - pleomorphic adenoma 3 nation, but biopsy could not confirm this (patient infections no. 10). - abscess 1 As surgery of a pleomorphic adenoma is not always radical, radiotherapy is necessary. CT did not therefore influence the treatment in these patients. Table 6. VI. Contribution of CT in 53 patients 2. The clinician's therapeutic choice was predom- Diagnostic No. of Choice of No. of inantly based on the findings of clinical examina- understanding patients therapy patients (Dg) (Th) tion and/or histological report, without taking into account the CT findings (patient nos. 24, 35). Dgl 0 Thl 0 In 5 patients, the unique information of theCT Dg2 2 Th2 14 Dg3 13 Th3 17 examination contributed to a definite choice of Dg4 3 Th4.5 22 therapy (Dg5, Th3). In 22 out of 53 patients, CT Dg5 35 not only provided unique information but also contributed to a major change of therapy (Dg5, Th4,5). The overall positive result of CT examination is 47 out of 53 patients. Table 6. VII. Combined results of diagnostic and therapeutic- impact Dg Th No. of 6.6 Illustrative patients and pathology patients Dg2 Th3 2 negative results of CT confused the understanding of the patient's Dg3 Th2 4 CT in 6 patients disease (Dgl, Dg2) Dg3 Th3 9 Dg4 Th3 3 Confusing CT-findings prove to occur in a Dg5 Th2 8 positive results oT small minority of patients. In our study, CT gave Dg5 Th3 5 CT in 47 patients Dg5 Th4.5 22 rise to confusion of the diagnosis in only two patients (Dg2). This was of no influence on the choice of therapy (Th2). One of these patients had a squa- not therefore influence the choice of therapy (tu- mous cell carcinoma of the base of ihe tongue. Di- mor factor). These 4 patients are graded as a nega- rect Iaryngoscopy showed a large necrotizing tumor tive result. The overall contribution of CT can be in the base of the tongue, filling up the valleculae, considered negative in 6 out of 53 patients. In 3 out growing over the whole epiglottis and extending to of 53 patients, CT provided information which sig- the laryngeal side of the epiglottis, the right ary- nificantly improved understanding of the patient's epiglottic fold and false vocal cord. The tumor in- disease (Dg4). In this patient material, all patients filtrated the right laryngeal ventricle. The true vocal with Dg4 occurred in combination with Th3, which cords and subglottic space were free of tumor. There was no invasion of the piriform sinus. CT On CT, inverted papilloma may show a typical showed only asymmetry and protrusion of a large continuous mass from middle meatus to antrum. tumor into the lumen of the laryngeal vestibule and Bone erosion, areas of calcification within the tu- aryepiglottic fold, with broadening of the right mor mass, or bone sclerosis of the sinus wall adja- false cord. The exact extent of tumor in the base of cent to the tumor, can also be seen (12). In the sec- the tongue could not be estimated and infiltration ond patient with an inverted papilloma, CT provid- of the piriform sinus could not be excluded. This ed unique information since the endoscopic exam- difficulty in diagnosing the tumor by CT was main- ination was hampered by the presence of a large tu- ly due to absence of fat planes and the fact that no mor in the right nasal cavity, protruding into the contrast medium was administered. nasopharynx (patient no. 3) (fig. 6.3) (Dg5, Th3). A carcinoma at the right side of the base of the CT had little or no effect on the understanding tongue was detected in a 47-year old man (patient of the patient's disease (Dgl, Dg2) no. 27). The clinical extension of tumor correlated well with the CT-findings (Dg3, Th3). Regional In 13 patients, CT had little or no effect on the lymph node enlargement on the right side was well understanding of the disease. In 4 of these patients, detected by CT. CT thus confirmed clinical staging. CT was of no influence in the choice of therapy Smaller lesions of the tongue or floor of the (Dg3, Th2). One of these patients had a benign dis- mouth prove to be difficult to detect by CT. The use ease and received systemic treatment (patient no. of oral contrast medium then becomes important. 16), the others were too ill for any treatment. The This is demonstrated in a patient with an ulcerating patient with the benign disease (patient no. 16) had carcinoma of the floor of the mouth, below the tip Wegener's granulomatosis (fig. 6.1). This is a very of the tongue, and lateral to the frenulum on the rare disease, consisting of the pathological triad of left side. It was not possible to detect the tumor glomerulitis, granulomas in the respiratory tract without the use of the oral contrast medium. Appli- and vascuJitis of the small arteries and veins. The cation of oral contrast medium clearly showed the disease is treated with Endoxan. The conchae are surface of the inferior part of the tongue and the ul- easily destroyed by this disease (10). cer crater of the tumor in the floor of the mouth in the direct sagittal CT-scans (fig. 6.4). In 9 patients in which CT had little or no effect on diagnostic understanding of the patient's dis- A 31 -year old woman presented with a glue ear ease, CT showed the same pathology as was seen by on the left side, slight blood loss on blowing the clinical and endoscopic examination. This in- nose and a swelling in the left mandibular angle (pa- creased confidence in the treatment chosen (Dg3, tient no. 5). At endoscopy, a tumor was seen in the Th3). nasopharynx, originating from the left lateral re- In one of these patients, the findings at surgery cess (fossa of Rosenmueller) and extending to the confirmed the CT findings (patient no. 9). The nasopharynx and crossing the midline. A solid lym- other patients received radiotherapy or chemother- phoma was palpated in the upper cervical region in apy. The patient who underwent surgery had an in- front of the sternocleidomastoid muscle. Tumor verted papilloma (Dg3, Th3). Histologically, in- and lymphoma were also seen on CT. No invasion verted papilloma shows hyperplastic respiratory into the skull base was demonstrated. CT con- epithelium with an inverting pattern. Squamous firmed the findings of clinical examination (Dg3, epithelium and keratinizing squamous epithelial Th3). areas are also present (2). As malignant transfor- mation can occur, and as there is a high tendency CT provided information, which substantially of inverted papilloma to recur, it is important to improved the understanding of the patient's disease know the exact extent of tumor (14). The inverted (Dg4) papilloma often involves large areas of the nasal and paranasal sinus mucosa. A common site is the Significant improvement in diagnostic under- junction of the antrum and ethmoid sinus. This standing (Dg4) occurred in 3 patients (patient nos. characteristic is shown in patient no. 9 (fig. 6.2). 7, 11, 17). One benign disease presented in this I.W

Figure 6.1. Wegener's granulomatosis. Thickening of mucosal lining of nasal septum. Note the destruction of Icfl inferior concha. 140

Figure 6.2. Inverted papilloma. Characteristic location of the small tumor ai the junction of ant rum and ethmoid sinus (white arrous). 141

Figure 6.3. Inverted papilloma. A. .Axial sections. The riyht nasa] caviiy is completely tilled with tumor. The rumor protrudes into the nasopharynx and obstructs the drainage of the maxillary and ethmoid sinus on the right, B. Coronal sections. I he opening of the right maxillary is visible and is obstructed by tumor. 142

f iiiiitr 6..?. linerted pupilloma. A. A\ial sections, f he nyhl nasal ca\it> i*. compfeleK tilled \MTII lunior. Flic tumor protrudes into the iu(M>pharyn\ and obstructs the drairuii-e ul the ma\ilkn\ arid ethmoid Minis on the riiihi. li. C Cironal si.v!it>ns. The opening of the riuhi maxillary is visible and is obstructed h> tumor. 143

Figure 6.4. Squamous cell carcinoma below front part of the tongue. Direct sagittal scan. The ulcer crater becomes visible after application of oral contrast medium (arrow).

Figure 6.5. Hemangioma in anterior part of right nasal cavity, slightly displacing the septal cartilage to the left. 144

figure 6.6. Memuneioma of right temporal and infra-temporal space. A vial scans. 145

group: a hemangioma, a very rare tumor, which broma completely filled the partially resected can be divided into a cutaneous and a mucosal type. maxillary sinus, the right part of the nasopharynx The mucosal type of hemangioma is most frequent- and the middle cranial fossa (fig. 6.8). The pterygo- ly located in the oral and nasal cavities (2). The lesi- palatine fossa was also invaded by tumor. These on is composed microscopically of dilated thin- findings influenced surgical treatment (Dg5, walled vessels in relatively little stroma. It usually Th4,5). develops as a polypoid or sessile lesion in the muco- In the three patients with a pleomorphic ade- sa of the cartilagenous system. The hemangioma noma (patient nos. 44, 47, 48), much diagnostic in- presented in a 26-year old woman and was located formation was obtained (Dg5). This, however, did in the right nasal cavity at the level of the limen not influence patient management, since these pa- nasi, the boundary of the nasal vestibule (patient tients are routinely treated with both surgery and no. 17). CT improved diagnostic understanding by radiotherapy (Th2) (figs. 6.9 and 6.10). showing enhancement of the tumor in the anterior Therapy was also not influenced in two pa- part of the nasal cavity (fig. 6.5) (Dg4, Th3). A tients with a non-Hodgkin lymphoma. In both pa- hemangioma of the infratemporal space is de- tients, CT examination revealed more information monstrated in fig. 6.6. than clinical examination (Dg5). The decision to treat the patient with chemotherapy had, however, The understanding of the patient's disease already been made, based on the findings of the depended upon diagnostic information provided clinical examination of the large tumor (Th2). only by CT (Dg5) One of the patients, a 23-year old woman (patient no. 15) suffered severe weight loss and had a There were 35 patients in whom CT provided large swelling around the right ear with otalgia; she information unavailable by other non-surgical in- also had severe trismus which hampered clinical vestigations (Dg5). Seven of these patients had a be- examination, but endoscopic examination proved nign disease such as: inverted papilloma, angiofi- to be possible under general anaesthesia. CT broma or pleomorphic adenoma. One patient had showed a very large tumor extending from the an abscess. This concerned a 62-year old man with sphenoid sinus to the level of the hyoid bone. The paralysis of his vocal cord (patient no. 24). CT sho- tumor destroyed part of the base of the skull and wed a space occupying process in the right parapha- floor of the sphenoid sinus and the pterygoid pro- ryngeal space, extending to the floor of the mouth, cess. This was also shown on conventional tomo- slightly narrowing the oropharynx and also extend- graphy. The tumor occupied the pterygoid fossa, ing to the medial side of the right part of the mandi- pterygopalatine and infratemporal fossa, the para- ble (fig. 6.7). The vagus nerve (X), accessory nerve pharyngeal space and part of naso- and orophar- (XI), internal and external carotid artery and jugu- ynx. The tumor proved to be a non-Hodgkin lym- lar vein are located in this area. The histologieal phoma. Comparing the findings of E.N.T. exami- character of the process could not be identified on nation and conventional tomography on the one CT. As the lesion was not well defined on CT, a ma- hand, and CT study on the other, CT provided lignant process was suspected radiologically. How- exact information on the extension of tumor into ever, on clinical inspection, a red mucosa and swel- the retromaxillary space and parapharyngeal space ling of the soft palate were seen. The swelling in- (Dg5). This, however, did not influence patient creased over a ten-day period and was very painful management (Th2). and fluctuating. The swelling proved to be an ab- A 55-year old man, who had undergone radio- scess. Initially, the CT report was not taken into ac- therapy two years previously, for a squamous cell count, so there was no influence on therapeutic carcinoma, complained of difficult deglutition (pa- management. Following Wittenberg's grading tient no. 10). Indistinct speech was also noticed. CT method the patient belongs to the Th2 group (Dg5, examination showed a tumor in the nasopharynx, Th2). In one of the seven patients mentioned above, closely related to the medial orbital wall, the upper a recurrent angiofibroma was seen after previous part of the left antrum and the infraorbital mar- resection (patient no. 49). This recurrent angiofi- gins. The medial and inferior orbital margins C

\\ «.ith I In- It'll (A. H. .iml ( i 147

Figure 6.H.I. Juvenile angiof'ihroma of right nasopharynx, inwtdinu the riiihi inJrniemponil space, nasal omit. ma\illar> MIIU-. lloor of* sphenoid sinus, interior orbital fissure (arrou head) and sphenopaiatine fossa. "Ihere is enhanccmem with intraxenous contra*t medium. I4N

iixurc fhS.II. KiviiriVMI ;iiij!inliliriiiii;i. Siltiation ;ilu-i siiium. A. I he riL'hi m.i\ill;it\ Minis h.is IHVII ICM.MI.-J. H. I IK- .IIILMI>IIIM«III.I U \isiNi1 unu-iioi ID ihc ri.uhl tcmpoiiiiiKiiulihulai ionn. < . I IK- UK-.IICI «inu ol ilu- "plK'iioiJ hone IKI~ Kvn nn.nli.\l In IIK- IIIHIOI. a>. has iIK- k-inponil lossa (1)1 lurro» IK-;KIS). 1-W

Figure 6.9. Pleomorphic adenoma, originating from the salivary glands of the soli palate. The patient had a Homer's swidrome. which is clearly explained by the C'T images. The parapharyngeal and infratcmporal spaces are entirely occupied h> the tumor. Internal jugular vein and internal carotid artery are displaced posteriorly (arnm heads). I here is sharp demarcation between the tumor and the deep lobe of the parotid gland (arrow). The left mandihular ramus is atrophied due to pressure '•>( the lumor (large arrow head). The pharynv is narrowed. c

i-iüu/'f f> }ü. i'lcniiupbk• .)iJt'n»'jn.i I lu-- p.iiii/ni w.i-^\ iitpii>m !uv I \\v Tumm i*. 1 or iiiiii;iio Imm ifu' t.Uvp tnht iil llic p.iioikl L'I.IIU! (( iMiip.iu- IIL-IÜ .nui k'lt «MI --I W I I lU' p.lï.lpIl.irWi;-,-..] sp.Ki' iv IIH.uil- UIMUM .IN is ilu' maii.ll picï\;joiil mn^lc (li. ( . ,itui O) Inu-in.i! ..IUMU! .nuf mw 151

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I in .iMtMi oi luniiM iii:>> i !K- i-.it I fn. ph.ir'% ii • i- .ili;!. •••" .MM i! i.-l". ! nun M ii . I). I . .ii1.1 I i Vu .ik .n U-I.I. r -

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153

showed irregularity and signs of infiltration by tu- pying the parapharyngeal space and the lateral part mor (fig. 6.11). This could explain the trochlear of the lower neck. Scar tissue could not be distin- nerve (IV) paresis. The findings on CT examination guished from tumor. The patient developed a facial were not confirmed by biopsy: several biopsies were and abducens paresis (VII and VI) which can be ex- negative. After six months, biopsy proved positive plained by the location of the tumor. The skull base in the area shown by CT, although a second CT ex- proved to be involved as was also seen on conven- amination demonstrated the same pathological tional tomography. process. At the time of the first CT examination, A 38-year old man complained of hearing loss therapy was not influenced by these CT results and pain deep and medial to the right ear (patient (Dg5, Th2) (fig. 6.11). This in contrast to patient no. 2). An exophytic ulcerating tumor of the torus no. 46 (fig. 6.12). tubarius was found on inspection. Hislological ex- The combination Dg5, Th3 occurred in 5 pa- amination revealed an undifferentiated carcinoma. tients (patient nos. 2, 3, 4, 8 and 12). One of them, CT showed invasion of tumor into rectus capitis a 17-year old female patient, underwent radiothera- and capitis longus muscle. This could not be detect- py for a squamous cell carcinoma of the nasophar- ed clinically (Dg5, Th3) (fig. 6.14). The medial pter- ynx (patient no. 12). Two years later, biopsy ygoid muscle was not involved. Lymph node in- showed submucous recurrence of tumor. CT volvement was not found clinically or by CT. showed no further extension of tumor to surround- The combination Dg5, Th4,5 occured in 22 out ing tissues or skull base. CT was not able to identify of 53 patients. A number of patients are reviewed. the presence of tumor in the submucosa, but did One of them, an 83-year old man, presented with a demonstrate that there was no extension of tumor large nasopharynx tumor which almost completely into the deeper structures (Dg5, Th3). occupied the nasopharynx and the choanae (patient In post-radiotherapy patients, a biopsy is the no. 19). Histologically, there proved to be an undif- only definite method of excluding recurrence of tu- ferentiated carcinoma. CT demonstrated the exact mor. extension of tumor: there was no invasion of tumor A 77-year old woman had a metastasis in the into the skull base. This influenced therapy (Dg5, nasopharynx from a breast carcinoma (patient no. Th4,5). 4). CT showed a large tumor mass in the nasophar- A 56-year old man had undergone radiothera- ynx, extending to both sphenoid sinuses, left eth- py for a carcinoma of the nasopharynx, more than moid sinus, nasal cavity, infratemporal spaces and a year previously. There now proved to be a sub- right maxillary sinus, with destruction of the poste- mandibular lymph node metastasis. There were rior part of the left medial orbital wall. Destruction neurological symptoms of V, VI, VII and VHIth of the sella, anterior and middle cranial fossa was nerves, indicating invasion of tumor into the base also shown (fig. 6.13). CT provided unique infor- of the skull. A CT scan showed destruction of the mation which was not available by other non-surgi- middle cranial fossa on the left and invasion of the cal investigations (Dg5, Th3). nasopharynx tumor into the brain and infratempo- A mass in the neck due to a metastasis in cervi- ral space (Dg5, Th4,5). Status after surgery for a cal lymph nodes is the presenting symptom or sign purulent left sinusitis was also shown: the left medi- of a squamous cell carcinoma in the nasopharynx in al antral wall had been resected. The lateral wall about 50% of all cases (20). One of the patients in showed an eroded aspect and there was mucosal our study, a 73-year old man, presented with a mass thickening (fig. 6.15). The submandibular lymph on the left side of the neck, and underwent radical node metastasis was not detected by CT since CT neck dissection (pt. no. 8). There proved to be a was limited to the area requested. metastasis of a squamous cell carcinoma. Two Carcinoma of the nasal vestibule, or anterior months after the radical neck dissection, a new intranasal carcinoma, is rare (2). In our patient ma- mass developed, and the patient was then referred terial, two patients proved to have a carcinoma in to the University Hospital. CT showed a large tu- the nasal vestibule. One patient, a 77-year old man, mor of naso- and oropharynx, extending laterally presented with a squamous cell carcinoma in the in the direction of the ear and parotid gland, occu- right vestibule, invading the nasolabial fold, alar 154

lixtiri' ft.l}. Metastasis ui a brc.iM earamuna min ilu1 iiasophai\n\ Desti IKIIIIII O! ihe Icli pan ül the sphcnoul "ins: (am>« \). I he en lire nasal ca\ ii> K filled \\ iih lumoi. ;h ^ ifie nasopluii \ in. I he ! IIHH O\ ihe ntnlJle ei.ini.il 1»ISN,I nmn-ii> nl ihe plun>n\ due HI the cnlaruemenl of torus tuharius («hiic arrow head I. lln.' invdial ptcrvgoid in is well preser\ed (arrows). H. Coronal seetion. I he parapharyngeitl space is panialK tiLX'tipied b> tumor (arrows). 15b

Figure 6.15. Undifferentiated carcinoma of nasopharynx. Situation after radiotherapy for the carcinoma, and after surgery lor a purulent sinusitis: resection of left medial aniral wall. A. Axial sections. Large tumor on ihe left, eroding the lip of petrosal bone and part of the sphenoid (pterygoid process) (arrows). B. Coronal sections. Note also the presence of tumor in the brain and infratemporal space. 157

Figure 6.15. Undifferentiated carcinoma of nasopharynx. Situation alter radiotherapy for the carcinoma, and after surgery for a purulent sinusitis: resection of left medial antral wall. A. Axial sections. large tumor on the left, eroding the tip of pcirooal bone and part of the sphenoid (plerygoid process) (arrows). B. Coronal sections. Note also the presence of tumor in the brain and infratemporal space. - ••:h'!i,' \ .tii.i It \\i.i: v._ •!,•:,. S.--. .!.-.'• : • .«:• ^ . i V !,. I .':;

•In' :!t.'l:: ij'

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cartilage, the upper lip and gingiva, and also malignancy may be a metastasis in the neck. destroying part of the palatine process of the right Squamous cell carcinoma is the most frequent type maxilla (pt. no. 21). This invasion of tumor into the of tumor (fig. 6.19). The palatine tonsillar carcino- soft tissues of the face had already been clearly ma spreads via contiguous infiltration of adjacent demonstrated by CT, as had the bone destruction structures, and by lymphatic metastasis. The jugu- (Dg5, Th4,5) (fig. 6.16). The other patient had an lodigastric node is the lymph node primarily in- undifferentiated carcinoma of the vestibulum nasi volved. The retropharyngeal lymph node may also and columella (pt. no. 18). The invasion of the tube affected. Byrd (4) analyzed the CT findings in 25 mor into the anterior nasal spine was important, patients with palatine tonsil squamous cell carcino- since it influenced therapeutic management: the pa- ma. Extension to the base of the tongue, the mobile tient was not sent for radiotherapy as had been the tongue, lateral pharyngeal wall, supraglottic larynx initial plan (Dg5, Th4,5). The destruction of the and lymph nodes is well demonstrated in axial nasal spine is well demonstrated on direct sagittal scans, if intravenous contrast material is used. Ex- scans, as is invasion of tumor into the soft tissues tension to the soft and hard palate can be de- (fig. 6.17). monstrated best on coronal scans. A hemangiopericytoma was found in an One of the patients with a tonsillar tumor was 80-year old woman who complained of bleeding a 72-year old woman. She had suffered from a sore from the nose (patient no. 13). At surgery (lateral throat for three months (patient no. 28). E.N.T. rhinotomy), the tumor mass proved to originate examination under general anaesthesia showed a from the middle concha and anterior ethmoidal tonsillar tumor on the left side, extending to the up- cells, and to extend into the nasal cavity. CT had per pole of the left tonsil and nasopharynx, and also shown the exact location of the tumor and also extending to the soft palate, the base of the tongue demonstrated that there was no invasion of the sur- and the hypopharynx. True and false vocal cords rounding bony walls: the medial orbital wall and were free of tumor, as were the arytenoids. The anterior cranial fossa proved to be intact (fig. 6.18). epiglottis was not recognizable. Histological exami- As the endoscopic examination did not provide this nation showed the tumor to be a squamous cell car- information, CT improved diagnostic understand- cinoma. CT not only confirmed the findings of ing and influenced patient management (Dg5, E.N.T. examination, but also clearly demonstrated Th4,5). Hemangiopericytoma is a tumor belonging the deep invasion into the tongue and floor of the to the group of vasoformative tumors of head and mouth (fig. 6.20). CT also showed that the tumor neck. It is a malignant tumor, as opposed to the almost reached the sphenoid bone. This could not hemangioma, which also belongs to the group of be demonstrated by any other non-surgical pro- vasoformative tumors. The neoplasm is histologi- cedure (Dg5. Th4.5). cally complex and demonstrates great variability. In patients with large tumors of the pharynx, Wherever capillaries are found, hemangiopericy- oral and nasal cavity, CT is the method of choice in toma may develop. The head and neck region ac- diagnosing the extent of tumor. counts for approximately 25% of hemangiopericy- A 62-year old woman had a large tumor of the tomas, whereas the orbit, oronasopharyngeal re- right tonsil which hampered inspection (patient no. gion and sinus account for approximately 5% of 32). Lateral conventional tomography showed a the total number of reported hemangiopericytoma large tumor extending from oropharynx to naso- (18,19). The tumors are locally aggressive and infil- pharynx. There was no destruction of bone. On trative. They manifest a high recurrence rate. CT, the tumor showed extension into the para- and Lymph node involvement is unusual. retropharyngeal space and extension to the nasal Carcinomas of the tonsils and tonsiltar region cavity anteriorly, to the level of the submandibular account for 1.5 to 3% of all cancers (2). Men are af- gland inferiorly and the infratemporal space supe- fected more than women, and the neoplasm is most riorly. The invasion of muscular tissue by tumor commonly seen in the seventh decade in men, and was only recognizable on CT examination (Dg5, the sixth decade in women. A sore throat may be Th4,5). CT scored higher in the T-cIassification. the only symptom and the first indication of the The lymph node metastasis was not demonstrated, Kid

Figure 6.17. UndifTerentiaied carcinoma of the iKisaJ vestibule ;jnd lla. Diuvi s;mila) IO demon sunk* unicrior nasal spine (arrow head). B. Normal nose (direct sayillal sea

Figure b.lti. Jleman^iopericyloin;) nl riiihi nasal L;IVII\. C oion.il v(.\iion--. Nnic (he picsencc ot tiimoi in tl nasal c.nn\. eroding Ihe nasal septum. 161

Figure 6.19. Squamous cell carcinoma of lefl tonsil, invading soil palate (white arrow), parapharyngeal and ini'raicmporal space (D). Compare left and right side. (Coronal sections). figure 6.2(1. Si]ii;uiuniN cell nui ot left IOMMI \oiuc ih.n ihc IHMUM is m\ .UIIIIL' M visible and IKIS mil been ili . (A\i;tl M.v(u»fi\ A. H .intl ( ( i>fiin.i) ^e«.!inu D) 163

since contrast medium had not been used, the slices of 53 patients CT provided information unavailable had been thick and the patient had been inade- by other non-surgical procedures (Dg5). In this quately positioned. group (Dg4 and Dg5), the improvement in diagnos- Invasion of the parapharyngeal space was tic understanding of the patients' disease was main- shown in a patient who had a squamous cell carci- ly due to the fact that CT examination can show pa- noma of the soft palate. It concerned a 78-year old thology in the deeper regions around the pharynx, man with dysphagia of three months duration (pa- especially in the retromaxillary, the retropharyn- tient no. 23). Clinical examination showed a large geal and the parapharyngeal spaces. Improvement ulcerating tumor of the soft palate extending to the in diagnostic understanding is also obtained in pa- tonsils on both sides. No invasion of the parapha- tients with large tumors, which hamper clinical ryngeal spaces was suspected. CT, however, clearly examination, and in regions which are not readily revealed invasion of tumor into the parapharyngeal accessible to palpation. In the soft tissue regions space (Dg5, Th4,5). which are better accessible to palpation (tongue and A 75-year old woman presented with a swelling floor of the mouth) CT may not only confirm the of the tongue and complained of dysphagia (patient findings of palpation, but can also provide further no. 51). The referring clinician wanted to know if information. there was ex .nsion of tumor into the soft palate The influence of CT on therapy was most im- and parapharyngeal space. CT showed a large tu- pressive in patients of the Dg5 group. In 22 out 53 mor of the right part of the tongue, extending to the patients (about 37%), CT contributed to a change soft palate, retropharyngeal and parapharyngeal in therapy since CT provided unique information, space, and also invading part of the floor of the unavailable by other non-surgical procedures. The mouth and base of the tongue (Dg5, Th4,5). Displa- overall contribution of CT can be considered nega- cement of the lingual septum was noticed in both tive in 6 out of 53 patients (about 11%). In 47 out the axial and the coronal sections. The narrowing of 53 patients (about 88%), CT proved to play a of the pharynx could be demonstrated on axial sec- positive role in therapeutic management. Based on tions as well as on coronal sections. Two enlarged I he above, we may conclude that high-resolution lymph nodes were also present. CT is indispensable in the treatment of suspect and malignant lesions of pharynx, nasal and oral cavity.

6.7 Conclusions References Confusing diagnostic CT findings occurred only in a minority of patients (Dg2). These confus- 1. Baehren W, Haase Si, Wierschin W el al: Wertigkcil dcr ing findings resulted mainly from the lack of fat tis- Computertomographie bci dcr Diagnoslik bocsariiger Tu- sue around muscles, vascular and other structures, morcn dcr Mundhochlc und ihrcr regionacren Metastasie- and the fact that contrast medium had not been rung. lonschr. Roentgenstr. 136: 525-530. 1982 2. Balsakis JCi: Tumors of the Head and Neck. Clinical and used. In 13 out of 53 patients CT had little or no ef- Pathological Considerations. 2nd Edition, Williamd and fect on diagnostic understanding (Dg3). CT con- Wilkins. Baltimore/London firmed the clinical findings. In some patients with 3. Bohman L, Mancuso AA, Thompson J, Hanafee W: CT a generalized disease, such as a Wegener's granulo- approach to benign nasopharyngeal tumors. AJR 136: matosis, CT findings are not as important since the 173-180. 1981 4. Byrd SE, Schoen PJ, Gill G, Richardson M: Computed To- treatment is systemic. CT can only demonstrate the mography of palatine tonsillar carcinoma. J. Comput. As- influence of therapy on tumor size. Submucosal sist. Tomogr. 7 (6): 976-982. 1983 spread of tumor cannot be detected by CT. Neither 5. Dinesh Chandra De: Contrast Study of the Nasopharynx. can CT provide a histological diagnosis. If recur- Experience in Suriname. Dissertation 1979 rent carcinoma after surgery or radiotherapy has to 6. Fineberg HV, Wittenberg J, Ferruci JT: The clinical value be excluded, biopsies are indispensable. Significant nf body computed tomography over time and technologic change. AJR 141: 1067-1070. 1983 improvement of diagnostic understanding occurred 7. Hoover LA, Hanafee WN: Differential diagnosis of naso- in 3 out of 53 patients (about 66%) and in 35 out pharyngeal tumors by Computed Tomography scanning. 164

Arch. Orolaryngol. 109 (1): 43-47. 1983 oropharynx, tongue base, floor of the mouth: Normal anat- 8. Hopping SB, Keller JD, Goodman ML et al: Nasopharyn- omy and range of variations and applications in staging car- geal masses in adults. Ann. Olol. Rhinol. Laryngol. 92: cinoma. Radiology 148: 725-731. 1983 1982 16. Ruedi L, Zuppinger A: Zur Roentgen-Kontrasl Untersu- 9. Jing BS, McGraw: Contrast nasopharyngography in the chung der Nasopharynx. Hals-Nasen-Ohren 35: 500-507. diagnosis of tumors. Arch, of Otolaryngol. 81: 365-371. 1935 1965 17. Silver AJ, Mawad ME, Hilal SK et al: Computed Tomo- 10. Kassei EE, Cooper PW, Kassei RN: CT of nasal cavity. J. graphy of the nasopharynx and related spaces. Part 1: Anat- Otolaryngol. 12: 1. 1983 omy: Part II: Pathology. Radiology 147: 725-738. 1983 11. Larsson SG, Mancuso AA, Hanafee W: Computed Tomo- 18. Stenhouse D, Mason DK: Oral hemangiopericytoma - a graphy of the tongue and floor of the mouth. Radiology case report. Br. J. Oral. Surg. 6: 114. 1968 143: 493-500. 1982 19. Stout AP: Tumors featuring pericytes: Glomus tumors and 12. Lund VJ, Glyn AS, Lloyd AS: Radiological changes asso- hemangiopericytoma. Lab. Invst. 5: 217. 1956 ciated with inverted papilloma of the nose and paranasal si- 20. Wang CC, Meijer JE: Radiotherapeutic management of nuses. The British Journal of Radiology 57: 455-461. 1984 carcinoma of the nasopharynx: An analysis of 170 patients. 13. Mancuso AA, Bohman L, Hanafee W, Maxwell D: Com- Cancer 28: 566. 1971 puted Tomography of the nasopharynx. Normal and Vari- 21. Wittenberg J, Fineberg H V, Black EB el al: Clinical efficacy ants of Normal. Radiology (37: 113-121. 1980 of computed body tomography. AJR Ml: 5-14. 1978 14. Momose KJ, Weber AC, Goodman M et al: Radiological 22. Wittenberg J, Fineberg HV, Ferruci Jr JT et al: Clinical effi- aspects of inverted papilloma. Radiology 134: 73-79. 1980 cacy of computed body tomography II. AJR 134: 1111- 15. Muraki AS, Mancuso AA, Harnsberger HR et al: CT of the 1120. 1980 165

CHAPTER 7.

SUMMARY AND CONCLUSIONS

The aim of the study was to facilitate the iden- the impact on therapeutic management in a total of tification of anatomic structures and the interpreta- 134 patients. A number of patients are also demon- tion of pathologic changes in CT-images of para- strated. It proved that CT examination is confusing nasal sinuses, pharynx and related regions. Second- in a very small percentage of patients, leading to in- ly, the impact of CT on diagnosis and patient man- appropriate therapy in one patient. The overall agement was analyzed. contribution of CT was negative in 11 (5 + 6) out of In Chapter 2 the technique of examination of 134 (81 +53) patients (about 8%). There was con- the paranasal sinuses and pharynx is described. In fusing diagnostic information or the patients' con- order to refresh anatomical knowledge of the area dition or disease was such that therapy was impos- concerned, a brief description of paranasal sinuses, sible. In 123 (76 + 47) out 134 (81+53) patients pharynx and related region is given in Chapter 3. In (about 90%) CT contributed to a positive result: Chapter 4 the structures and organs on the CT im- CT confirmed the clinical findings and increased ages are identified. As the extension of pathological confidence in the treatment chosen, or CT provided processes into the hard palate, cribriform plate, in- information which contributed to a change in tlier- ferior orbital wall, base of skull and cranial fossa is apy. best demonstrated in coronal scans, structures and CT does not provide a histological diagnosis, organs are identified on axial and coronal CT im- although there may be a more or less characteristic ages. It proves to be difficult exactly to identify the pattern in specific disease entities. tonsils, tonsillar fossa and piriform sinuses with the Based on the above, we may conclude that high current technique. resolution CT is indispensable in the treatment of In Chapters 5 and 6 special attention is given suspicious and malignant lesions of paranasal si- to the diagnostic value of the CT examination and nuses and pharynx. 167

SUBJECT INDEX

Abscess 136, 137, 145, 146 temporal Acinic cell carcinoma superficial 28-34 cheek 98, 99, 104, 106 deep 34 Adenocarcinoma 97, 98, 99, 115, 116 vertebral 44-49 ethmoid sinus 93, 97, 114, 116 Auditory canal hard palate 98, 116 internal 31, 32 maxillary sinus 97, 106 Auditory tube Adenoid cystic carcinoma 97, 98, 99, 109, 111, 115, 135, 137 (Eustachian tube) 12, 13, 38, 39, 84 hard palate 98, 109, HI, 115 maxillary sinus 97 Base-line scan 9 nasopharynx 135 Bone Adenoma-pleomorphic 135, 136, 145, 149, 150 frontal 10, 26, 60-63 naso- and oropharynx 135 hyoid 12, 52-57 oropharynx 135, 136, 150 lacrima! 10 soft palate 135, 149 nasal 10, 28-37 Albright syndrome 107, 111 occipital 28-35 Alveolar process 66-72 sphenoid 26 Alar cartilages 9, 10 temporal 26-29 Ameloblastoma 98, 99, 105, 106 zygomatic 28-38 mandible 98, 105, 106 Buccal fat pad 20, 71, 72, 114, 115 maxilla 98 Bulb-olfactory 64-67 Amyloid and extramedullary plasmacytoma maxillary sinus 120, 123 Canal Anaplastic carcinoma carotid 33, 34 maxillary sinus 97 mandibular 42-53 Aneurysmal bone cyst 92 optic 28, 74-77 Angiofibroma 132, 135, 145, 147, 148 pterygopalatine 38, 39 Anterior nasal spine 10, 60-63, 159, 160 Vidian or pterygoid 78, 79, 81 Arch Carcinoma zygomatic 34, 35 acinic cell 98, 99 Artery adeno-97, 98,99, 115, 116 alveolar 74, 75 adenoid cystic 97, 98, 99, 109, 111, 115, 135, 137 basilar 28, 29, 82 anaplastic 97, 99 carotid colloid 98, 99, 113, 116 external 38-49, 52-56 mucoepidermoid 98, 99, 116 internal 38-56, 83 papillary 97, 99 frontal 26, 27 squamous cell 97, 99, 110, 111, 112, 116, 135, 136, 137, inferior alveolar 42 143, 151, 153, 158, 159, 161, 162, 163 infraorbital 38 undifferentiated 97, 99, 106, 115, 116, 135, 136, 137, 151, internal maxillary 36 152, 153, 155, 156, 157, 160 lingual 52, 74-79 Cartilage maxillary 35, 36, 74-77 alar 9, 10 ophthalmic 66-69 septal 38 sphenopalatine 9 thyroid 12 submental 74-83 Cavernous sinus 11, 80, 82, 84 superior alveolar 36 Cavity supraorbital 60-63 nasal 9, 12, 31-41, 60-77 I6,S

(Cavity, continued) plerygoid 16, 17, 18, 78, 79 oral 12, 15 pterygopalatine 16, 17 post-maxillectomy 93, 94 Rosenmueller Choana 9, 12, 78. 79 (pharyngeal recess) 13, 37, 38, 80, 81 Clinoid process scaphoid 19, 82, 83 posterior 80, 81 lonsillar 15 Clivus 33, 35, 82, 85 Colloid carcinoma 97, 113, 116 Ganglion Concha pterygopalatinc 19 inferior 9, 10, 36-41, 62-77 Giant cell granuloma 91, 92 middle 9, 10, 34-35, 62-77 Gland superior 9, 10, 70-73 lacrimal 26-28 Condyle parotid 18, 20, 38, 39, 82-85 mandibular 33-39 pituitary 28, 80, 81 occipital 38 sublingual 18 Coronoid process submandibular 18, 52-57 of mandible 38, 72-75 Cribriform plate 66-69 Hamulus Crista galli 62-67 of pterygoid 10, 78, 79 Cyst Hard palate 42, 43, 66-77 nasolabial 126 Hemangioma 136, 138, 139, 143, 144 nasopalatine duct 125 Hemangiopericyloma 135, 159, 160 retention cyst 92 Hiatus scmilunaris 10, 13, 66 Hyperostosis Dens axis 40-43 external 96, 99 Duct Hypopharynx 15 naso frontal 13 nasolacrimal 13, 34, 37 Inverted papilloma 97, 112, 113, 136, 138, 140, 141, 142 parotid 18, 20 and squamous cell carcinoma 113, 116 submandibular 18 Jugular canal 35 Epiglottis 54-56 Jugular trunk 21, 23 vallecula 54-56 Eustachian tube Lacrimal gland 26-32, 62, 63 orifice 12, 13, 38, 39 Lacrimal sac 32 External ear 26-40 Lamina papyracea 26-31, 62-70 Extramedullary plasmacytoma 97, 118, 119, 120, 123 Lens 30, 60 Leomiasis ossea 96, 99, 121, 122 Falx cerebri 60 Ligament Fascia atlanto-occipital 12 buccopharyngeal 13 hyoepigloltic 12 cervical 13 stylohyoid 12 pharyngo-basilar 13, 14 Lingual septum temporal 26-32, 66-71 see septum Fibrosarcoma 97 Lymph nodes Fibrosis dysplasia 92, 96, 107, 108, 111 anterior cervical 20, 22 Fissure infraclavicular 21 inferior orbital 32, 33, 70-75 internal jugular 21, 22, 57 pterygomaxillary 17 jugulo digastric 21, 22 superior orbital 30, 31, 72-75 jugulo omohyoid 21, 22 Foramen facial 20 infraorbital 64, 65 lateral cervical 20 lacerum 35 mastoid 20 ovale 35 occipital 20, 21 rotundum 32, 78, 79 parotid 20, 2] sphenopalatine 34 retroauricular 20, 21 spinosum 35 retropharyngeal 20 Fossa lateral 20, 58, 59 infratemporal 16, 17 medial 20 (Lymph nodes, continued) superior 36-39 spinal accessory 22, 58, 59 inferior 40-43 submandibular 20, 21, 58, 59 occipital 30 submental 20, 21, 58, 80 orbicularis oculi 26-37 supraclavieular 21 orbicularis oris 44-48, 62, 65 transverse cervical 22 palatoglossus 12, 17 pharyngopalatine 12, 82, 83 Mandible 32-57, 66-85 platysma 50-57, 76-85 coronoid process of 38, 72-75 procerus 26 mandibular canal 42-53 pterygoid 17 mandibular condyle 33-59 lateral 12, 34-39, 76-85 mandibular protuberance 66, 67 medial 12, 36-51, 78-85 Mastoid 25-35, 26-36 rectus Maxilla 10, 33-49, 62-77 inferior 30-33 alveolar process 66-75 lateral 28-30 tuberosity of 42, 76, 77 medial 28-30, 62-71 Meatus superior 26, 62-71 external auditory 32 rectus capitis posterior 34-41 inferior 13, 38-41, 64-77 scalenus middle 13, 60-77 anterior 54, 55 superior 13, 72, 73 medius 50, 57 Medulla oblongata 38 semispinalis c.ipitis 34-57 Melanoma (malignant) semispinalis cervicis 52-57 maxillary sinus 97 splenius capitis 32-35 Membrane (see also fascia) sternocleidomastoid 32-57 mocous 13 stylogkmus 12, 17, 50, 51 Metastatis slylohyoid 12, 14, 50, 51 of breast carcinoma 135, 137, 153, 154 stylopharyngeal 14 Mucocele 90, 123, 124 superior oblique 28, 62-67 ethmoid sinus 97, 123, 124 temporal 12, 26, 30-39, 64-79 Mucoepidermoid carcinoma tensor palati 12, 14, 36, 82-85 (see carcinoma) trapc/ius 32-57 Muscle /.ygomatic 40-49, 62-71 buccinator 18, 42-51, 66-77 constrictor pharyngeal Nasal cavity 9, 31-41, 60-77, 132 inferior 12, 14 Nasal cartilage 10 middle 12, 14 Nasal spine (anterior) 10, 62, 159, 160 superior 12, 14 Nasolabial cyst 98, 126, 127 depressor Nasopalatine cyst 98, 125, 127 labii inferioris 56 Nasopalatine duct 127 anguli oris 52-53 Nasopharynx digastric 14, 17, 18, 36-53, 72-81 see pharynx genioglossus 12, 14, 17, 50, 51, 72-81 Nerve geniohyoid 12, 14, 17, 52-55. 72-81 facial 20, 36 hyoglossus 14, 17, 50-55 inferior alveolar 42-52 inferior oblique 62-65 lacrimal 28, 66 lateral rectus capitis 38 lingual 19 levator anguli oris 62, 63 minor occipital 40 levator labii superioris 42-47, 62-65 olfactory 9 levator palati 12, 14, 36, 82, 85 optic 28-31, 66-73 levator palpebrae 26, 62-71 vagus 56 longissimus capitis 38-57 Non-Hodgkin lymphoma 97, 135, 136, 137 longissimus colli 54, 55 longus capitis 36-57 Olfactory bulb 64-67 longus colli 44-56 Oral cavity 15 masseter 18, 34-53, 72-85 Orbit mentalis 52-55 CT-identification 25 mylohyoid 12, 14, 17, 18, 50-57, 72-81 Orifice obliquus capitis of Eustachian tube 12, 13, 38, 39, 80, 81 170

Oropharynx 15 Septum Ossifying fibroma 96, 97, 121, 123 lingual 48-55, 72 Osteogenic sarcoma nasal 32-43, 64-77 mandible 98, 116, 118 Sinus maxilla 98, 116, 117, 123 cavernous 11 see paranasalsinus Palate Sinusitis hard 42, 43, 66-77 chronic 96, 97, 101, 106 soft 42-45, 78-85, 163 intracranial complications of 90, 91 Papillary carcinoma Soft palate ethmoid sinus 97 see palate Paranasal sinus Space frontal 10, 11, 25, 26, 60-63 parapharyngeal 15, 36-49, 82, 84 ethmoid 10, 11, 28-33, 62-71 pre-epiglottic 54-56 maxillary 10, 11, 32-43, 62-75 retromaxillary 15, 16, 17, 34 sphenoid II, 30-33, 72-S3 retropharyngeal 12 Parotid gland 20, 36-45 submandibular IS, 19 Pharyngeal recess 12, 38, 39, 80, 81 Spine Pharyngeal tubercle 12, 13, 81 anterior nasal 10, 62, 159, 160 Pharynx of sphenoid 14 anatomy 13, 15 Squamous cell carcinoma CT-identification 38-53, 80-85 (see carcinoma) pathology 135, 136 Styloid process 14, 38 Pituitary gland 28, 29, 80, 81 Sublingual gland 18 Plasmacytoma Submandibular gland 18, 52-57 see extramedullary Submandibular duct 18 Pleomorphic adenoma Submandibular lymph node 20, 21, 58, 80 see adenoma Synchondrosi» Polyps 92, 97, 99, 102, 103, 106 petrooccipital 82-85 Postmaxillectomy cavity 93, 94 Preepiglottic space 54-57 Torus tubarius 12, 38, 39, 80, 81, 155 Process Tongue posterior clinoid anatomy 12, 14, 15 see clinoid CT-identification 44-55, 66-84 pterygoid 36 pathology styloid 14, 38 Tonsil 12, 14, 159, 161 Pterygoid palatine 12, 14 fossa 40 pharyngeal 12 hamulus 78, 79 Trigeminal cave 82, 84 muscles Trochlea 26 lateral 12, 34-39, 76-85 Tuberosity medial 12, 36-51, 78-85 of maxilla 42, 76-77 plates Tubercle lateral 38-41, 78, 79 pharyngeal 12, 81 medial 38-41, 78, 79 process 36-47, 78, 79 Undifferentiated carcinoma Pterygopalatine fossa 16, 17, 33-36, 74-77 (see carcinoma) Pterygopalatine ganglion 19 Uvula 12, 46, 47 Pyocele 123 frontal sinus 124, 127 Valleculae epiglotticae 52-55 Vein Recess deep cervical 42-55 pharyngeal 12, 38 deep temporal 34 Reid's baseline 5 facial 40-55, 62-79 Rim enhancement 127 jugular Rosenmueller external 52 fossa of 12, 37, 38, 80, 81 internal 36-56 lingual 52, 74 Sarcoidosis 93 (Vein, continued) 171 I medical temporal 30 vertebral 44-49 occipital 36 Vestibule 12, 153, 158, 160 ophthalmic 19, 73 Vomer 34, 76 retromandibular 40-49 submental 54, 55, 74 Wegener's granulomatosis 92, 136, 137, 138, 139 superior alveolar 36 superior ophthalmic 28 Zygomatic superficial lingual 48 arch 68-75 superficial temporal 28-34 muscle 40-49, 62-71 173

SAMENVATTING EN CONCLUSIES

Het doel van de studie was de identificatie van anatomische structuren en de interpretatie van pathologische veranderingen op de CT-beelden van sinus paranasales, pharynx en aangrenzende gebieden, te verge- makkelijken. Ook was het doel na te gaan welke invloed het CT-onderzoek op de diagnose en het therapeutisch handelen had. In hoofdstuk 2 werd de techniek van het onderzoek beschreven. Teneinde de anatomische kennis van het betrokken gebied op te frissen werd een korte beschrijving van de anatomie van het gebied gegeven (hoofdstuk 3). In hoofdstuk 4 werden structuren en organen op de CT-beelden geïdentificeerd. Daar de uit- breiding van pathologische processen in het palatum durum, de lamina cribrosa, orbitabodem, schedelbasis, voorste en middelste schedelgroeve het best aangetoond wordt op coronale scans, zijn deze structuren en organen zowel in het axiale als in het coronaie vlak benoemd. Duidelijke identificatie van de tonsillen, fossa tonsillaris en sinus piriformis is moeilijk met de huidige techniek. In de hoofdstukken 5 en 6 werd de diagnostische waarde van het CT-onderzoek en de invloed op hel therapeutisch handelen nagegaan bij in totaal 134 patiënten. Een aantal van deze patiënten werd uitvoerig beschreven. CT-onderzoek bleek in slechts een klein percentage verwarrende informatie te geven en leidde tot inadequate therapie bij één patient. De bijdrage van CT was negatiefin II (5 + 6) van de 134 (81 +53) patiënten (ca. 8%). De diagnostische informatie was verwarrend, öf de conditie van de patient of de ziekte was van dien aard dat therapie onmogelijk was. Bij 123 (76 + 47) van de 134 patiënten (ca. 90%) droeg CT bij tot een positief resultaat. CT bevestigde de gegevens van het klinisch onderzoek en deed het vertrouwen in de gekozen therapie toenemen, of CT gaf informatie die bijdroeg tot een wijziging in de therapie. CT geeft niet een histologische diagnose, hoewel het CT-beeld zeer karakteristiek kan zijn voor bepaalde ziektebeelden. Concluderend kunnen we stellen dat CT' onmisbaar is bij het behandelingsplan van suspecte en maligne Ieasies van de sinus paranasales, pharynx en aangrenzende gebieden. 174

CURRICULUM VITAE

De auteur werd geboren op 21 december 1938 te Nijverdal. Na M.U.L.O.-examen (1955), Analist-examen A (1959), en Staatsexamen H.B.S.-B (1964), werd het Arts-examen afgelegd cp 23 november 1972 aan de Katholieke Universiteit te Nijmegen. De auteur was vervolgens gedurende een jaar als arts-assistent werkzaam in het Revalidatiecentrum HELIOMARE te Wijk aan Zee, en was ruim twee jaar als schoolarts verbonden aan de Districtsschool- artsendienst te Arnhem. Vanaf mei 1976 tot mei 1980 werd de opleiding tot radiodiagnost genoten in het Academisch Ziekenhuis te Utrecht (Opleiders: Prof. dr A.C. KlinkhamerenProf. dr. C.B.A.J. Puijlaert). Hierna volgde inschrijving in het Specialisten Register op 1 mei 1980. Na waarnemingen in het Diakonessenhuis te Hilversum en het Wil- helmina Ziekenhuis te Doetinchem vestigde de auteur zich op 1 juli 1982 als radiodiagnost in het Juliana Zie- kenhuis te Veenendaal. STELLINGEN

Computertomografïsch onderzoek in het axiale en coronale vlak is onmisbaar bij de diagnostiek en behandeling- van kwaadaardige aandoeningen in het hoofd-halsgebied.

Dit proefschrift

II Gezien de toenemende doeltreffendheid van radiodiagnostisch onderzoek is het een kunstfout dat de Faculteiten der Geneeskunde in Nederland het onderwijs hierin nu juist beperken.

III

De primaire oorzaak voor de kostenstijging van klinische zorg ligt niet in de toepassing van kapitaal-intensieve radiodiagnostische technieken, maar in de toename van bepaalde cardiochirurgische en andere intensieve behandelingen.

J. A. Showstack et ai, N.EngU.Med. 1985:313:1201-1207

IV Omdat er in de Westerse wereld een onrustbarende stijging is van het aantal vrouwen tussen de 45 en 50 jaar waarbij borstkanker wordt geconstateerd (boven de 50 jaar is er een tragere toename) is optimale mammo- grafie en voortdurende bijscholing van de radiodiagnost noodzakelijk.

Up to now CT is the procedure of choice in imaging of the head and neck region, but Magnetic Resonance Imaging (MR1) has improved dramatically within the past two years. The number of machines is limited so that the clinical value of MRI versus CT is not completely evaluated. In the field of this thesis we mostly insist on the fact that MRI is a totally safe technique which allows the study in three planes, including the sagittal, without moving the patient's head.

J. Vignaud, december 1985

De diagnose emphysemateuze pyelonephritis kan met aan zekerheid grenzende waarschijnlijkheid gesteld worden op grond van anamnese, klinisch onderzoek en de conventionele Röntgen buikoverzichtsopname.

VII

Met het invoeren van het begrip budgettering in de ziekenhuizen is de gezondheid van de mens van schatbare waarde geworden. VIII

Het nadeel van de laatbloeier is de korte zomer die nog rest.

Het in druk zien verschijnen van een proefschrift of artikel vermindert aanvankelijk de zelfkritiek van de auteur.

Als fusieperikelen, budgetteringsproblemen en promotiezorgen de overhand beginnen te krijgen wordt het tijd voor muziek, immers: "Du holde Kunst in wieviel grauen Stunden, wo mich des Lebens wilder Kreis umstrickt, hast du mein Herz zu warmer Lieb'entzunden, hast mich in eine bess're Welt entriickt!" Uit: An die Musik, F. Schubert. Tekst: Schober

Stellingen behorend bij het proefschrift: High-Resolution Computed Tomography of the Paranasal Sinuses, Pharynx and Related Regions, Gertrude Maatman, 9 September 1986