Imaging of head and neck and various modalities of imaging with neck levels and deep spaces

1. RADIOLOGY: HEAD AND
NECK
DR VIBHAY PAREEK
RADIATION ONCOLOGY
JUPITER HOSPITAL

2. CONVENTIONAL RADIOLOGY
• Temporal Bone: Law’s View, Schullars View, Stenver’s View,
Transorbital View, Submentovertical View.
• Nose And Paranasal Sinuses: Water’s View, Caldwell View, Lateral
View, Right And Left Oblique Views, Lateral And Occlusal Views Of
Nasal Bone.
• Neck: Lateral View And Anteroposterior Views Of Neck, Soft Tissue
Lateral View Nasopharynx, Submandibular Salivary Gland

3. LAW’S VIEW (LATERAL VIEW OF
MASTOID)
• In 1913, Dr Frederik Law Described Lateral View
Of Mastoid Bone.
• Sagittal Plane Of The Skull Is Parallel To The Flim
• X Ray Beam Is Projected 15 Degree
Cephalocaudal.

4. STRUCTURES SEEN:
• External Auditory Canal (EAC)
(Superimposed On Internal
Auditory Canal (IAC)),
• Mastoid Air Cells,
• Tegmen,
• Lateral Sinus Plate
• Temporomandibular Joint.

5. SCHULLAR’S VIEW
• 1906, Dr Arthur Schuller, An Austrian Neuroradiologist, Described An Oblique View
Of Mastoid Bone.
• X-ray Beam Is Projected 30° Cephalocaudal And Prevents Superimposition Of Two
Sides Of Mastoid Bones.
• Structures Seen: Eac Superimposed On Iac, Mastoid Air Cells, Tegmen, Lateral Sinus
Plate, Condyle Of Mandible, Sinodural Angle And Atticoantral Region (Key Areas For
Cholesteatoma And Its Erosion).

7. SCHULLER S VIEW

8. CLINICAL APPLICATIONS:
Extent of pneumatization, sclerotic mastoid, destruction of intercellular septa
(mastoiditis),
location of sinus plate (position of sigmoid sinus) and
tegmen (roof of middle ear and floor of middle cranial fossa),
cholesteatoma and
longitudinal fracture of petrous pyramid.

9. STENVER’S VIEW:
• In 1917, Dr H. W. Stenver Described Stenvers View Of Temporal
Bone
• Long Axis Of The Petrous Bone Lies Parallel To The Film.

10. STRUCTURES SEEN
• Entire Petrous Pyramid,
• Arcuate Eminence,
• Internal Auditory Meatus,
• Labyrinth With Its Vestibule,
• Cochlea
• And Mastoid Antrum

11. STENVER’S VIEW:

12. TOWNE’S VIEW:
• In 1926, Dr E. B. Town Of England Described Towns View.
• This Is An Anteroposterior View Of Skull With 30° Tilt From
Above And In Front.
• It Shows Both Petrous Pyramids, Which Can Be Compared.

14. TOWNE’S VIEW
• Structures Seen: Both Side Temporal Bones,
• Arcuate Eminence And Superior Semicircular Canal, Mastoid
Antrum, IAC, Tympanic Cavity, Cochlea And EAC
• Clinical Applications: Acoustic Neuroma And Apical Petrositis.

15. TRANSORBITAL VIEW:
• This is an anteroposterior view of skull.
• Orbitomeatal line is at right angles to the film.
• X-ray beam passes through the orbit.
• Structures seen: IAC, cochlea, labyrinth and both
• petrous pyramids projected through the orbits.
• Clinical applications: Acoustic neuroma and petrous
pyramid.

16. TRANSEORBITAL PROJECTION:

17. SUBMENTOVERTICAL VIEW:
• VERTEX REMAINS NEAR THE FILM AND X-RAY BEAM IS
PROJECTED FROM THE SUBMENTAL AREA.

18. STRUCTURES SEEN:
• EXTERNAL AUDITORY
CANNAL,
• MIDDLE AIR CLEFT. IE.
MASTOID CELLS, MIDDLE
EAR & EUSTACHIAN TUBE
• INTERNAL AUDITORY CANAL
• SPHENOID SINUSES

19. NOSE AND PARANASAL SINUSES
• Water’s view (occipitomental view):
• In 1914, Dr C. A. Waters and C. W. Waldron, two British
radiologists, introduced the Waters view.
• Nose and chin touch the film and X-ray beam is projected from
occipital side.
• Open mouth view shows sphenoid sinus. Petrous bones are projected
below the maxillary sinuses.
• Fractures of right and left nasal bones and their lateral displacement
can be seen.

21. STRUCTURES SEEN
• MAXILLARY (SEEN BEST)
• FRONTAL AND SPHENOID
SINUSES
• ZYGOMA, ZYGOMATIC
ARCH
• NASAL BONES, FRONTAL
PROCESS OF MAXILLA,
SUPERIOR ORBITAL
FISSURE
• AND INFRATEMPORAL
FOSSA.

22. CALDWELL VIEW (OCCIPITOFRONTAL VIEW):
• Eugene W. Caldwell, In 1903, Described A View Of The Paranasal Sinuses That
Still Bears His Name, “The Caldwell View”
• Nose And Forehead Touch The Film And X-ray Beam Is Projected 15–20°
Caudally.
• Frontal And Ethmoidal Sinuses Are Seen Well In This View.

23. STRUCTURES SEEN
• Frontal, Ethmoid And Maxillary Sinuses,
• Frontal Process Of Zygoma, Zygomatic
Process Of Frontal Bone
• Superior Margins Of Orbits, Lamina
Papyracea,
• Superior Orbital Fissures.

24. LATERAL VIEW
Lateral side of the skull lies against the flim and X ray beam is
projected perpendicular from other side.

25. STRUCTURES SEEN :
Anterior and posterior extents of sphenoid, frontal and maxillary sinuses,
sella turcica, Ethmoid sinuses, alveolar process, condyle and neck of
mandible.

26. NECK, LARYNX AND PHARYNX
Lateral View Of Neck
•Structure Seen: Outline Of Base Of Tongue, Vallecula,
•Hyoid Bone, Epiglottis And Aryepiglottic Folds,
Arytenoids,
•False And True Cords With Ventricle In Between Them,
•Thyroid And Cricoid Cartilages, Subglottic Space
•And Trachea, Prevertebral Soft Tissues, Cervical Spines
•And Pretracheal Soft Tissues And Thyroid.

27. BARIUM SWALLOW
• Procedure Used To Examine Upper Gastrointestinal Tract,which Include The
Pharynx, Esophagus, Cardia Of Stomach.
• The Contrast Used Is Barium Sulfate.
• Types Of Contrast Study
(I) Single Contrast Study
(Ii) DOUBLE CONTRAST STUDY

28. CONTRAINDICATION
• Suspected Esophageal Perforation.
• Tracheo-esophageal Fistula
• If Strong Clincal Suspicion Of Aspiration Or Tef,then Omnipaque
Swallow (Iohexol) Advised.
Xray View
• Soft Tissue Neck,chest – Ap & Lat

29. NORMAL-AP /LAT VIEW - SCOUT

30. AP/LAT VIEW WITH BARIUM

31. • EFT: LATERAL VIEW: EPIGLOTTIS (RED ARROW). POST
CRICOID IMPRESSION (YELLOW ARROWS).
• CRICOPHARYNGEOUS IMPRESSION (WHITE ARROW).RIGHT:
AP-VIEW: SMALL LATERAL PHARYNGEAL POUCHES

32. CA ESOPHAGUS
• THE STENOTIC SEGMENT IS LONG GIVING A “RAT-TAIL”
APPEARANCE
BARIUM SWALLOW SHOWS MILD DILATATION OF THE
ESOPHAGUS WITH IRREGULAR STENOTIC LESION IN THE
LOWER END OF THE ESOPHAGUS “MOTH EATEN
APPEARANCE

33. SIALOGRAPHY
• Radiologic examination of the salivary glands
• The submandibular and parotid glands are investigated by this method
• The sublingual gland is usually not evaluated this way because of difficulty in
cannulation

34. PROCEDURE
• Obtain Preliminary Radiographs
Any Condition That Is Visibe W/O Contrast
Optimum Technique Obtained
• 2-3 Min Before Procedure Give Lemon
• Contrast Media (Iohexol) Injected Into Main Duct
• After Procedure Suck On Lemon To Clear Contrast
• 10 Min After Procedure Take Radiograph

35. PAROTID RADIOGRAPHS SET-UP

38. ORTHOPANTOMOGRAPHY (TOMOGRAPHY OF
THE MANDIBLE)
• A Pantomograph Is A Panoramic
Radiograph Machine.
• It Permits Visualization Of Entire
Maxillary And Mandibular Dentition,
• Alveolar Arches And Contiguous
Structures On A Single Extraoral Film

39. ULTRASOUND
• Ultrasound Is Sound Within A Frequency Above The Upper Limit Of
Normal Hearing.
• Ultrasound Images Are Formed From Reflected Sound Waves.
• Sound Waves Are Generated In Short Bursts By The Transducer (Or
Probe)
• And The Sound Energy That Is Reflected Back Is Collected At The Point
Of Origin (The Transducer)

40. TRANSDUCER (PROBE)
• Piezoelectric Material Is Used To Produce Sound Wave
• Usually Lead Zirconate Titanate
• The Higher The Frequency Of The Probe The Lesser The Depth Of Penetration
But Gives Better Spatial Resolution.
• In Neck Most Of The Structures Of Interest Are Superficial And Required A
Higher Frequency Probe Of Greater Than 7.5 Mhz

41. ADVANTAGES
• No Known Harmful Effects And No Contraindications.
• High-resolution Ultrasound Is Quick And Accurate;
• Further, It Is Relatively Inexpensive Compared To CT Or MRI.
• In Addition To Using Echoes To Generate Images, We Can Analyze The Returning
Echo Frequencies. This Doppler Analysis Allows Identification Of Moving Blood As
Well As Its Direction And Magnitude

42. ULTRASOUND APPEARANCE OF COMMON
ABNORMALITIES.
Lymph Nodes
•Normal Lymphnode May Be Visualized By Usg In Healthy Subject, They Are Often
Not Seen Due To Their Small Size And Similar Echo-texture With Surrounding
Structure.
•When Apparent, Lymph Nodes Are Reactive, Inflammatory Or Neoplastic.
•Retropharyngeal Lymph Nodes Cannot Be Seen With Ultrasound.

43. • REACTIVE LYMPH NODE. (A) AN OVAL-
SHAPED, LOW-REFLECTIVE LYMPH
NODE WITH AN ECHOGENIC HILUM
(ARROW)
• (B) FLORID COLOUR DOPPLER FLOW
TO THE CENTRAL HILUM CONSISTENT
WITH A BENIGN REACTIVE LYMPH
NODE

44. • SQUAMOUS CELL
CARCINOMA LYMPH NODE
METASTASIS.
• AN ENLARGED LOW
REFLECTIVE MASS WITH
AN IRREGULAR BORDER
(LONG ARROW)
• CAROTID ARTERY (SHORT
ARROW)

45. THYROID
• For Ultrasound Imaging Thyroid Disorder May Be Considered Into Two
Groups
• Nodular
• Diffuse
• Major Role Of Usg In The Assessment Of Disease
1.Detection Of Focal Masses
2.Differentiation Of Multinodular Goiter/Hyperplasia From Other Nodular
Disease
3.To Document The Extent Of A Known Thyroid Malignancy;
4.Follow Up To Look For Residual, Recurrent Or Metastatic Carcinoma;
5.Guidance For FNAC Or Fine Needle Aspiration For Biopsy.

46. SALIVARY GLAND DISEASE
• Both The Parotid And Submandibular Glands Are Superficial And
Well Sited For Ultrasound Examination
• Ultrasound Accurately Differentiates Salivary Gland Tumors From
Other Lesions Outside Gland
• Calculi Larger Than 2mm Are Detected By Usg
• And Useful In Defining Location Of Calculi In Relation To The
Gland Parenchyma
• It Detects The Presence And Extends Of Any Abscess Formation.

47. • DOPPLER ULTRASOUND MEASURES BLOOD FLOW OF VESSELS.
• IN COLORDOPPLERFLOWING BLOOD APPEARS EITHER RED OR BLUE,
• WHICH DEPENDS UPON THE BLOOD DIRECTION, TOWARDS OR AWAY FROM THE
TRANSDUCER.
• „ POWERDOPPLER: IT CAN DEMONSTRATE TISSUE PERFUSION.

48. APPLICATIONS OF ULTRASOUND
• Differentiating Cystic From Solid Masses
• „Metastatic Lymph Nodes
• „Tumor Invasion Of Carotid Vessels And Internal Jugular Vein.
• „Tumors Of Parotid And Submandibular Salivary Glands
• „Salivary Duct Stones Even Less Than 2 Mm
• „Detection And Drainage Of Salivary Gland Abscess Under US Guidance
• „Masses Of Thyroid And Parathyroid Glands And US Guided Fine Needle Biopsy
• „ Neck Lymphoma.

49. COMPUTED TOMOGRAPHY
• In 1972 Godfrey Hounsfield Of Great Britain Invent CT.
• Computed Tomography (Ct) Is Accomplished By Passing A Rotating Fan Beam Of X-
rays Through The Patient And Measuring The Transmission At Thousands Of Points.
• The Data Are Handled By A Computer That Calculates Exactly What The X-ray
Absorption Was At Any Given Spot In The Patient.
• Compared With Plain X-rays, Ct Uses About 10 To 100 Times More Radiation

50. COMPUTED TOMOGRAPHY
IMAGING
• Imaging Can Be Obtained In Several Planes.
• In Most Cases The Axial (Transaxial) Plane, Usually Parallel To The
Orbitomeatal Or Infraorbitomeatal Plane, Is Used With The Patient Lying
Supine
• In Addition, Direct Coronal Imaging And Even Direct Sagittal Imaging
Can Be Performed.
• In Fact Images Can Be Reformatted In Any Plane Or Any Angle

51. DIFFERENT VIEWS OF CT PNS• CORONAL IMAGE
AXIAL IMAGE
SAGITTAL IMAGE

52. COMPUTED TOMOGRAPHY
• Conventional CT Scanners Have Traditionally Operated In A Step-and-
shoot Mode, Defined By Data Acquisition And Patient Positioning
Phases
• Helical CT Is Characterized By Continuous Patient Transport Through
The Gantry While A Series Of X-ray Tube Rotations Simultaneously
Acquires Volumetric Data.
• The Evolution Of Multidetector Ct Scanners (Mdcts) Has Resulted
From The Combination Of Helical Scanning With Multislice Data
Acquisition.

53. COMPUTED TOMOGRAPHY
• In General, The Basic Four Densities On CT Images Are The Same As Those In Plain X-
rays:
• Air Is Black,
• Fat Is Dark Gray,
• Soft Tissue Is Light Gray,
• Bone Or Calcium And Contrast Agents Are White

54. CT IMAGE DISPLAY
• Hounsfield Unit: Value Of CT Number
• Defined By The Relationship Between The Linear Attenuation Value Of The Material
Being Scanned And That Of Water.
• Gas = -1000 Hu
• Water = 0 (Zero) HU
• Bone = +1000 HU
• Fat = - 80 To -100 HU

55. CT IMAGE DISPLAY
• The Window Level Is Simply The Midpoint Of The Densities Chosen For Display
• For Imaging Of The Soft Tissues Of The Head And Neck, A Window Level Of
Approximately 40 To 70 HU Is Usually Chosen, At A Midpoint Approximately Equal
To The Density Of Muscle
• For Imaging Bony Structures Such As Paranasal Sinuses And Temporal Bone, Window
Levels From 0 To +400 HU And A Very Wide Window Width Of 2000 To 4000 HU
May Be Chosen

56. THE TERMINOLOGY COMMONLY USED TO DESCRIBE THE
ABOVE MENTIONED WINDOWS INCLUDES SOFT TISSUE
WINDOWS (WINDOW WIDTH OF 250 TO 400 HU) AND BONE
WINDOWS (2000 TO 4000 HU).
• SOFT TISSUE WINDOW CT IMAGE
• BONE WINDOW CT IMAGE

57. CONTRAST CT:
• Intravenous Contrast Agents Allow Identification
Of Rim Enhancement In Pathological Lymph
Nodes And
• Increase The Definition Of Primary Tumors.

58. SPIRAL CT
• Helical Or Spiral CT Scans A Volume Of Tissue And
• Provides Better Quality Images Than The Conventional CT.
• It Covers More Than 300 Cm Tissue During A Single Breathhold Of 30 Seconds

59. MULTIDETECTOR CT SCANNERS (MDCTS)
• MDCT Can Reduce Scan Time, Permit Imaging With Thinner Collimation, Or Both
• Multidetector CT Offers The Additional Advantages Of Decreased Contrast Load,
Reduced Respiratory And Cardiac Motion Artifacts, And Enhanced Multiplanar
Reconstruction Capabilities.

60. CT ANGIOGRAPHY:
• With Intravenous Bolus Administration Of Iodinated Contrast Material.
• Permitted Successful Imaging Of Entire Vascular Distributions
• CT Angiography Has Become An Important Tool For Assessment Of The
Abdominal And Iliac Arteries And Their Branches, The Thoracic Aorta, The
Pulmonary Arteries, And The Extra- And Intracranial Carotid Circulation.

61. PROCESSING OF VOLUMETRIC DATA:
• The Volumetric Data Can Be Processed To Produce
• Multiplanar Images: Sagittal And Coronal
• Three-dimensional (3D) Images
• Virtual Endoscopy: Such As Laryngoscopy, Bronchoscopy And Sinuscopy

62. 3-D IMAGE REFORMATTING
• To Evaluate Bony Structure
• Like Fracture, Tumour,
Exostosis, Destructive Lesions
Etc.
• Helps Immensely In Planning
Reconstruction Operation

63. 3-D RECONSTRUCTION OF
CT-ANGIOGRAPHY
• 3- D Reconstruction Of Cervical
Vessels From CT Volumetric Data
Set Obtained After Administration
Of Contrast Material
• Gives Better Result Than MR
Angiography

64. OPTIMAL SLICE THICKNESS
• 3 Mm Or 5mm = Neck Structure
• 2 Mm = Facial Bone, Sinunasal Cavities And Orbit,
Laryngohypopharyngeal Region
• 0.8 – 1 Mm = Temporal Bone

65. APPLICATIONS OF CT,
• Extension Of Mucosal Tumors Of Suprahyoid Neck And Metastatic Neck Lymph Nodes (Ring
Enhancement)
• „Postoperative Neck
• „Salivary Gland Tumors And Metastatic Neck Lymph Nodes
• „Computed Tomography Sialography
• Cervical Lymphadenopathy
• „Trauma, Inflammation And Cancer Of Larynx And Laryngopharynx With Metastatic Neck Nodes
• „Large Or Fixed Thyroid Tumors Invading And Compressing Larynx, Laryngopharynx, Trachea And
Mediastinum
• „Paranasal Sinuses Prior To Endoscopic Sinus Surgery, Severe Nasal Polyposis, Tumors
• „ Facial Trauma
• „Temporal Bone And Skull Base Tumors, Semicircular Canal Fistulas, Cochlear Implants.

66. MRI IMAGING PROTOCOLS
• The Rate Of Energy Loss Is Designated As The Longitudinal (T1) And Transverse (T2)
Relaxation Times.
• T1 Represents The Restoration Of The Longitudinal Magnetization Along The Axis Of The
Main Magnetic Field
• T2 Represents The Decay Time Of The Magnetization In The Transverse Plane.
• Substances (eg.,Fluid) That Have A Long T1 Will Appear Dark On T1-weighted Images,
Whereas Those With Short T1 (Fat) Will Display High Signal Intensity.

67. IMAGING PROTOCOLS
• On T2-weighted Images, A Long T2 Substance (Fluid) Will Appear
Bright.
• The Commonly Used Pulse Sequences Are T1-weighted (T1w), T2-
weighted (T2w), Gadolinium-enhanced T1w, Spin (Proton) Density,
Fat-suppressed And Gradient Echo Imaging.

68. • T1W: Because Of High Soft Tissue Discrimination, T1W Images Show
Exquisite Anatomical Details.
• „T2w: The Pathological Lesions Increase T2 De-phase Times, Which Produce
Higher Signal Than Surrounding Normal Tissue In T2w Images.
• The Combination Of T1w And T2w Images Is Good For Characterizing Fluid
Containing Structures, Solid Components And Hemorrhage.

69. MRI HEAD SAGITTAL SECTION
T1-WEIGHTED
MRI HEAD AXIAL SECTION T2-
WEIGHTED

70. GADOLINIUM-ENHANCED T1W:
• Intravenous Gadolinium (Used In T1W) Reduces T1 Relaxation Time And Enhances
Lesions, Which Appear As High Signal Intensity Areas
• Improved Delineation Of Tumor Margins Relative To The Lower Signal Of Muscle,
Bone, Vessel And Globe.
• Gadolinium Enhancement Is Optimally Used With Specific Fat Suppression
Techniques.

71. SHORT-TAU INVERSION RECOVERY:
• The STIR Sequence Suppresses High Signal Intensity From Fat (That
Turn Fat Black) And Fluid Containing Structures Remain High Signal
Intensity.
• In Stir, Decreased Signal-to-noise Ratio Degrades The Image.
Magnetic Resonance Angiography:
• It Uses Specific Sequences
• And Demonstrates Flowing Blood.

72. DIFFERENT CHARACTERISTICS
• (To Quickly Identify A T1WI: Fat Is White,
CSF And Vitreous Are Black, And Nasal
Mucosa Is Low Signal.)
• (To Quickly Identify A T2wi: Csf, Vitreous,
And Nasal Mucosa Are White. Fat Is Low To
Intermediate In Signal.)

73. DIFFERENT CHARACTERISTICS
• To Quickly Identify A Gadolinium-enhanced
T1WI: Nasal Mucosa Is White, Fat Is White, And
CSF And Vitreous Are Black
• To Quickly Identify A Stir Image(fat Suppresion):
Fat Is Almost Completely Black; Csf, Vitreous,
And Mucosa Are White

74. ADVANTAGES
• Superior Soft Tissue Contrast Resolution Than CT
• No Radiation Exposure
• Less Image Quality Gets Hampered By The Presence Of Dental Fillings

75. DISADVANTAGES
• Long Image Acquisition Time
• More Chance Of Motion Artifacts
• Difficult To Stage Both Primary Tumour And Neck Nodal Disease
• Higher Cost And Less Availability
• Absolute Contraindications To MRI Include Patients With Cardiac Pacemakers,
Cochlear Implants, And Ferromagnetic Intracranial Aneurysm Clips.
• Those Patients At Risk For Metallic Orbital Foreign Bodies Should Be Screened
With Plain Films Or Ct Before Mri.

76. APPLICATIONS OF MRI
• Tumors Of Nasopharynx, Oropharynx, Oral Cavity And Tongue
• „Extracapsular Spread Of Tumor From Nodes
• „Perineural Spread And Extension Beyond Gland Of Salivary Gland Tumors
• „Tumors Of Nose And Paranasal Sinuses: Distinguish Between Tumor And Obstructed
Sinus Secretions (Hydrated Fluid,viscous, Desiccated);
• Perineural Spread To Anterior Cranial Fossa, Orbit, Parapharyngeal Space And
Pterygopalatine Fossa And Cribriform Plate Extension
• „Lesions Of IAC, Facial Nerve Canal, And Jugular Foramen; Acoustic Schwannoma
• „Skull Base Tumors

77. TECHNETIUM-99M (99MTC)-
PERTECHNETATE SCAN:
• In Salivary Gland Imaging 99mtc Pertechnetate Imaging May Be
Useful For Assessing Salivary Gland Function In Autoimmune And
Inflammatory Disease Of The Salivary Glands.
• If Obstructed, The Degree Of Obstruction As Well As The Follow-up
Of Obstruction After Treatment Can Be Assessed.
• In Evaluating Neoplasms Of The Salivary Glands The Findings Of
The 99mtcpertechnetate Scan Are Almost Pathognomonic Of
Warthin's Tumor And Oncocytoma.

78. THYROID IMAGING
• Most Nuclear Medicine Imaging Uses Various Isotopes Of Iodine (131I And
123I), Technitium-99m Pertechnetate To Determine Thyroid Function, Identify
Hot Or Cold Nodules, Or Access Extent Of Thyroid Masses And Tumors.
• 1- 4 % Of Hot Nodules – Malignant
• Upto 25 % Of Cold Nodule – Malignant

79. POSITRON EMISSION TOMOGRAPHY
• Used For Staging And Evaluation Of Recurrence For Primary Head And Neck
Tumors, Detecting Distant Lymph Node, Soft-tissue And Skeletal Metastases
• More Accurate Than CT Or MRI In Detecting Residual Or Recurrent Nodes
• Highly Reliable After 3 – 4 Months Of End Of Treatment.

80. INDICATIONS OF FDG WITH
INTEGRATED PET/CT
• SCC Patients With
 Equivocal Nodal Disease Following Conventional Assessment;
-Suspicion Of Recurrent/Residual Disease.
• Patients With Occult Primary Tumors.
• Post-treatment Papillary And Follicular Thyroid Cancer Patients With Elevated
Thyroglobulin And Negative 131-i Scan.
• Patients With Clinical Suspicion Of More Disease Than Conventional Assessment
Demonstrates.
• Patients Where Resectability Is In Doubt.

81. NECKSPACES

82. DEEP NECK SPACE ANATOMY
• Space Involving Entire Length Of Neck
• Space Limited To Above The Hyoid Bone
• Space Limited To Below The Hyoid Bone

83. CERVICAL FASCIAL PLANES

84. SPACE INVOLVING ENTIRE LENGTH OF
NECK
1. Retropharyngeal Space
2. Prevertebral Space
3. Carotid Sheath Space

85. RETROPHARYNGEAL SPACE
• Between Visceral Division Of
Middle Layer And Alar Division Of
Deep Layer
• Extend From Skull Base To T2
Level
• More Common In Children Due To
Presence Of Retropharyngeal Node

87. RETROPHARYNGEAL SPACE
• Lateral Soft Tissue X-ray (Extension, Inspiration) Abnormal Findings:
• 1. C2-post Pharyngeal Soft Tissue >7mm
• 2. C6–adults >22mm, Peads >14mm
• 3. STS Of Post Pharyngeal Region >50% Width Of Vertebral Body

88. PREVERTEBRAL SPACE
• Potential Space Posterior To
Prevertebral Division And
Anterior To Vertebral Bodies
• Extends From Skull Base To The
Coccyx

91. CAROTID SHEATH SPACE
• Made Up From All Deep Cervical Fascia
• Infection From Any Deep Fascia Can Spread To This Space.

94. SPACE LIMIT TO ABOVE THE HYOID
BONE
1. PARAPHARYNGEAL
SPACE
2. SUBMANDIBULAR
SPACE
3. MASTICATOR SPACE
4. TEMPORAL SPACE
5. PAROTID SPACE

95. PARAPHARYNGEAL SPACE
(LATERAL PHARYNGEAL SPACE)
Boundary
• Superiorly : Skull Base
• Inferiorly : Hyoid Bone
• Laterally : Medial Pterygoid M.
• Medially : Buccopharyngeal Fascia
• Anteriorly : Submandibular Space
• Posteromedialy : Prevertebral Fascia And
Retrophryngeal Space

97. SUBMANDIBULAR SPACE
Divided Into 2 Spaces By Mylohyoid M.
1. Sublingual Space (Above Mylohyoid M.)
2. Submaxillaly Space (Below Mylohyiod
M.)
• These 2 Spaces Can Communicate Each
Other By Mylohyoid Cleft

99. MASTICATOR SPACE
• Between Masticator M. And
Superficial Layer Of Deep Cervical
Fascia
(Masticator M. = Massestor M.,Medial
And Lateral Pterygoid M. And
Temporalis Muscle)
• Locate Anterior And Lateral To
Parapharyngeal Space

100. PAROTID SPACE
• Between Parotid Gl. And Superficial Layer
Of Deep Cervical Fascia
• Infection Can Spread Easily To
Parapharyngeal Space Due To
Uncompleted Encircle At Upper Inner
Surface Of Parotid Gland.

102. SPACE LIMIT TO BELOW THE HYOID
BONE
Anterior Viseral Space (Pretracheal Space)
• Between Trachea, Esophagus And
Middle Layer Of Deep Cervical
Fascia
• Extend From Hyoid Bone To
Superior Mediastinum

107. LEVELS OF CERVICAL LYMPH
NODES

108. Deep Lymph Nodes
1. Submental
2. Submandibular (Submaxillary)
Anterior Cervical Lymph Nodes (Deep)
3. Prelaryngeal
4. Thyroid
5. Pretracheal
6. Paratracheal
Deep Cervical Lymph Nodes
7. Lateral Jugular
8. Anterior Jugular
9. Jugulodigastric
Inferior Deep Cervical Lymph Nodes
10. Juguloomohyoid
11. Supraclavicular (Scalene

110. Level I A
Submental Nodes, Between The Medial Margins Of The Anterior
Bellies Of The Digastric Muscles.

111. Level I B
Submandibular Nodes, Lateral To Level I A Nodes And Anterior To The
Back Of The Submandibular Salivary Gland.

113. Level II
Upper Internal Jugular Nodes, Posterior To The Back Of The
Submandibular Salivary Gland, Anterior To The Back Of The
Sternocleidomastoid Muscle And Above The Level Of The Bottom Of The
Body Of The Hyoid Bone.

115. Level III
Middle Jugular Nodes, Between The Level Of The Bottom Of The Body
Of The Hyoid Bone And The Level Of The Bottom Of The Cricoid Arch,
Anterior To The Back Of The Sternocleidomastoid Muscle.

117. Level IV
Low Jugular Nodes, Between The Level Of The Bottom Of The Cricoid
Arch And The Level Of The Clavicle, Anterior To A Line Connecting The
Back Of The Sternocleidomastoid Muscle And The Posterolateral Margin Of
The Anterior Scalene Muscles; They Are Lateral To The Carotid Arteries.

119. Level V
Posterior Triangle Nodes, Posterior To The Back Of The Sternocleidomastoid
Muscle, And Posterior To The Line Described In Level IV.

121. • Level V AAbove The Level Of The Bottom Of The Cricoid Arch.
• Level V B Between The Level Of The Bottom Of The Cricoid Arch And
The Level Of The Clavicle

122. Level VI Upper Visceral Nodes, Between The Carotid Arteries From The Level Of
The Bottom Of The Body Of The Hyoid Bone To The Level Of The Top Of
Manubrium.
Level Vii Superior Mediastinal Nodes, Between The Carotid Arteries Below The
Level Of The Top Of The Manubrium And Above The Innominate Vein.

129. DEEPNECKSPACES

130. 1-visceral Space :
2-carotid Space :
3-retropharyngeal Space :
4-posterior Cervical Space :
5-perivertebral Space :

131. 1-ANTERIORVISCERAL SPACE :
A) EXTENSION :
FROM THE HYOID TO THE ANTERIOR MEDIASTINUM & DOESN’T EXTEND INTO THE
SUPRAHYOID SPACE

132. B) Contents :
1-larynx (Laryngocele, SCC & Chondrosarcoma)
2-hypopharynx / Esophagus (Zenker’s Diverticulum & SCC)
3-trachea (Carcinoma & Benign Stenosis)
4-thyroid Gland
5-parathyroid
6-embryonal Remnants (Thyroglossal Cyst , 3rd
Branchial Cyst)
7-paratracheal Lymph Nodes (Mets, Lymphoma)
8-recurrent Laryngeal Nerve Paralysis

134. Glottic Scc, Axial Contrast Ct Image Shows A Glottis Mass In The Left True Cord Reaching The
Anterior Commissure (Black Asterisk), Mild Thickening Of Posterior Commissure Is Noted
(Thick Black Arrow) With Sclerosis Of Left Arytenoid And Left Lamina Of Thyroid Cartilage

135. ADVANCED SCC, AXIAL CT+C SHOWS A LEFT CORD MASS (THIN WHITE
ARROWS) REACHING ANTERIOR COMMISSURE (ASTERISK), NOTE THE
SCLEROSIS OF THE LEFT THYROID LAMINA AND LEFT CRICOARYTENOID
JOINT (THIN BLACK ARROWS)

136. Medullary Thyroid Carcinoma In A 32-year-old Man, (A) Transverse Sonogram Of The Right Lobe Of The Thyroid
Shows A Large Nodule With Coarse Calcification And Posterior Acoustic Shadowing (Arrows), (B) Axial Ct Shows
The Nodule With An Internal Focus Of Coarse Calcification (Arrows)

137. Anaplastic Thyroid Carcinoma In An 84-year-old Woman, (A) Transverse Sonogram Of The Left Lobe Of The
Thyroid Shows An Advanced Tumor With Infiltrative Posterior Margins (Arrows) And Invasion Of Prevertebral
Muscle, (B) Axial Ct+c Shows A Large Tumor That Has Invaded The Prevertebral Muscle (Arrows)

139. PARAMEDIAN THYROGLOSSAL DUCT CYST

140. 2-Carotid Space:
A) Extension :
-From Skull Base To The Aortic Arch
-It Traverses The Suprahyoid & Infrahyoid
B) Contents :
1-carotid Artery (Aneurysm, Thrombosis, Dissection)
2-IJV (Thrombosis)
3-cranial Nerves (9-12), Schwannoma & Neurofibroma
4-lymph Nodes (IJV Chain Of Nodes), Mets & Lymphoma
5-embryologic Remnants : 2nd
Branchial Cleft Cyst
6-sympathetic Plexus : Paraganglioma (Carotid Body Tumor)

142. Carotid Aneurysm, (A) Non-contrast-enhanced Axial Ct Shows A Round Soft Tissue Density Mass In The
Right Carotid Space Is Seen, (B) Ct+c Shows A Round Mass Showing Homogeneous Enhancement Is Seen
In The Right Carotid Space, (C) Ct+c, Coronal Multiplanar Reformation (Mpr) Shows The Right Internal
Carotid Fusiform Aneurysm And Its Top And Bottom Continuity With The Internal Carotid Artery Are
Shown

143. THROMBOSIS OF IJV

144. THROMBOSIS OF JUGULAR VEIN

145. PARAGANGLIOMA : T1+C AT THE LEVEL OF THE SUPRAGLOTTIC LARYNX

146. PARAGANGLIOMA, (A) T1-WEIGHTED NON-CONTRAST MR, (B) CT+C

148. CAROTID BODY TUMOR

149. 3-Retropharyngeal Space:
A) Extension :
-Posterior Potential Midline Space Extends Superiorly To The Base Of The
Skull & Inferiorly To The Posterior Mediastinum At The Level Of The
Tracheal Bifurcation (T3 Level)
B) Contents :
1-retropharyngeal Abscess
2-fat (Lipoma & Liposarcoma)
3-lymph Nodes (Mets ,Infection & Lymphoma)

151. Axial Ct+c Of The Skull Base At The Level Of The Hard Palate Shows An Enhancing Right Lateral
Retropharyngeal Lymph Node (Asterisk) And 2 Enhancing Left Superficial Parotid Masses

152. 4-Posterior Cervical Space :
Contents :
1-fat
2-cranial Nerve XI (Schwannoma, Neurofibroma)
3-brachial Plexus :
-Schwannoma, Neurofibroma
-Direct Invasion Of Apical Lung (Pancoast Tumor), Breast Carcinoma &
Lymphoma
4-primitive Embryonic Lymph Sacs (Cystic Hygroma)
5-lymph Nodes (Lymphoma, Metastases, TB)

154. Lipoma, The Mass Has The Signal Intensity Of Fat On A T1 (A) And The Signal Is Completely Suppressed With Fat Suppression
(B)

155. Lymphoma, Ct Image At The Level Of The Hyoid Bone Shows Multiple Rounded Lesions Medial To The
Sternocleidomastoid Muscles And Dorsal To The Internal Jugular Veins, These Bilateral Multiple Lesions
Are Located In The Posterior Cervical Space

156. 5-Perivertebral Space :
Contents :
1-spine (OM, Tumors)
2-paraspinous Muscles (Myositis, Abscess , Sarcoma, Fibromatosis)
3-brachial Plexus
4-vertebral Artery

158. Sarcoma, Large Soft Tissue Mass Adjacent To The Vertebral Body Centered In The Perivertebral Space