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  1. 1. Role Of Imaging & Normal Radiological Anatomy Of Head & Neck With Emphasis On Oral Cavity Presenter :Dr Isha Jaiswal Senior Resident Radiotherapy Date 10th September 2018
  2. 2. ROLE OF IMAGING IN HEAD & NECK CANCER • For Diagnosis & Staging • For Treatment Planning (both surgery & radiotherapy) • For Response Evaluation • For Detection Of Recurrences
  3. 3. TYPES OF IMAGING XRAY • Panoramic Xray oral cavity • Paranasal sinus • X ray lateral Face And Neck USG Neck CECT Face And Neck MRI Face And Neck Whole body PET-CT Scan
  4. 4. Panoramic Xray oral cavity Indication • for determining bone invasion • for planning dental treatment of oral cavity prior to chemotherapy and radiation to reduce subsequent complications • for early detection of maxillofacial complications of cancer therapy when they do occur; • for detection of recurrent tumors within the maxillofacial complex.
  5. 5. characteristic features of malignant lesions in plain radiographs include • atrophy of cortical lamina • osteolytic defects • in later stages, teeth lose their bony support at the site of infiltration bone defect in the left mandibular body. The osteolytic lesion reaches the alveolus of the lower left canine that had lost bony support Discrete radiolucency in mandible on right side.
  6. 6. Xray paranasal sinus • PARANASAL SINUS:  Paired structure  Frontal sinus located between inner & outer table of skull bone posterior to glabella  Ethmoid sinus in labyrinth of ethmoid bone  Maxillary sinus within body of maxilla  Sphenoid sinus in body of sphenoid bone behind shella turcica • XRAY PNS  Standard views include the Water’s, Caldwell, lateral and basal views.  Usually filled with air  Abnormal Xray may show fluid or mass
  7. 7. Water’s (occipitomental) Extend neck, nose & chin of pt. touches film/table OML will be 37 degree from table Structures seen • Maxillary sinus (seen best) • Frontal sinus • Sphenoid sinus (if mouth open )
  8. 8. Caldwell’s (occipitofrontal) view Pt. place nose & forehead against upright table with neck extended to elevate OML 15 degree from horizontal Structures seen • Frontal sinus (seen best) • Ethmoid sinus • Maxillary sinus
  9. 9. Lateral view Structures seen • Ant.& post extent of sphenoid, frontal,& maxillary sinus • Ethmoid sinus
  10. 10. Pt. raise chin, hyperextend neck until OML is parallel to film, head rests on vertex. Vertex near film .Xray taken from sub mental area Structures seen • Sphenoid sinus (seen best) • Post Ethmoid sinus • Maxillary sinus Basal (submentovertical) view
  11. 11. XRAY lateral soft tissue neck Indication • Useful in assessing patients with potential pathology of upper aerodigestive tract. • Detects foreign bodies ,airway compromise, trauma and infections such as croup, epiglottitis deep neck infections such as retropharyngeal abscesses • determination of the distribution of detected malignancies in vertebra Advantages • cheap, non invasive, readily available investigation tool • Useful in planning for conventional radiotherapy Drawbacks • Poor visualisation of oral cavity and oropharynx • Limited use in oncology
  12. 12. XRAY LATERAL NECK 1. Hard Palate 2. Soft Palate 3. Nasopharynx 4. Oropharynx N O
  13. 13. XRAY LATERAL NECK 1. Calcified tracheal cartilage rings 2. Hyoid bone 3. Epiglottis 4. Thyroid cartilage 5. Cricoid cartilage T C H E
  14. 14. Ultrasound Advantages • Availability • Cheap • No radiation • Differentiate solid vs cystic • Real time • Colour Doppler vascularity identified Disadvantages • Cannot be used for deep seated tumors • Air and acoustic window interference • Interobserver variability • Lack of reproducibility • Cannot be incorporated into TPS Indications • used to evaluate superficial lesions • For clinically occult nodal evaluation • For evaluation of Thyroid gland • for image guided fnac & biopsy
  15. 15. USG FEATURE OF MALIGNANT L.N • increase in size • Nodal parenchyma exhibited inhomogeneous low or mixed echogenicity. • Irregular margin with round shape. • Sharp borders. • Loss of normal hilar echogenicity. • Doppler sonograms, has peripheral or mixed vascular pattern
  16. 16. • usually the first modality used because it is widely available, relatively cheap, quick and easy to perform and reproducible. • The examination time is short with less motion artefacts than an MR scan. • Thin slice, high resolution image acquisition allows high quality Multiplanar reconstructions with superior evaluation of bony structures and calcifications. • Evaluation of CT images is also easier than evaluation of MR images. CECT Face & Neck Scan
  17. 17. CECT SCAN Feature Of Malignancy • Tumours appear as asymmetrical thickening of the mucosa (a) • can show areas of necrosis (b) • enhances according to its vascularity (a star) Patient with cancer of the right pyriform sinus. CECT scan a showing asymmetrical thickening of the pyriform sinus (arrow) on the right.(a;above) slight thickening of the posterolateral hypopharyngeal wall (b;arrowhead) lymph node with central necrosis (b;arrow) indicating metastasis
  18. 18. • More than 1cm size except jugulodigastric(1.5 cm) (short axis) • Shape: spherical rather than ellipsoidal; Heterogeneous enhancing pattern • Eccentric cortical hypertrophy. • Necrotic center: hypo-dense • Cluster of 3 or more borderline nodes • Margin :ill defined CT FEATURES OF MALIGNANT LYMPH NODE
  19. 19. CECT Scan Face & Neck Advantages • Widely available • Fast imaging • Detail crossectional images • Good bony details • Detect clinically occult metastatic L.N • multiplanar reconstructions • Aids in RT planning • Gives electron density information • less motion artefacts Disadvantages • Radiation exposure • Relatively expensive • Poor Soft tissue contrast • Artifact due to dental fillings • Underestimating ulcerative and infiltrative lesions • overestimating tumor extent due to inflammation/ oedema & distortion of adjacent normal structures • Contraindicated in allergy to contrast media, kidney failure
  20. 20. MRI FACE AND NECK: features of malignancy • On MRI, the tumour is usually hyperintense to muscle on T2- weighting and hypointense or isointense to muscle on T1- weighting. • The plain T1-weighted images are particularly useful in differentiating tumour from surrounding fat, detecting neurovascular bundle and bone marrow involvement. • Patient with Ca pleomorphic adenoma of submandibular gland on left with invasion of mandible. • In T2-MR image lesion is heterogenously hyperintense to muscle and there is loss of the cortical hypointense line indicating bone invasion (arrow). (a) • In T1-weighted image lesion is hypointense to muscle and there is replacement of the normal marrow fat by the tumour. (b) • The contrast T1-weighted image shows some enhancement of the lesion. (c)
  21. 21. CT SCAN & PET SCAN FOR SAME CASE • Contrast enhanced CT scan at the same level d shows the heterogenously enhancing mass which extends into the mandible. • The cortical bone erosion (arrow) is seen better in the bone window setting e. • The PET-CT scan at the same level showing the increased glucose uptake by the tumour with extension into the mandible
  22. 22. (B,C ) Coronal T1-weighted image through the hard palate and soft palate, respectively MRI Anatomy Of Oral Cavity :coronal images at level of hard & soft palate ( A ) Coronal illustration through the hard palate. Note the mylohyoid muscle forming the inferior and lateral borders of the OC,, and the extrinsic tongue muscles (hyoglossus and genioglossus).
  23. 23. (C) Axial illustration at level of tongue demonstrating tongue & RMT. PMR, pterygomandibular raphe (facial band connecting buccinator & sup. constrictor ). MRI Anatomy Of Oral Cavity :coronal at level of FOM &Tongue ( A ) Axial illustration at level of FOM demonstrating extrinsic muscles ( B ) Axial T2wt image at the level of the FOM (D)Axial T2-wt image at the level of oral tongue.
  24. 24. Advantages • Multiplanar scanning • better soft tissue contrast • can determine the involvement of local soft tissues, as well as vessels and nerves. • Better for perineural infiltration & intracranial extension, bone marrow involvement • May differentiate recurrent tumor and post treatment fibrosis and radiation necrosis • less artifact from dental fillings. Disadvantages • higher costs • longer acquisition time • No electron density information • Contraindicated in pts with pacemaker and implants • Poor bone visualisation • potential artefacts (motion artefacts, flow artefacts, field distortion artefacts due to metal or at air bone interfaces or with blood products MRI Face & Neck
  25. 25. 18 FDG PET Features of malignancy • On PET-CT, the morphological changes due to the tumour are seen as in CT with increased uptake of glucose in those tumours which are FDG avid , • other processes resulting in glucose uptake like infection, inflammation show false positive results • It is a nuclear medicine functional imaging technique used to observe metabolic processes in the body detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide, most commonly FDG • the concentrations of tracer imaged will indicate tissue metabolic activity
  26. 26. 18FDG PET-CT Indications Advantages • Functional imaging • In detection of unknown /small primary tumor • In evaluating clinically occult nodal involvement • To detect distant mets • In follow up to differentiate between recurrent tumor and post treatment fibrosis and radiation necrosis Disadvantages • Limited availability • Costly • False Positive uptake in inflammation and infections
  27. 27. 18FDG PET-CT
  28. 28. Oral Cavity Radiological Anatomy & Presentation Of Cancer • Lip • Buccal Mucosa • Anterior Tongue • Floor Of Mouth • Alveolus • Hard Palate • Retromolar trigone
  29. 29. Axial CECT Neck At Level Of C4 Bone Muscles: Tongue, SCM, Trapezius Gland Vessels Vallecula Epiglottis pharynx
  30. 30. • CT is complemented by the puffed cheek technique (PCT), when oral cavity lesion suspected. • PCT involves voluntary blowing of the oral cavity with air during the CT. Compliance with the technique is variable, Puffed Cheek Technique T ALV HP BM FOM
  31. 31. Retromolar trigone Triangular region bounded • ant: post surface of last molar • Post: ant tonsillar pillar • Lat:buccal mucosa • Apex: pterygoid hamulus
  32. 32. FLOOR OF MOUTH • Floor of the mouth is a U-shaped area formed by 2 mylohyoid muscle & hyoglossus • Anteriorly is bounded by the gingiva of the mandible and posteriorly by the anterior faucial pillar. • Contains sublingual space: fatty connective tissue space within the floor of mouth, contains sublingual salivary glands, submandibular duct ( warthon duct), lingual artery, vein and nerve and hypoglossal nerve (XII C.N.)
  33. 33. ORAL CAVITY CANCERS • Tongue • Buccal mucosa • Floor of mouth • Retromolar trigone • Lips
  34. 34. Tongue
  35. 35. Presentation ulcer along the lateral border of the Lt tongue. • CE CT demonstrates an enhancing mass located on the lateral aspect of anterior tongue on left. • does not cross the midline and is limited to the intrinsic muscle of the tongue. • no extension to the gingival mucosa or involvement of the adjacent mandibular bone. • No enlarged lymph nodes are identified
  36. 36. Carcinoma tongue: CT axial ,coronal & bone window Ulcerated lesion involving the left posterolateral tongue No enlarged submental or submandibular lymph nodes. Edentulous mandible and maxilla. No osseous destruction
  37. 37. Carcinoma Tongue: MRI large oral tongue lesion is seen arising from left half. involves the entire extent of the left tongue from tip to level of circumvallate papillae, predominantly involves ventral aspect with deep invasion into the intrinsic muscles. Anteriorly crossing the midline with involvement of the right tongue
  38. 38. CARCINOMA BUCCAL MUCOSA CT image showing a malignant lesion in the left buccal mucosa. CT image showing a mass from the Lt buccal mucosa extending to the RMT and involving submandibular region Advanced lesion infiltrating mandible
  39. 39. Presentation Swelling and pain in right cheek. Chronic tobacco chewerCARCINOMA BUCCAL MUCOSA Serial section of CECT neck showing heterogenously enhancing mass lesion in the right buccal mucosa with multiple enlarged right Level Ib lymph nodes
  40. 40. CARCINOMA BUCCAL MUCOSA: advanced
  41. 41. CARCINOMA FLOOR OF MOUTH • patient presented with a large ulcer at the left floor of the mouth CT showed an infiltrating tumour with irregular borders at the anterior left floor of the mouth and gingivo-buccal sulcus, that crossed the midline and eroded the mandibular bone. There was a centrally necrotic lymph node metastasis at the anterior border of the left sternocleidomastoid muscle.
  42. 42. Retromolar trigone cancer Axial contrast enhanced CT right retromolar trigone mass (arrows)
  43. 43. HARD PALATE TUMORS Right hard palate mass with invasion of the upper alveolar ridge(arrows)
  44. 44. LIP CANCER UPPER LIP LOWER LIP Extensive carcinoma of the lip
  45. 45. Oropharynx Radiological Anatomy & Presentation Of Cancer Soft Palate Base of tongue Tonsil
  46. 46. CT (sagittal) image showing a base of tongue growth.
  47. 47. CARCINOMA BASE OF TONGUE (A)axial: ulcerated contrast enhancing soft tissue mass in BOT (arrowheads)lesion crosses midline with large level II L.N. lingual artery involved (curved arrow) (B)Sagittal image: ant. Spread in FOM(white arrowhead)lesion extend into vallecula (black arrowhead);preepiglottic space (asterisk) not involved
  48. 48. Ca Tonsil Clinical picture CECT scan MRI
  49. 49. CA Rt. TONSIL
  50. 50. An MRI image showing right tonsillar growth associated with Rt cervical adenopathy. PET CT of the same patient CARCINOMA TONSIL
  51. 51. CA SOFT PALATE
  53. 53. Nasopharynx Radiological Anatomy & Presentation Of Nasopharyngeal Cancer
  54. 54. • Roof: Formed By Basiocciput & Basispenoid • Floor: Formed By Soft Palate Anteriorly; Deficient Posterior Communicates With Oropharynx . • Anterior :Nose • Posterior: Atlas Axis Vertebra, Retropharyngeal Space, Prevertebral Fascia • Lateral Wall: Contain Openings Of Eustachian Tube
  55. 55. • Lateral wall: contain openings of eustachian tube bounded by elevation called as torus tubarius
  56. 56. NASOPHARYNGEAL CANCERS Usually originate in lateral wall from fossa of Rosenmüller Anterior Spread into nasal cavity
  57. 57. Posterior spread: into retropharyngeal lymph node Post. Lateral spread & involvement of prevertebral muscles
  58. 58. nasopharyngeal tumor with infratemporal fossa extension Inferior Spread: to oropharynx
  59. 59. Superior spread: infilteration of orbital cavity via inferior Orbital fissure
  60. 60. Nose & Paranasal Sinus Radiological Anatomy & Presentation Of Cancer
  61. 61. 64 An CT face axial 7 coronal section showing the nasal cavity with the paranasal sinuses.
  62. 62. • Sagittal CT scans showing the frontal, ethmoidal and sphenoidal sinuses. • Arrows indicate the hiatus semilunaris 66
  63. 63. The Ohngren line. Sagittal CT shows a squamous cell carcinoma with the origin in the posterior maxillary sinus. The white line refers to the Ohngren line, where cancer posterior to this line was previously considered unresectable. The posterior black line is the border between a T4a and a T4b cancer (AJCC 7th edition). This tumour erodes the posterior maxillary wall and bulges into the orbital apex • line that connects the medial canthus of the eye to the angle of the mandible. • divides the maxillary sinus into (1) an anterior-inferior part, and (2) a superior-posterior part. • Tumours that arise in the anterior-inferior part, i.e. below Ohngren's line, generally have a better prognosis than those in the other group
  64. 64. 68 CT of a nasal vestibule carcinoma that has spread by direct invasion of the upper lip and gingivolabial sulcus. CARCINOMA NASAL VESTIBULE
  65. 65. Maxillary sinus squamous cell carcinoma. (a) Axial CT shows erosion of the lateral nasal wall and lacrimal duct (arrow) and growth into the middle meatus (asterisk) (b) Coronal CT in another patient with a carcinoma mimicking a nasal polyp, however, the lateral nasal wall is eroded (arrow)
  66. 66. (a) Axial CT and (b) T2-weighted MR imaging demonstrate a tumour (black arrowheads) • extending to the skin of the cheek (white arrowhead) bony erosion of the lateral maxillary sinus wall and the pterygoid plates (arrows) are better visualized using CT; • extension of the tumour and distinction from obstructed fluid-filled sinuses and surrounding oedematous soft tissue are best evaluated using MR imagin
  67. 67. Maxillary Sinus Cancers: suprastructure with pattern of spread Advanced tumor: alveolar process destruction with loosening of a tooth (E) and abutment of the orbital floor
  68. 68. Ethmoid sinus adenocarcinoma (b) Contrast-enhanced coronal CT shows an intracranial component (arrowheads) verified at (c) coronal contrast-enhanced T1-weighted MR imaging. There is no meningeal enhancement due to the dural barrier. The tumour also respects the orbit and was classified as a T3 cancer. (a) Coronal CT shows opacification of the left nasal cavity, anterior ethmoid sinus and frontal recess. The clue to a malignant process is the erosion of the lateral lamella (arrow).
  69. 69. • Extends from the level of Hyoid Bone to lower border of Cricoid cartilage. • Corresponds to C4 - C6 vertebral bodies. • Subsites- • Pyriform sinus • Post cricoid region • Posterior pharyngeal wall Hypopharynx Radiological Anatomy & Presentation Of Cancer
  70. 70. Hypopharynx Radiological Anatomy
  72. 72. CARCINOMA HYPOPHARYNX • abnormal enhancing mass centred upon the right larynx/hypopharynx with large cervical lymph node • superior extent of the lesion extends from the right aryepiglottic fold, involving the paraglottic right space (without crossing the midline) and extending into the supraglottic larynx. • Inferior extent extends to right true cord with likely subglottic spread.
  73. 73. Larynx Radiological Anatomy & Presentation Of Cancer
  75. 75. Radiological Anatomy
  76. 76. Enlarged sub mental lymph nodeBounded by 2 ant. Belly of digastric
  77. 77. Bounded by ant. & post Belly of digastric Ant belly digastric Post belly digastric Mandible
  78. 78. Cranial border: caudal C1 Caudal border: caudal edge of hyoid
  79. 79. Cranial border: caudal edge of hyoid Caudal border: caudal edge of cricoid
  80. 80. Caudal border: 2cm cranial to cranial edge of sternoclavicular joint Cranial border: caudal edge of cricoid
  81. 81. Cranial border: cranial edge of hyoid
  82. 82. THANKYOU