Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241Ultrasonographic imaging of head and neck pathology Ralf Schon, DDS, MD*, Jurgen Duker, DDS, MD, ¨ ¨ ¨ Rainer Schmelzeisen, DDS, MD Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Klinik und Poliklinik fur ¨ Mund-Kiefer-Gesichts Chirurgie, Hugstetter Straße 55, D-79106 Freiburg im Breisgan, Germany This article demonstrates the properties of sonographic images for the diagnosis of soft tissuepathologies in the head and neck. Ultrasonography in medicine has been used as an imagingtechnology since 1950. Developments in computer technology have allowed modern ultrasoundmachines to produce real-time high-quality images of soft tissues; however, limitations must beconsidered. A total reﬂection of sonographic waves on bone and a complete extinction behindair-ﬁlled cavities, such as the oral cavity and the paranasal sinus, limit the sonographic investi-gation to soft tissues. Ultrasonography is recommended as the ﬁrst imaging technique of choicefor suspected soft tissue pathology in the head and neck. It is noninvasive, inexpensive, quick toperform, and can easily be performed in children and pregnant women. Unlike with computedtomography (CT) and magnetic resonance imaging (MRI), injectable contrast media or sedationin infants (both requiring intravenous tube placement) is not needed for sonography. Typicalindications for sonographic evaluation in the head and neck include infection, cysts, salivarygland diseases, neck masses, and neoplasms. In the head and neck, a 7.5-MHz scanner is routinely used for sonography. Sonographicimages in B-mode (brightness mode) show the texture and borders between tissues as a black-and-white picture. Color duplex sonography allows the visualization of moving tissues, such asblood cells. Relative movement toward the scanner is color-coded red and relative movementaway from the scanner, blue. The visualization of tissue perfusion, such as in hyperemia in in-ﬂammatory changes, vascularization of tumors, and for the evaluation of the location of bloodvessels relative to pathologic ﬁndings, adds valuable diagnostic information to the B-modepicture. Dynamic sonographic evaluation techniques demonstrate in real time mobility andcompressibility of the investigated tissues. Color Doppler mode allows for the quantitative eval-uation of the perfusion in larger vessels. The interpretation of sonographic images for head and neck surgeons not used to sono-graphic images may be initially diﬃcult because the sonographic images are not produced in de-ﬁned axial and coronal planes, such as those known for CT and MRI. A basic knowledge of thesonographic anatomy of the head and neck is required for the understanding of sonographicﬁndings. Typical eﬀects in sonographic imaging such as echo enhancement behind tissues, whichcauses lower attenuation compared with the surrounding tissues (such as in pleomorphic adeno-mas of salivary glands or cystic lesions) or total reﬂection of the sonographic waves with a shad-owing eﬀect behind strong reﬂectors, eg, bone or stones of the salivary glands, may be evident.These eﬀects can be used to interpretate the ultrasonographic image. This article presents sonographic images of typical pathologic ﬁndings in the head and neckand correlates these pathologies with the clinical picture. * Corresponding author. E-mail address: email@example.com (R. Schon). ¨1061-3315/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.PII: S 1 0 6 1 - 3 3 1 5 ( 0 2 ) 0 0 0 0 9 - 4
214 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Sialolithiasis of salivary glandsFrequency/incidence The most common cause of salivary obstruction is the formation of intraductal sialolith.Sialoliths are most frequently found in the submandibular gland (Fig. 1A) .Signs and symptoms Patients present with recurrent swelling, which usually occurs during eating and drinking.Typical chronic changes of the gland may occur after some years (Fig. 2D).Etiology/pathophysiology Formation of viscous mucous plaques can occur in the ducts and may result in the obstruc-tive changes . Mineralization of plaques causes ﬁrm stone-like sialoliths (Fig. 1A, B).Image of choice for diagnosis Because it is noninvasive, easy to apply, and inexpensive, sonography is the ﬁrst imagingmethod of choice for diagnosis of suspected salivary gland disease. Depending on the degreeof mineralization, sialoliths may show in X rays (Fig. 1A) . Sialography gives indirect infor-mation on the presence of a stone in the ductal system, and obstructive changes within the glandmay be obvious. Stones of the submandibular glands are often located at the posterior border ofthe mylohyoid muscle (Fig. 1A).Fig. 1. Intraductal sialolith of the submandibular gland is demonstrated in sialography. (A) Contrast media in theintraglandular ductal system shows the obstruction within the gland caused by the stone located posterior to themylohoid muscle. (B) In B-mode sonography, the stone is obvious as a strong reﬂector with a posterior shadowing eﬀect.(C) Inﬂammatory reaction in sialolithiasis with hyperemia of the submandibular gland is evident in color duplexsonography.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 215 Fig. 1 (continued )Image hallmarks The sialolith shows a strong echo caused by the complete reﬂection of the ultrasonic wave.Posterior to the sialolith, the echo is extinguished, and a shadow posterior to the stone is present(Fig. 1B). Hyperemia as inﬂammatory reaction of the gland tissue is demonstrated by color du-plex sonography (Fig. 1C).Management The preferred therapy is the surgical removal of the stone. Removal from an intraoral root ispossible when the stone is located in the anterior part of the submandibular or parotid duct. If astone is located below the mylohyoid muscle, the submandibular gland has to be removed to-gether with the stone by a submandibular approach. Care has to be taken not to harm the lin-gual nerve, which crosses over the duct.
216 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨SialadenitisFrequency/incidence Acute sialadenitis most often aﬀects the submandibular gland rather than the parotid and mi-nor salivary glands. The frequency of acute exacerbation of a chronic infection of the salivarygland increases with the degree of obstructive changes of the gland tissue.Signs and symptoms Acute sialadenitis leads to a massive swelling of the aﬀected gland (Fig. 2A). Pus may be foundon palpation of the salivary gland at the exit of the duct. The skin overlying the aﬀected gland isusually swollen and red. Patients complain of massive pain, and mouth opening can be limited.Etiology/pathophysiology Sialadenitis can be caused by radiation and viral or bacterial infection. Acute streptococcusstaphylococcus sialadenitis arises by retrograde infection in an obstructed gland. Degenerationof acina is seen along with interstitial inﬂammatory cell inﬁltrates . Multiple or singleabscesses may form in acute glands (Fig. 2E). Changes in the immune system or electrolytesmay also cause inﬂammation of the salivary glands.Image of choice for diagnosis Color duplex sonography is the imaging method of choice for the diagnosis of sialadenitis.Image hallmark In the sonographic image, the gland is massively enlarged in side comparison. Hyperemia ofthe acute gland is seen in color duplex sonography (Fig. 2B). A chronic recurrent infectionFig. 2. (A) Acute sialadenitis with swelling of the left parotid gland. (B) Color duplex sonography shows hyperemia of themassively enlarged gland. In chronic sialadenitis, hyperemia is less obvious compared with ﬁndings in acute sialadenitis. (C) Aswelling of the right parotid gland is less obvious in a patient with chronic parotitis. (D) Pathological changes of the salivarygland tissue with multiple microabscesses caused by recurrent sialadenitis is evident in sonography and (E) sialography.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 217 Fig. 2 (continued )with less massive enlargement of the parotid gland presents with irregular echogenic structureswithin the gland (Fig. 2C). Microabscesses and sclerotic changes of the gland appear as multiplehypoechoic or inhomogeneous lesions (Fig. 2D). Further information on pathologic changeswithin the gland may be gained by sialography (Fig. 2E).Management The management of acute infection is antibiotic therapy. After recurrent infections with per-manent changes of the salivary gland, tissue removal of the gland becomes necessary.
218 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ Fig. 2 (continued )Salivary retention cystFrequency/incidence After injury or abscess of the parotid gland, saliva may be retained within the gland.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 219Signs and symptoms Symptoms of a salivary retention cyst is nonpainful swelling with ﬂuctuation (Fig. 3A).Image of choice for diagnosis Sonography, using B-mode for the demonstration of cystic lesions, is the imaging method ofchoice.Image hallmarks The salivary retention cyst has a regular border and an hypoechoic echo. The lesion is com-pressible with the transducer (Fig. 3B). Enhancement of the sonographic echo posterior to thecyst is seen.Management The management of a salivary retention cyst is surgical, with removal or drainage. Drainageof the cyst into the duct system or the oral cavity can be performed under intraoperative sono-graphic guidance.Pleomorphic adenomaFrequency/incidence Pleomorphic adenoma is the most common benign salivary gland tumor, with the highest in-cidence in the parotid gland. Most pleomorphic adenomas arise in women in their 30s and 40s.Fig. 3. (A,B) A patient with a ﬂuctuating swelling of the left parotid gland without signs of acute infection shows a cysticlesion in the sonographic picture. The space occupying the hypoechoic lesion shows a regular border and is compressible.(B) Enhancement of the sonographic echo posterior to the cyst is evident.
220 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ Fig. 3 (continued )The second most common salivary gland tumor is the Whartin tumor (papillary cyst adenomalymphomatosum), which occurs more frequently in men. Whartin tumor is often present in bothparotid glands .Signs and symptoms The tumor presents as a ﬁrm mobile swelling of the gland. The adenoma is usually painlessand does not aﬀect the facial nerve. The growth of the tumor over a period of several months isoften reported by patients.Etiology/pathophysiology The pleomorphic adenoma derives primarily from myoepithelia—sometimes adipose, chon-droid, and osseous elements may be present in these tumors. The pleomorphic adenoma shows aslow growth with a minor risk for malignant transformation .Image of choice for diagnosis With typical patient history, tumor location, and palpation of the tumor, B-mode sonogra-phy is the imaging method of choice.Image hallmarks The lesion presents as a hypoechoic mass with a regular border and cannot be compressed.The echo enhancement posterior to the lesion is typical (Fig. 4). In Whartin tumor, a polycysticappearance of the lesion may be seen sonographically.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 221Fig. 4. The noncompressible hypoechoic intraparotid mass is preauricularly located and presents a regular border.Posterior echo enhancement, a typical sign in pleomorphic adenoma, is less obvious compared with ﬂuid-ﬁlled cysticlesions.Management The management of suspected pleomorphic adenoma is surgical. Histological ﬁndings such asmalignancies may deﬁne further treatment.Malignant neoplasm of the parotid glandFrequency/incidence The more common malignancies of the salivary glands are mucoepidermoid carcinoma(28%), acinus cell carcinoma (23%), adenocarcinoma (16%), and adenocystic carcinoma (9%). Epithelial malignancies of the salivary glands are less common and the most common siteis the parotid gland.Signs and symptoms Patients present with an induration or swelling of the gland, which is often painful (Fig. 5A).In contrast to benign lesions, malignancies of the parotid gland may present with facial nervepalsy.Etiology/Pathophysiology Malignant tumors of the major glands are typically invasive. Some low-grade malignanciesmay derive from surrounding tissues. Most often, the malignancies arise de novo. The malignanttransformation of benign neoplasms is rare .
222 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Fig. 5. (A) A patient presented with a painful swelling of the left parotid gland. A beginning weakness of the orbicularbranch of the facial nerve was noted. (B) MRI in axial and coronal view demonstrated the invasive growth of anadenocystic carcinoma of the parotid gland. (C) In sonography, the neoplasm of the salivary gland shows an irregularborder and an inhomogeneous echo pattern with unechoic, hypoechoic, and echodense structures. Micronervereconstruction of the facial nerve using a sural nerve graft was performed immediately after surgical removal of thetumor. Secondarily, a deepithelialized parascapular ﬂap was used for tissue augmentation. Monitoring of the buried ﬂapwas performed by color duplex sonography. (D) The postoperative appearance of the patient 24 months after tumorresection, postoperative radiation, and 6 months after soft tissue augmentation.Image of choice for diagnosis The imaging method of choice for primary evaluation of a swelling in the area of the parotidgland is sonography (Fig. 5C). Further information on the extent of a tumor or the inﬁltrationof the neighboring anatomic structures may be gained by CT and/or MRI (Fig. 5B).Image hallmarks Malignant tumors of the salivary glands show an irregular border and an inhomogeneousecho pattern with unechoic, hypoechoic, and echodense structures. There may be dorsal shad-owing and dorsal signal enhancement behind the lesions (Fig. 5C). The inﬁltration of adjacentanatomic structures with invasion of muscles or destruction of the ascending ramus of the man-dible is visible by sonography (Fig. 5C).Management Surgical management is the therapy of choice. Depending on the extent of the tumor and thepathohistologic ﬁndings after tumor resection, radiation and/or chemotherapy may be indicated(Fig. 5D).
224 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ Fig. 5 (continued ) ¨Intraparotid lymph nodes in Sjogren syndromeFrequency/incidence Intraparotid lymph nodes may be present in Sjogren syndrome. Benign lymphoid epithelial ¨lesions of Sjo ¨gren syndrome are less common than Whartin tumor. The disease predominatelyaﬀects middle-aged women. Lymphomas may develop in the setting of Sjogren syndrome. ¨
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 225Signs and symptoms Visible swelling in the parotid gland area may be present (Fig. 6A). Xerostomia is usually themain oral symptom; dry eyes is the main ocular symptom.Etiology/pathophysiology Sjogren syndrome, also known as sicca syndrome, is a chronic, progressive autoimmune dis- ¨ease characterized by lymphocyte inﬁltration of the salivary and lacrimal gland with loss of thesecretory epithelium. Parotitis can be caused by periductal and acinal inﬁltration. Sjo ¨grensyndrome may present as primary or secondary disease with other autoimmune disorders, suchas rheumatoid arthritis .Image of choice for diagnosis Sonography is the imaging method of choice for the diagnosis of swelling in the area of thesalivary glands. The diagnosis of Sjogren syndrome is veriﬁed by Schirmer test to evaluate the ¨lacrimal secretion and pathohistologic evaluation of the mucosal specimen.Image hallmarks Intraparotid groups of lymph node tissues with hyperemia are visualized by color duplexsonography (Fig. 6B).Fig. 6. (A) A patient with Sjogren syndrome presented with a swelling in the area of the parotid gland. (B) Color duplex ¨sonography demonstrates multiple intraparotid lymph nodes with hyperemia.
226 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Management The treatment of this autoimmune disease is based on the patient’s symptoms. Replacementof saliva and tears may limit mucosal injury caused by reduced secretion. In severe cases, ste-roids and immunosuppressive agents are indicated .Malignant lymphomaFrequency/incidence Neoplasms originating in lymphatic tissue can occur at any age, although the highest inci-dence occurs in patients aged 60 to 70 years. Manifestation of malignant lymphomas in thecervical and inguinal lymph nodes is common.Signs and symptoms Patients may present with reduced general condition, with fever, loss of weight, and anemia;however, patients are often asymptomatic. Swelling of lymph nodes in single or multiple loca-tions may be present (Fig. 7A).Etiology/pathophysiology Malignant lymphomas comprise histologically diﬀerent diseases of the lymphatic tissues,such as Hodgkin and non-Hodgkin lymphomas. The cause of malignant lymphomas is notclearly understood, although it may be related to a viral factor. An increase of incidence inHIV-positive patients has been reported.Image of choice for diagnosis For the evaluation of cervical lymph node enlargement, sonography is the imaging method ofchoice. Other imaging techniques, such as CT and MRI, are indicated for staging purposes andfor the evaluation of extended neoplasms, which can inﬁltrate bone. The diagnosis is veriﬁed bypathohistologic evaluation.Image hallmarks An enlargement of one of multiple lymph nodes may be present. Lymphatic tissue or groupsof lymph nodes may show hyperemia. Margins in-between the lymph nodes and to the sur-rounding tissues may not be deﬁned (Fig. 7B).Management The histologic ﬁnding deﬁnes the treatment of choice and the prognosis. The oncologic ther-apy with chemotherapy and/or radiotherapy, depending on the histopathologic ﬁnding, is theﬁrst line of treatment. Surgical intervention may be indicated in rare cases.Thyroglossal duct cystFrequency/incidence Thyroglossal duct cysts (TDCs) are usually not apparent at birth. The majority of lesions arediagnosed in the ﬁrst 20 years of life.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 227Fig. 7. (A) A patient presented with an asymptomatic swelling in the left canine fossa. The swelling was treated as asuspected odontogenous infection by a dental practitioner with repeated incisions for 6 months. (B) In color duplexsonography, a well-vascularized neoplasm without clear margins was evident. A highly malignant B-cell lymphoma wasdiagnosed after biopsy. (C) The extend of the tumor with inﬁltration of the maxillary sinus is demonstrated in CT.
228 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Signs and symptoms TDCs are typically located in the midline between the hyoid bone and the thyroid cartilage.A swelling of the anterior ﬂoor of the mouth may be present (Fig. 8A).Etiology/pathophysiology The thyroglossal duct connects the foramen cecum and the developing thyroid. The duct usu-ally atrophies after the thyroid descends to its ﬁnal position. Parts of the duct may be persistentand become cystic in nature. Malignancies may develop in TDCs .Image of choice for diagnosis The cystic formation in the midline can be investigated by noninvasive sonography. Thelesion can also be demonstrated by CT with contrast media (Fig. 8B).Image hallmarks A hypoechoic cystic mass in the midline of the anterior ﬂoor of the mouth is demonstrated pre-and postoperatively (Fig. 8C,D). The lingual artery is seen next to the cystic lesion (Fig. 8E).Management Surgical removal of the cyst is recommended.Sublingual infection formationFrequency/incidence Abscess formation in the submandibular space with perimandibular abscess formation ismore common than sublingual abscess formation.Signs and symptoms Firm painful swelling of the ﬂoor of the mouth and in the sublingual area is found in sublin-gual infection (Fig. 9A). The mouth opening may be limited. The clinical diagnosis of an earlysublingual abscess or inﬁltration of the ﬂoor of the mouth may be diﬃcult to make because ﬂuc-tuation is not always present.Etiology/pathophysiology The most common cause for sublingual and perimandibular abscess formation is odonto-genic infection. Nonodontogenic causes include cystic lesions, sialadenitis, lymphadenitis, orsoft tissue injuries. The infection may spread from the submandiblar space into the sublingualspace because of the connection at the posterior aspect of the diaphragm oris.Image of choice for diagnosis After diagnosis of the underlying odontogenic cause using X ray, such as panoramic views,the presence of an abscess can be investigated by sonography.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 229Fig. 8. (A) A patient presented with a nonpainful swelling in the midline of the anterior ﬂoor of the mouth. (B) CTperformed with contrast prior to referral of the patient demonstrates the lesion located in the midline. (C) Thesonographic images in two planes with the transducer placed in a vertical and horizontal position in the submental areademonstrate the cystic lesion preoperatively and (D) after surgical removal. (E) The lingual artery is seen postoperativelyin power mode.
230 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ Fig. 8 (continued )Image hallmarks Hyperemia of the left sublingual area without signs of abscess formation is demon-strated in an acute inﬂammatory reaction. The transducer is placed in a vertical and horizontalposition to produce images in two planes (Fig. 9B).Management The treatment of choice may diﬀer concerning the degree of the infection. When there is nosign of abscess formation, treatment of the underlying dental cause and antibiotic treatment areindicated. Drainage of an abscess by intraoral or extraoral incision is needed when an abscesshas already formed.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 231 Fig. 8 (continued )Second branchial cleft cystFrequency/incidence The second branchial cleft cyst (BCC) represents approximately 95% of all BCCs. The ﬁrstBCC represents approximately 1% of these cysts .Signs and symptoms The swelling in the midportion of the anterior aspect of this sternocleidomastoid muscle canbe palpable and visible (Fig. 10A). Recurrent swelling in this area may be present because ofinﬂammation.Etiology/pathophysiology Anomalies may develop in the development of the ﬁrst, second, and fourth branchial arches.Image of choice for diagnosis Soft tissue anomalies can be seen using sonography.Image hallmark A ﬂuid-ﬁlled, unechoic, compressible cystic process is demonstrated next to the carotid ar-teries using color duplex sonography (Fig. 10B).Management Second branchial and brachial cleft cysts are structural abnormalities and do not resolvespontaneously. Therefore, complete surgical excision is the treatment of choice .
232 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Fig. 9. (A) Firm, painful swelling of the ﬂoor of the mouth and in the sublingual area is found in sublingual infection.Noninvasive sonographic investigation can be easily performed in infants and children. (B) Using color duplexsonography with the transducer placed in the submental area, hyperemia as a sign of the inﬂammatory reaction withoutabscess formation was evident.Cervical lymph node metastasisFrequency/incidence Most lymph node metastasis in the head and neck region originate from squamous cell car-cinomas. Metastatic disease of other neoplasms, such as malignant melanoma, prostate andbreast adenocarcinoma, or tumors of unknown primary origin, are less common.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 233Fig. 10. (A) A patient presented with a swelling of the midportion of the sternocleidomastoid muscle. (B) A ﬂuid-ﬁlledunechoic cystic process is demonstrated next to the carotid arteries by color duplex sonography. The compressibility ofthe cystic lesion was seen when compression was applied with the transducer.Signs and symptoms Cervical swelling, which can be painful, may be present (Fig. 11A, Fig. 11D).Etiology/pathophysiology Cervical lymph node metastasis is frequently found in patients with squamous cell carcinomaof the oropharyngeal cavity. Carcinomas of other origin may cause also nodal metastasis(Fig. 11D, E).Image of choice for diagnosis Sonography has a high accuracy for the demonstration of pathologic ﬁndings of cervicallymph nodes compared with CT and MRI.Image hallmarks The echo-free central aspect of a lymph node metastasis is a typical sign for central necrosisin the tumor mass (Fig. 11B). Compression or inﬁltration of the internal jugular vein or inﬁltra-
Fig. 11. (A) A patient presented with cervical swelling on the right side. (B) Color duplex sonography demonstrates alymph node metastasis with central necrosis and compression of the internal jugular vein. (C) Cervical metastasis inanother patient with inﬁltration of the internal jugular vein is evident in color duplex sonography. (D) A patientpresented with a swelling with a similar clinical appearance as that in (A). (E) Color duplex sonography shows a well-vascularized tissue, a metastatic disease of a thyroid carcinoma.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 235 Fig. 11 (continued )tive growth of lymph node metastasis may be an important prognostic ﬁndings (Color Fig. 11B,C). A high degree of vascularization is not typical for metastasis of squamous cell carcinomasbut can be present in other neoplasms, such as thyroid malignancies (Fig. 11D, E).Management Tumor resection is the treatment of choice. Pathohistologic ﬁndings after ablative tumor sur-gery and neck dissection may indicate radiotherapy and/or chemotherapy.Glomus vagale tumorFrequency/incidence Approximately 3% to 5% of all paragangliomas originate from the vagus nerve. The femaleto male ratio is approximately 3 to 1, and the mean age of patients is 48 years .
236 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Signs and symptoms Patients with glomus tumours present with a slow-growing painless neck mass; pulsationof the mass may be palpable. When the tumor is located in the pharyngeal area, bulging ofthe lateral pharyngeal wall may be present. In extensive cases where the recurrent laryngealnerve and hypoglossal nerve are involved, paralysis of the soft palate and a back-drop phenom-enon of the posterior pharyngeal wall may be evident. Vagal nerve paralysis with hoarseness andaspiration may develop .Etiology/pathophysiology Paragangliomas show a unique anatomic feature. The cervical tumor forms ﬁnger-like pro-jections, which may invade ﬁssures and foramens of the skull base. Bone as well as dura maybe inﬁltrated and destroyed.Image of choice for diagnosis The cervical tumor can be detected using sonography (Fig. 12A); however, for the diagnosisand further evaluation of the tumor when located next to the skull base, medial to the mandible,and near the pharyngeal, MRI and MR angiography are recommended to demonstrate the ex-tend of the tumour and the degree of its vascularization (Fig. 12B, C).Image hallmarks A highly vascularized tumor next to the carotid artery is demonstrated using color duplexsonography (Fig. 12A). The extend of the tumour with bulging of the lateral pharyngeal walland the vascularization are demonstrated in MRI, MR angiography, and conventional catheterangiography for preoperative immobilization (Fig. 12B–D).Management The surgical removal of the tumor is indicated because tumor growth causes furtherdestruction of bone as well as dura. The tumor can be approached by submandibularincision. Temporary osteotomy of the mandible to access the superior pharyngeal spacemay be necessary. When an intracranial extension of the tumor is present, a craniotomyfor the complete removal of the lesion and the involved dura is indicated. After completeresection, recurrence is rare . Embolization prior to tumor resection is recommended be-cause bleeding of the tumor is a possible complication. There is a risk of damage to cranialnerves, the hypoglossal, and the facial nerve when the tumor is located next to the jugularforamen .HemangiomaFrequency/incidence With an incidence of 3% in newborns and a development in the ﬁrst 3 months of infancy,hemangioma is the most common congenital lesion. Almost 12% of 1-year-olds present witha hemangioma. The head and neck are the most common sites for the development of heman-gioma .
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 237Fig. 12. A patient presented with an asymptomatic right cervical swelling. (A) Using color duplex sonography, a well-vascularized tissue was obvious next to the carotid arteries. (B,C) MR angiography and conventional catheterangiography during preoperative embolization show the vascularization of the tumor.(D) MRI demonstrates the extendof the inﬁltrative growing tumor with bulging of the lateral pharyngeal wall.
238 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ Fig. 12 (continued )Signs and symptoms Hemangioma can appear as cutaneous skin lesions, subcutaneous masses, or both, as com-pound lesions. Cutaneous lesions appear as erythematous masses. Subcutaneous lesions canpresent as soft, cystic, and compressible lesions with bluish discoloration of the overlying skin(Fig. 13A). The high degree of perfusion may be palpable and audible.Etiology/pathophysiology Hemangiomas may develop from arrested mesenchymal vascular primordial and are there-fore true congenital malformations rather than neoplastic processes. They usually grow rapidlyuntil the age of 6 to 8 months. They then slowly and spontaneously resolve over the next years.Fifty percent of hemangiomas are resolved by the age of 5 years, 70% by the age of 7 years, andalmost all will spontaneously resolve by the age of 12 years [9,10].Image of choice for diagnosis Sonography is the imaging technique of choice because it is noninvasive and easy to performin infants without sedation or the use of contrast media.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 239 Fig. 12 (continued )
240 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨Image hallmarks Color duplex and color Doppler sonography allow for the qualitative and quantitative anal-ysis of the vascularization within the lesion (Fig. 13B, C). The depth of soft tissue inﬁltration ofthe lesion can be measured. The results can be used for close follow-up and monitoring of thegrowth, especially during the ﬁrst 8 months.Management Hemangiomas tend to involute spontaneously. Therefore, observation and sonographic fol-low-up of the lesion is indicated. Approximately 10% to 30% of hemangiomas require treatmentFig. 13. (A) Subcutaneous hemangioma of the left cheek presents in a 5-month-old patient as soft, cystic, compressiblelesions with bluish discoloration of the overlying skin. (B) The high degree of perfusion, which may be palpable andaudible, and the depth of inﬁltration of the lesion is demonstrated by color duplex sonography. (C) Color Dopplersonography allows for the qualitative and quantitative analysis of the vascularization pattern in the lesion.
R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241 ¨ 241 Fig. 13 (continued )because of threatening function, or potential disﬁguration or obstruction. Extensive surgerywith or without preoperative embolization may be indicated. Because of surgical removal ofthe inﬁltrative growing hemangioma, there may be disturbance of normal growth or damageof vital structures. To avoid damage, control of the lesions by systemic or intralesional steroidsare the ﬁrst line of therapy. Laser treatment has also been used [5,11]. Radiotherapy can causemalignancies and is therefore obsolete.References  Ellis GL, Auclair PL, Gnepp DR. Surgical pathology of the salivary glands. Philadelphia: WB Saunders; 1992.  Langlais RP, Kasle MJ. Sialadenitis: the radiolucent ones. Oral Surg Oral Med Oral Pathol 1975;40:686–90.  Eversole L. Salivary gland pathology. In: Fu Y-S, et al, editors. Head and neck pathology with clinical correlation. New York: Churchill Livingstone; 2001. p. 242–90.  Campbell SM, Montanaro A, Bardana EJ. Head and neck manifestations of autoimmune disease. Am J Otolaryngol 1983;4:187–216.  Kellman RM, Freije JE. Clincal considerations for non-neoplastic lesions of the neck. In: Fu Y-S, et al, editors. Head and neck pathology with clinical correlations. New York: Churchill Livingstone; 2001. p. 665–9.  Cote DN, Gianoli GJ. Fourth branchial cleft cysts. Otolaryngol Head Neck Surg 1996;114:95.  Uruquhart AC, et al. Glomus vagale: paraganglioma of the vagus nerve. Laryngocope 1994;104:440.  Samii M, Draf W. Surgery of the skull base. An interdisciplinary approach. Berlin: Springer; 1989. p. 414–25.  Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classiﬁcation based on endothelial characteristics. Plast Reconstr Surg 1982;69:412. Philipps SE, Constantino PD, Houston GD. Clinical considerations for neoplasms of the oral cavity and oropharynx. In: Fu Y-S, et al, editors. Head and neck pathology with clinical correlations. New York: Churchill Livingstone; 2001. p. 472–3. Waner M, Suen JY, Dinehart S. Treatment of hemangiomas of the head and neck. Laryngoscope 1992;102:1123.