Neck

1. Pathology of the neck spaces
”Part I”
Presented by :
Dr.Ahmed Abdelkarim, MD
Head & neck
imaging

2. Overview of the neck spaces
Parapharyngeal
Space
Masticator
Space
Parotid space Pharyngeal
mucosal space
Retropharyngeal
space
Carotid space
Posterior cervical
space
Perivertebral
space
Visceral space
Anterior cervical
space
Pure suprahyoid
Pure infrahyoid

3. Pathology of the neck spaces “part I”
Parapharyngeal
space
Importance
Pharyngeal
mucosal space
Thornwaldt Cyst
Infl.Tonsillitis &
abscess
Neoplasm
Masticator space
Infl.Abscess
Neoplasm
Parotid space
Infl.Parotitis
Neoplasm

4. Pathology of the neck spaces “part I”
Parapharyngeal
space
Importance

5. Pathology of the neck spaces “part I”
Parapharyngeal
space

6. Parapharyngeal space
 PPS displacement pattern helps define actual space of origin
 PMS mass lesion pushes PPS laterally
 MS mass lesion pushes PPS posteriorly
 PS mass lesion pushes PPS medially
 CS mass lesion pushes PPS anteriorly
 Lateral retropharyngeal space mass (nodal) pushes PPS anterolaterally
Importance
 Combining center of mass lesion with displacement
direction of PPS yields strong impression of "space
of origin" of SHN mass lesion

7. Pathology of the neck spaces “part I”
Pharyngeal
mucosal space
Thornwaldt Cyst
Infl.Tonsillitis &
abscess
Neoplasm

8. Pathology of the neck spaces “part I”
Pharyngeal
mucosal space

9. Pathology of the neck spaces “part I”
Thornwaldt
cyst

10. Tornwaldt Cyst
Nasopharyngeal bursa, Thornwaldt cyst
 Definitions
 Benign developmental nasopharyngeal (NP) midline cyst covered by mucosa anteriorly & bounded by longus
muscles posteriorly
 Most common signs/symptoms
 Rarely symptomatic
 Tornwaldt syndrome (rare)
 Chronically infected large cyst (> 2 cm)
 Causes periodic halitosis, unpleasant taste
 Age
 Most common in young adults
 Most common lesion of nasopharyngeal mucosal space, occurring in 4% at autopsy
 Seen on ~ 5% of routine brain MR

11. Tornwaldt Cyst
Nasopharyngeal bursa, Thornwaldt cyst
 Midline, well-circumscribed pharyngeal mucosal space (PMS) cyst on posterior nasopharyngeal wall
between prevertebral muscles
Best diagnostic
clue

12. Tornwaldt Cyst
Nasopharyngeal bursa, Thornwaldt cyst
 T1WI
 TC intermediate to high signal depending on cyst fluid protein concentration
 T2WI
 Lower T2 signal possible with high protein content

13. Tornwaldt Cyst
Nasopharyngeal bursa, Thornwaldt cyst
 PMS Retention Cyst
 Off midline Simple cyst
 Often multiple, lateral pharyngeal recess lesions hyperintense on T2
DIFFERENTIAL
DIAGNOSIS

14. Pathology of the neck spaces “part I”
Inflammatory
Tonsillitis
&
tonsillar
abscess

15. Tonsillar Inflammation
Acute tonsillitis
 Definitions
 Acute, nonsuppurative tonsillar inflammation
 Most common signs/symptoms
 Fever, sore throat
 Stridor, odynophagia, dysphagia, trismus indicate severe inflammation and airway compromise
 Signs: Tonsillar swelling, redness, exudate
 Typically bilateral; unilateral tonsillar deviation more commonly associated with TA/PTA
 Age
 Children and young adults
 Etiology
 Most commonly secondary to respiratory virus
 Adenovirus, influenza virus, parainfluenza virus,rhinovirus,
respiratory syncytial virus
 30-40% bacterial: Group A β-hemolytic streptococci most
common
 Occasional Neisseria, Arcanobacterium, Mycoplasma,
Chlamydia

16. Tonsillar Inflammation
Acute tonsillitis
 Bilateral tonsillar enlargement with variable attenuation/enhancement
Best
diagnostic clue

17. Tonsillar Inflammation
Acute tonsillitis
 Striated pattern of internal enhancement (tiger stripe sign) relatively specific for nonsuppurative
tonsillitis
Best
diagnostic clue

18. Tonsillar/Peritonsillar Abscess
Intratonsillar abscess
 Definitions
 Tonsillar abscess: Abscess within palatine tonsil
 Peritonsillar abscess: TA spreads to adjacent spaces
 Most common signs/symptoms
 Fever, sore throat, dysphagia, & tender cervical nodes
 Trismus & uvular deviation common, even with uncomplicated tonsillitis
 Age
 Usually occurs in child or young adult
 Imaging recommended if severe trismus to exclude
PTA & determine local extension of pus

19. Tonsillar/Peritonsillar Abscess
Intratonsillar abscess
 TA: Fluid within large tonsil + peripheral enhancement
Best diagnostic
clue

20. Tonsillar/Peritonsillar Abscess
Intratonsillar abscess
 PTA: TA extends into adjacent spaces
 Parapharyngeal (PPS), masticator (MS), submandibular (SMS) spaces
Best diagnostic
clue

21. Pathology of the neck spaces “part I”
Neoplasm
Nasopharyngeal
carcinoma
&
NHL

22. Nasopharyngeal Carcinoma
 Definitions
 Primary mucosal malignancy arising in nasopharynx, most strongly associated with EBV infection
 Most common signs/symptoms
 Conductive hearing loss secondary to middle ear obstruction
 Obstruction or infiltration of eustachian tube
 Bloody nasal discharge or epistaxis
 50-70% present with mass from metastatic nodes
 Uncommonly presents with cranial neuropathies
 Age
 Peak incidence: 40-60 years
 Pediatric NPC rare; most often undifferentiated NK
 M:F = 2.5:1

23. Nasopharyngeal Carcinoma
 Lateral pharyngeal recess mass with deep extension and cervical adenopathy
Best diagnostic
clue

24. Nasopharyngeal Carcinoma
 Arises in lateral pharyngeal recess, a.k.a. fossa of Rosenmüller
 Nodal disease in 90% at presentation

25. Nasopharyngeal Carcinoma
Consider
Carefully evaluate nasopharynx whenever middle ear obstruction in adult

26. Nasopharyngeal Carcinoma
 Certain key tumor findings should be sought
 Parapharyngeal fat infiltration (T2)
 Skull base invasion (T3)
 Intracranial or cranial nerve involvement (T4)

27. Nasopharyngeal Carcinoma
 Nodal disease is common; nodes often large and shows necrosis
 Retropharyngeal, level II and V nodes most often
 Supraclavicular nodes = N3b
 Important, therefore, to describe any low neck nodes (IV or VB) as potentially supraclavicular

28. Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
 Definitions
 3 subsites of Waldeyer lymphatic ring: Adenoids, palatine tonsils, lingual tonsils
 Most common signs/symptoms
 Nasopharyngeal adenoidal NHL: Nasal obstruction, serous otitis media
 Palatine or lingual tonsil NHL: Sore throat, otalgia, tonsillar mass
 B symptoms: Systemic complaints such as fever, sweats, weight loss
 Children with large PMS NHL may present with airway compromise
 Age
 Adult more common than pediatric; > 50 years
 M:F = 1.5:1
 Clinical profile
 Most common presentation: Adult with PMS
mass & neck mass
 Increased incidence in patients with AIDS,
Sjögren syndrome, Hashimoto thyroiditis,
and other autoimmune conditions

29. Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
 Large PMS mass with associated cervical adenopathy > 50% of time
 Most common sites of NHL of PMS
 Palatine tonsil > nasopharyngeal adenoids > lingual tonsil
Best diagnostic
clue
 Consider
 NHL of PMS when imaging shows bulky mass of adenoidal,
tonsillar, or base of tongue (lingual tonsil).

30. Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
 Lymph nodes are homogenous with no evidence of necrosis

31. Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
 More than one site often involved

32. Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
 Nasopharyngeal /oropharyngeal Carcinoma
 Poorly circumscribed PMS mass
 Focal disease
 Associated malignant, often necrotic, adenopathy
DIFFERENTIAL
DIAGNOSIS

33. Pathology of the neck spaces “part I”
Masticator
space
Infl. Abscess
Neoplasm

34. Pathology of the neck spaces “part I”
Masticator
space

35. Pathology of the neck spaces “part I”
Inflammatory
Masticator
space abscess

36. Masticator Space Abscess
 Definitions
 Abscess within MS usually arises from molar tooth (odontogenic) infection or following dental procedure
 Most common signs/symptoms
 Principal symptom: Trismus
 Fever, high white blood cell count
 Tender, swollen cheek
 Physical exam: Tenderness and limited mouth opening makes examination difficult
 Initial presentation may clinically mimic TMJ disease (i.e., TMJ pain and trismus)
 Age
 Increasing incidence with increasing age
 Dental problems generally increase in older people
 History of bad dentition or recent dental manipulation common

37. Masticator Space Abscess
 Marginally enhancing cystic lesion within MS
Best diagnostic
clue

38. Masticator Space Abscess
 Adjacent muscles are swollen, enhancing without associated fluid = myositis
 Adjacent fatty planes are "dirty" = cellulitis
 Linear markings in subcutaneous fat and thickening of skin when
associated help differentiate infection from malignant tumor

39. Masticator Space Abscess
 Mandibular osteomyelitis: Cortical destruction with periosteal elevation
 Is mandibular osteomyelitis present?
 If so, requires more extensive surgical intervention and protracted antibiotic
therapy

40. Masticator Space Abscess
 Signs of molar tooth infection or suggesting dental source
 Empty socket (from extraction) ± gas
 Radiolucency ± gas involving tooth itself (caries) ± periodontal lucency surrounding molar tooth root
 Fistula = radiolucent line leading from tooth area through bone into adjacent soft tissue

41. Pathology of the neck spaces “part I”
Neoplasm
Schwannoma
Sarcoma

42. Masticator Space CNV3 Schwannoma
 Definitions
 Encapsulated tumor of Schwann cell, which displaces rather than infiltrates fascicles of CNV3 in MS
 Most common signs/symptoms
 Most common asymptomatic neoplasm in deep facial soft tissues
 Even large lesions may be asymptomatic
 Atypical facial pain, ↓ chin sensation
 Age
 Predominantly 3rd-4th decade
 Younger in patients with NF2

43. Masticator Space CNV3 Schwannoma
 Well-circumscribed, smoothly marginated soft tissue mass along course of CNV3 branch of CNV
 From Meckel cave to MS along CNV3
 Well-circumscribed, fusiform, or ovoid mass following course
of CNV3 suggests schwannoma
Best diagnostic
clue

44. Masticator Space CNV3 Schwannoma
 Bone CT
 Smooth enlargement of bony foramen involved
 Foramen ovale most commonly enlarged
Best diagnostic
clue

45. Masticator Space CNV3 Schwannoma
 Rarely affects CNV3 branches (inferior alveolar or mental nerves)

46. Masticator Space Sarcoma
 Definitions
 Malignant tumor of soft tissue origin (fat, muscle, nerve, joint, blood vessel, or deep skin tissues) in MS of
suprahyoid neck
 Most common signs/symptoms
 Enlarging soft tissue mass over mandible with increasing pain
 Cranial nerve deficits common if skull base involved
 Age
 Mean: 35 years old
 M:F = 2:1

47. Masticator Space Sarcoma
 Aggressive, poorly marginated MS mass with bone destruction and invasion of adjacent fascial planes
spaces
 MS; frequently extends outside of MS
 Often large (> 4 cm) despite superficial MS location

48. Masticator Space Sarcoma
 Bone CT:
 Allows assessment of SA matrix ± bone destructive changes

49. Masticator Space Sarcoma
 MR:
 Evaluation of soft tissues
 Perineural tumor spread along CNV3

50. Masticator Space Sarcoma
 Absent known systemic malignancy MS mass should suggest diagnosis of SA

51. Pathology of the neck spaces “part I”
Parotid space
Infl.Parotitis
Neoplasm

52. Parotid Space
Parotid space

53. Pathology of the neck spaces “part I”
Inflammatory
Parotitis

54. Acute Parotitis
 Definitions
 Acute inflammation of parotid gland
 Most common signs/symptoms
 Sudden-onset parotid pain and swelling
 Viral: Prodromal symptoms of headaches, malaise, myalgia
 Calculus induced: Recurrent episodes of swollen, painful gland, usually related to eating
 Age
 Bacterial: > 50 years and neonates
 Viral: Most < 15 years; peak age 5-9 years
 Adults usually immune from childhood exposure or MMR vaccine
 Bacterial: Localized infection may become
suppurative, with central abscess
 Viral: Usually from systemic viral infection
 Predisposing factors
 Dehydration, surgery, diuretics, or
anticholinergics reducing salivary flow
 Duct obstruction by calculus
 Immunosuppression, poor oral
hygiene, malnutrition

55. Acute Parotitis
 Enlarged parotid(s) with surrounding fat stranding
 Parotid retains normal configuration as it enlarges
 Usually involves entire gland but can be focal
Best diagnostic
clue

56. Acute Parotitis
 Calculus induced: Unilateral, with radiopaque stone in parotid duct
 Most frequent locations for calculus: Hilum of gland, distal parotid duct

57. Acute Parotitis
 – Ring enhancement of low-density abscesses (if present)

58. Acute Parotitis
 Viral: 75% bilateral; submandibular and sublingual glands may also be involved
 Bacterial: Usually unilateral

59. Pathology of the neck spaces “part I”
Neoplasm
Benign neoplasm
Malignant neoplasm

60. Parotid Benign Mixed Tumor
Pleomorphic adenoma
 Definitions
 Benign, histologically heterogeneous tumor of parotid
 Epithelial, myoepithelial, and stromal components
 Most common signs/symptoms
 Painless cheek mass
 Location-dependent symptoms and signs
 Superficial lobe or accessory parotid: Cheek mass
 Parotid tail: Angle of mandible mass
 Deep lobe: Enlarging mass pushes palatine tonsil into pharyngeal airway
 Facial nerve paralysis is rare and suggests malignancy
 Age
 Most common > 40 years
 Range: 30-60 years

61. Parotid Benign Mixed Tumor
Pleomorphic adenoma
 Sharply marginated intraparotid mass lesion
 Homogenous parenchyma
 lobulated margin
Best
diagnostic clue

62. Parotid Benign Mixed Tumor
 If very high T2 signal present, specific for BMT
Best
diagnostic clue

63. Parotid Benign Mixed Tumor
Pleomorphic adenoma
 Pear-shaped when arising in deep lobe and extending into stylomandibular tunnel
Consider
• Large asymptomatic masses arising from deep
lobe of parotid almost always BMT

64. Parotid Benign Mixed Tumor
Pleomorphic adenoma
 Dystrophic calcification may be present
 Calcifications unusual in other parotid tumors

65. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 Definitions
 Benign tumor with characteristic histopathologic appearance: Papillary structures, mature lymphocytic infiltrate,
& cystic changes
 Most common signs/symptoms
 Angle of mandible (tail of parotid) mass
 Painless
 Multiple masses ~ 20%
 Facial nerve weakness very rare
 Suggests malignancy
 Age
 Mean age at presentation = 60 years
 Malignant transformation < 1%
 Clinical profile
 90% of patients with Warthin tumor smoke
 Increased incidence with radiation exposure

66. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 Sharply marginated parotid tail mass with heterogeneous parenchyma
 Most common mass to arise in parotid tail superficial to angle of mandible
Best
diagnostic clue
 Parenchymal heterogeneity is characteristic

67. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 Large cystic component, septa or multiple adjacent cystic lesions

68. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 Mural nodule more suggestive of Warthin tumor

69. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 Intermediate T 2 signal “solid component “

70. Warthin Tumor
Papillary cystadenoma lymphomatosum, adenolymphoma,lymphomatous adenoma
 20% multifocal
 Multiple lesions in 1 gland or bilateral lesions
 May be synchronous or metachronous

71. Malignant Parotid Tumor
 Definitions
 Mucoepidermoid carcinoma (MECa)
 Malignant epithelial salivary gland neoplasm composed of variable mixture of both epidermoid & mucus-secreting cells arising
from ductal epithelium
 Adenoid cystic carcinoma (ACCa)
 Malignant salivary gland neoplasm arising in peripheral parotid ducts
 2nd most frequent parotid malignancy (after mucoepidermoid carcinoma)
 Most common signs/symptoms
 Palpable parotid mass, usually rock-hard
 Facial pain, otalgia, facial nerve paralysis
 Other cranial nerve involvement (CNV3)
 Age
 Usually 35-65 years old
 May be seen in pediatric population

72. Malignant Parotid Tumor
 Invasive, ill-defined PS mass

73. Malignant Parotid Tumor
 MECa:
 Malignant adenopathy often present
 1st order nodes = jugulodigastric nodes (level II)
 Intrinsic parotid nodes & parotid tail nodes also involved

74. Malignant Parotid Tumor
 ACCa ; Perineural tumor spread on mastoid CNVII

75. Malignant Parotid Tumor
 Intermediate to low T2 signal

76. Scheme of parotid neoplasm
Parotid neoplasm
Malignant parotid lesion Benign Parotid lesion
Pleomorphic adenoma
Homogenous
High T2
Warthin
Heterogeneous ”cyst”
Parotid tail
Multifocal
Elderly & smoke
Mucoepidermoid
LN
Adenoid cystic
Perineural spread
ill-defined well-defined
Biopsy

77. Parapharyngeal
space
Importance
Pharyngeal
mucosal space
Thornwaldt Cyst
Infl.Tonsillitis &
abscess
Neoplasm
Masticator space
Infl.Abscess
Neoplasm
Parotid space
Infl.Parotitis
Neoplasm
Pathology of the neck spaces “part I”