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Everything you need to know about Computed Tomography (CT) & CT Scanning

Neuroradiology: Head and Neck Pathology Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Neuroradiology ❯ Head and Neck Pathology

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  • Lymphatic malformations are rare, non-malignant masses consisting of fluid-filled channels or spaces thought to be caused by the abnormal development of the lymphatic system. These malformations are usually apparent at birth or by two years of age. Lymphatic malformations can affect any area of the body (except the brain), but most commonly affect the head and neck. When evident at birth (congenital), lymphatic malformations tend to be soft, spongy, non-tender masses. The specific symptoms and severity of lymphatic malformations varies based upon the size and specific location of the malformation. Some lymphatic malformations can be massive. Lymphatic malformations, regardless of size, can potentially cause functional impairment of nearby structures or organs and disfigurement of affected areas.
  • Several different terms were once used to describe conditions now grouped under the umbrella term “lymphatic malformations.” Such terms include cystic hygroma, lymphangioma, cavernous lymphangioma, cystic lymphangioma and lymphangioma circumscriptum. These terms have been abandoned because some of the outdated terms imply a relationship to cancer. Lymphatic malformations are not cancerous and there is no known risk of malignant transformation.
  • Lymphatic malformations affect males and females in equal numbers. Most lymphatic malformations are evident at birth or within two years of age. However, in some patients, lymphatic malformations may not become apparent until adulthood. The exact prevalence of lymphatic malformations in the general population is unknown, but is thought to be approximately 1:4000 live births. 
  • Lemierre syndrome is a rare and potentially life-threatening complication of bacterial infections that usually affects previously-healthy adolescents and young adults. It most commonly develops in association with a bacterial throat infection, but it may develop in association with an infection involving the ears, salivary glands (parotitis), sinuses, or teeth; or in association with an Epstein-Barr infection.[1] The bacteria typically responsible for infection in Lemierre syndrome is Fusobacterium necrophorum, although a variety of bacteria can be responsible. In people with Lemierre syndrome, the initial infection spreads into tissues and deep spaces within the neck, leading to the formation of an infected blot clot (septic thrombophlebitis), sometimes made up of pus, in the internal jugular vein (the blood vessel that carries blood away from the brain, face, and neck).
    https://rarediseases.info.nih.gov/diseases/6882/lemierre-syndrome
  • “Advanced Lemierre syndrome is a life-threatening condition.The current mortality (death due to the syndrome) is estimated to be between 5% and 18%, depending on the source of the data. However, as the mortality in the pre-antibiotic era reportedly was 90%, the outlook for people with Lemierre syndrome has improved significantly due to advances in antibiotic therapy and high-level intensive care.Receiving the diagnosis as quickly as possible and starting appropriate treatment increases the chance of survival. Severe complications of Lemierre syndrome may include osteomyelitis (bone infection), meningitis, acute respiratory distress syndrome, and septic shock.”
    https://rarediseases.info.nih.gov/diseases/6882/lemierre-syndrome
  • “The identification of thrombophlebitis of the IJ vein is the first hard evidence to suggest Lemierre’s syndrome in many patients. It is likely true that, as with our patient, these imaging studies are ordered in the majority of patients to assess for deep space infections of the neck and not IJ vein thrombophlebitis. Duplex ultrasonography, CT and magnetic resonance imaging have all been used for IJ vein imaging, with CT being most commonly requested in patients with Lemierre’s syndrome. Many authors consider contrast-enhanced CT as the preferred study in this setting as it allows for visualization of surrounding structures and is the most readily available.”
    Lemierre's syndrome.  
    Eilbert W, Singla N.  
    Int J Emerg Med. 2013;6(1):40. 
  • “Lemierre’s syndrome occurs primarily in young, otherwise healthy individuals and is characterized by a history of recent oropharyngeal infection, clinical or radiological evidence of IJ venous thrombosis and anaerobic bacteremia caused primarily by F. necrophorum. This is a rare illness in the modern era of antibiotic therapy, though it has been reported with increasing frequency in the twenty-first century. Lemierre’s syndrome should be suspected in young, healthy patients with prolonged symptoms of pharyngitis followed by symptoms of septicemia or pneumonia, or an atypical lateral neck pain. Diagnosis is often confirmed by the identification of IJ vein thrombophlebitis by an imaging study and growth of anaerobic bacteria on blood culture. Prolonged antibiotic therapy is the cornerstone of treatment, occasionally combined with anticoagulation.”
    Lemierre's syndrome.  
    Eilbert W, Singla N.  
    Int J Emerg Med. 2013;6(1):40. 
  • “Substernal nodular goiter usually results from simple goiter. Although bilateral glands are often involved, the large lesions are usually located in unilateral gland. Large substernal nodular goiter often causes compression of surrounding structures, secondary hyperthyroidism and malignant changes. Therefore, surgery will be indicated when the diagnosis is confirmed . However, if it is treated with surgery, the operative bleeding risk was high. Most of the cases are operated upon via a cervical or combined cervical-thoracic approach. Substernal goiter resection performed through cervical approach is minimally invasive with less potential complications. The patients don’t require thoracotomy and rehabilitate fast postoperatively.”
    Surgical treatment of large substernal thyroid goiter: analysis of 12 patients
    Bo Gao et al.
    Int J Clin Exp Med. 2013; 6(7): 488–496.
  • "Substernal goiter refers to the thyroid mass grows along dermal sternum from the neck to the substernal portion, descending below the thoracic inlet. The currently accepted definition of an intrathoracic goiter is a thyroid gland with more than 50% of its mass located below the thoracic inlet. It is characterized by slow progression and a longer course of illness. If the substernal goiter compresses the adjacent esophagus, trachea, nerves and blood vessels, then the corresponding symptoms would occur.”
    Surgical treatment of large substernal thyroid goiter: analysis of 12 patients
    Bo Gao et al.
    Int J Clin Exp Med. 2013; 6(7): 488–496.
  • "’The role of the radiologist in evaluation of substernal thyroid goiters is to provide the surgeon with an anatomic roadmap to guide surgical intervention. The radiologist provides an accurate account of the substernal extent of the mass and describes its impact on the trachea, esophagus, and vascular structures. Imaging the patient with the arms overheard can result in misleading substernal localization of the goiter. Substernal thyroid goiters should be imaged with the patient’s arms by the sides, because this is the position the patient will be in during surgery, and this position most accurately reflects the true anatomic location of the gland.”
    Preoperative Imaging of Thyroid Goiter: How Imaging Technique Can Influence Anatomic Appearance and Create a Potential for Inaccurate Interpretation
    Derek B. Pollard, Colin W. Weber and Patricia A. Hudgins
    American Journal of Neuroradiology May 2005, 26 (5) 1215-1217
  • “Surgeons have long been familiar with the impact when a patient with a large thyroid goiter simultaneously raises both arms overhead. Pemberton sign or “thyroid cork” describes the physical manifestation of marked facial plethora resulting from jugular vein compression when the thoracic inlet rises so that it is temporarily filled by a large substernal goiter. Although elevating the patient’s arms and shoulders above the head is desirable to eliminate the beam-hardening artifact from the shoulders, it may also have the adverse consequence of temporarily increasing the apparent descent of a substernal goiter.”
    Preoperative Imaging of Thyroid Goiter: How Imaging Technique Can Influence Anatomic Appearance and Create a Potential for Inaccurate Interpretation
    Derek B. Pollard, Colin W. Weber and Patricia A. Hudgins
    American Journal of Neuroradiology May 2005, 26 (5) 1215-1217
  • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the in- creased frequency of Ins”. 


    The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
  • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment”. 


    The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
  • “Advances in medical imaging technology have provided more sensitive, detailed and higher resolution images. Consequently, the frequency of INs has increased. A considerable volume of our referrals emerges from colleagues that seek our expertise in managing unexpected imaging findings in the head and neck region. Similarly, head and neck surgeons can encounter incidental findings in regions outside their “comfort zone”. Many times, we rely on the radiology report to suggest the next step in work-up. On other occasions, we initiate an immediate referral to another specialist without knowing if it is the most appropriate next step in management.”. 


    The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
  • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the increased frequency of INs.”.

    The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
  • Squamous Cell Carcinoma of the Neck:Staging
    - T1: tumor limited to one subsite of and = 2 cm
    - T2: > 1 subsite or > 2 cm, < 4cm without hemilarynx fixation
    - T3: tumor > 4cm with hemilarynx fixation
    - T4: tumor invading local structures (thyroid/cricoid cartilage, cervical soft tissues)
  • Squamous Cell Carcinoma of the Neck
    - Commonly are necrotic
    - Spread to local nodes (>50% at presentation)
    - Usually aggressive with poor prognosis
    - Can simulate lymphoma but nodes are usually more necrotic

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