10 8 Neck

therefore cannot be morphologically differentiated from pharyngeal carcinomas. The

imaging characteristics are compatible with
their histological grade.

Carcinoma ex Pleomorphic Adenoma

Carcinoma ex pleomorphic adenoma is a
malignant transformation of a (resected)
pleomorphic adenoma.
CT Morphology

Small tumors resemble pleomorphic adenoma

with benign characteristics, but larger tumors
are more inhomogeneous and infiltrative with
areas of necrosis. The CT morphology directly
reflects this variation in macroscopy.

Acinic Cell Carcinoma

Acinic cell carcinoma occurs almost exclusively
in the parotid gland and can be bilateral in 5%
of cases. They usually occur after the 40th
year but also are the second commonest
salivary malignancy in children.
CT Morphology
The tumors can either be solid or cystic. The
imaging characteristics are nonspecific. The
tumors generally have a benign appearance.

Metastases
Metastases occur almost exclusively in (the inttaglandular nodes of) the parotid gland. The
commonest primary is melanoma of the temporal skin or other parts of the neck. Less
frequent are head and neck, renal, lung,
breast, and Gi carcinomas.
CT Morphology
Unilateral or bilateral, enlarged intraglandular
lymph nodes with a homogeneous density.
After contrast administration homogeneous
enhancement is seen. Necrosis can be seen
occasionally, and is suggestive for malignancy.
Differentiation from nodal lymphoma is often
impossible.

Inflammatory and Autoimmune Lesions

Sialadenitis
Acute bacterial and viral sialadenitis are the
commonest pathologies of the salivary glands,
Bacterial infections usually ascend from the

oral cavity when saliva flow is decreased and

involve pathogens like Staphylococcus aureus.

Streptococcus pyogenes, Streptococcus

pneumoniae and Haemophilus influenzae.
Viral infections can be caused by mumps,
Coxsackie or (Parainfluenza viruses and
preferentially involve the parotid glands. Intraand periglandular lymph nodes may be
involved in Lhe process. The main role for
imaging is to differentiate adenitis from abscess formation. Abscesses are often formed
when acute adenitis is undiagnosed or incompletely treated. These abscesses can
spread quickly in rbe parapharyngeal space or
other parts of the neck.
CT Morphology
The involved gland is dense and somewhat enlarged. It enhances slightly. Abscesses are demarcated regions of low attenuation,

Sialolithiasis
Stones can be located in the salivary gland
ducts or the extraglandular ductal system,
from 80-90% occur in the submandibular
gland, 10-20% in the parotid and <5% in the
sublingual glands. The stones are usually
solitary and most often located in the
extraglandular ducts. Complete obstruction will
lead Lo gland atrophy while incomplete
obstructions
are
often
associated
with
recurrent infections and swelling. The main role
of CT lies in differentiating obstructive from
nonobstructive diseases. This directly affects
the choice of management.
CT Morphology
Sialoliths are readily identified at CT, and even
noncalcified stones can be detected. Some
80% of submandibular stones and 60% of
parotid stones are calcified. The gland is often
enlarged and more ill defined. After contrast
there is increased enhancement of the gland
on the affected side. In case of obstruction,
hypoat- tenuating dilated ducts can be
visualized (Fig. 8.27).

11 8 Neck
Fig, 8.27 Inflammation leads to
hypervascularization of the affected left submandibular gland
(arrows). Note the dilated duct
(arrowhead) on the coronal
volume-rendered image (a). A
curved planar reformation is
able to display the whole length
of the dilated duct (b). Note
that there is no stone visible,
which suggests a stricture, e.g.,
after spontaneous passage of a
sialolith.

Sialadenosis
This is a noninflammatory and nontender
chronic enlargement of the parotid glands that
can lead to xerostomia. It seems to be caused
by a degeneration of the autonomic nervous
system and is associated with a variety of endocrine and nutritional diseases, the most important being diabetes meilitus. It can also be
associated with medications, in which case
also the submandibular glands can be
involved.
CT Morphology
The CT appearance is nonspecific. The glands
are enlarged and appear either dense or
infiltrated by fat.

Sjogren's syndrome
This systemic autoimmune disorder can occur
alone or in association with connective tissue
diseases like rheumatoid arthritis. Classically,
symptoms are keratoconjunctivitis sicca, xerostomia and connective tissue disease. The adult
form is much commoner than the childhood
form and often proceeds to more advanced
stages. It is mainly seen in women 40-60yfears
old and is associated with parotid enlargement.
The peripheral ductuli and acini are involved
first and superinfection may lead to gland destruction and multiple abscesses.
There is a 40-fold enhanced risk of subsequent development of lymphoma in the
gland.
CT Morphology
in early stages of the disease the gland
appears normal. With progression of disease,

the gland enlarges and becomes denser. Later,

a honeycomb glandular pattern may develop,
which can also be seen in granulomatous
diseases or chronic sialadenitis.
Contrast can be retained in small punctate
or globular collections. Rarely, a macrocystic
change can occur resembling HIV-associated
lymphoepithelial cysts.

Granulomatous Diseases
These systemic diseases can also affect the intraparotid or periglandular lymph nodes.
CT usually shows multiple benign appearing masses throughout the gland that may
mimic lymphoma or other granulomatous diseases. Diffuse adenopathy is frequent.
Sarcoidosis affects the parotids in 1030% of patients leading to a chronic bilateral
nontender multinodular enlargement. Often
there
is
associated
adenopathy.
When
combined with uveitis and facial nerve
paralysis
this
condition
is
known
as

Heerfordt's syndrome.
Tuberculosis or atypical mycobacterial infections are rare and usually arise from a focus
in the tonsils. The parotid and submandibular
glands may be affected. The presentation can
be acute or more insidious and both clinical
and CT findings are nonspecific and can mimic
infectious sialadenitis or tumor.
Other causes include cut-scratch fever,
toxoplasmosis and actinomycosis. In the
last two

forms the disease can be associated with more

diffuse lymphadenopathy. In actinomyces infec-

tions the soft tissues (masticator space) are

also infected and sinus tracts are formed.

Thyroid and Parathyroid Gland

Pathology
Primary diagnostic methods in the thyroid are
serology,
scintigraphy,
and
ultrasound.
However, on CT examinations for other
indications one may come across coincidental
findings in the thyroid. CTis also indicated in
the evaluation of large thyroid tumors,
especially when malignancy is suspected.
iodinated contrast material should only be
given after TS1 l-values have been assessed, as
hyper thyroid patients may develop long-standing iodine-induced hyperthyroidism (IIHT). The
use of iodinated contrast agents is also con
train- dSeated when patients are scheduled for
ablative therapy with radioactive iodine (see
also Chapter 3). In these cases, MR! is the
modality of choice.

Goiter
Goiter is a benign enlargement of the thyroid
that is often asymmetric. It can be simple,
associated
with
iodine
deficiency,
or
multinodular, associated with autoimmune
disorders or dietary factors. The nodules in
multinodular goiter represent either colloid
nodules or true follicular adenomas of variable
sizes.
Patients
can
be
hypothyreotic.euthyreotic, or hyperthyreotic. Multinodular forms can become bulky, extending in the
anterior mediastinum. The frequency of carcinoma developing in multinodular goiter is 47%.
CT Morphology
Mixed solid and cystic zones are present in a
nodular and enlarged gland. Hemorrhages and
calcifications may be present (Fig. 8.28), Enhancement is patchy and inhomogeneous. The
trachea, esophagus or neck vessels can be displaced or compressed.

Thyroid Cyst
These are the result of degeneration of adenomas and are usually well-defined lesions,
often with fluid attenuation. With elevated protein content, hemorrhage, or infection, these lesions have a higher attenuation.

13 8 Neck

Fig, 8,28 Unilateral goiter causing enlargement of the left lobe of the thyroid gland and displacing the trachea to
the right side. Hypodense areas within the enlarged left lobe dnd a small calcification are present, signifying
regressive changes.

CT Morphology
These cysts are smooth and well defined. Their
attenuation depends on the cyst content and
varies from hypodense to isodense. The walls
are thin and lack calcifications. Large cysts
may be hard to identify as arising from the
thyroid but hyperat- tenuating(compressed)
thyroid tissue in the wall of these large cysts is
typical {Fig. 8.29).

Benign Thyroid Tumors

Thyroid nodules are very common and occur in

Fig. 8.29 Large thyroid cyst that leads to

displacement and extrinsic compression of the larynx
(compare to Fig. 8.11 a). It can be identified due to
the hyperenhanc- ing rim that is isoattenuating to
thyroid tissue and is

population. Colloid
(adenomatousj nodules are composed of
hyperplastic epithelium and are not true
neoplasms. They are usually non-functioning
and may be cystic (colloid cyst). Follicular
adenomas present as slow growing welldefined encapsulated nodules that can be
functioning or non-functioning. They are
usually solitary and measure up to 3 cm. They
may undergo cystic degeneration, calcification,
or hemorrhage. Although benign adenomas do
not undergo malignant transformation, 10-15%
of all single (non-functioning) adenomas are
malignant. The Hiirthle cell subtype is more
variable in size and shape and has less welldefined borders.
4-7%

of

the

adult

CT Morphology
Follicular adenomas are usually well defined,
relatively hypodense solid masses on noncontrast scans. Cyst formation and calcification can
PTC

often be seen. Some may show a marked en-

contiguous with the thyroid gland. Axial image (a),

coronal (b) and sagittal volume-rendered images (c)
from a thin-section mult is lice CT data set.

hancement with iodinated contrast. It is virtually impossible to differentiate benign

tumorous nodules from a nodular goiter.

Malignant Thyroid Tumors

The commoner malignancies of the thyroid are
usually well differentiated. Risk factors include
exposure to ionizing radiation during childhood
and prolonged increased levels ofTSH.
Papillary carcinoma is the commonest
thyroid malignancy accounting for 55-75% of
cases, especially in young or middle-aged adult
females. They may be multifocal or bilateral
and can have cystic, hemorrhagic, or calcified
components. Although these tumors grow
slowly, 50% oT patients have metastases in the
lo- coregional lymph nodes at diagnosis (Table
8.28).
1'ollicular
CitltMriOTna
is
most
frequently seen in young female adults and

Table 8.28 Thyroid carcinomas

FTC
ATC

Incidence

55-75%

15-20%

Iodine-storing

++

--

Metastases

Regional LN

Lungs

Lungs

Bone

MTC

8-15 X

2-8%

Regional

Regional LN
Lungs
Liver
Bone

PTC = papillary thyroid carcinoma, FTC = follicular thyroid carcinoma, ATC = anaplastic thyroid carcinoma, MTC
= medullary thyroid carcinoma, LN = lymph nodes

may be either well encapsulated or diffusely

infiltrative. It frequently invades vessels. Cystic
degeneration is rare. Spread to nodes is
infrequent {< 10%) but hematogenous
dissemination to lung or bones occurs early.
Anaplastic carcinoma occurs more
frequently in the elderly, especially in people
with longstanding goiter. These tumors are
often densely calcified and show necrosis. The

Malignant thyroid Tumors 269

Table S.29 TN-staging of thyroid carcinoma (UICE, 1997)

T1 Tumor 1 cm or less in greatest dimension,
limited to thyroid
T2

Tumor between 1 cm and 4 cm in greatest

dimension, limited to thyroid

T3

Tumor more than 4 cm in greatest dimension.

limited to thyroid

T4

Tumor of any size extending beyond the capsule

M0

Mo regional lymph node metastasis

Nla Regional metastasis in ipsilateial cervical lymph

nodes
Nib Regional metastasis in bilateral, midline or
contralateral cervical or mediastinal lymph
nodes

tumor is aggressive and invades neighboring

structures commonly. It metastasizes early,
with 70-80% of patients having affected
nodes, which are often necrotic.
Medullary carcinoma is rare. It has a
familial incidence and can be part of MENsyndromes:
MEN
Ila
associated
with
pheochromocytoma and parathyroid adenoma
and MEN lib associated with mucosal neuroma
and marfanoid facies. About 50% of patients
have lotoregional metastasis in the lymph
nodes and distanL metastases are common.
Metastases to the thyroid are rare and
often clinically occult. The commonest
primaries are bronchogenic and renal cell
carcinomas. The lesions are usually multiple
and sometimes hemorrhagic.
CT Morphology
The T-stages of thyroid carcinomas are given in
Table 8.29, The pattern of spread of the various
tumor types is provided in Table S.28.

Fig. 8.30 Parathyroid adenomas

may appear as a hypodense expansile mass on the
posterolateral aspect of the
thyroid gland (a), showing a
marked attenuation difference to
Lhe thyroid tissue (after IV
contrast administration). Ectopic
parathyroid adenoma lateral to
the aortic arch (b).

Imaging findings are nonspecific. There is

much overlap between benign and malignant
tumors. Thyroid carcinomas are well- to ill-defined lesions, often with in homogeneous contrast enhancement. Areas of hemorrhage,
necrosis, calcification, and cystic degeneration
are often present. Aggressive carcinomas show
ex- trathyroid spread or vascular invasion.

Parathyroid Tumors
Adenomas of the parathyroid can be Found
along the tracheoesophageal groove anywhere
from the upper neck to the mediastinum, but
frequently lie posterior to the thyroid poles. In
most cases tliey are associated with hyperparathyroidism. Multiple adenomas can be associated with MEN 1 and MEN Ila syndromes.
are very rare and usually
cause hyperparathyroidism. They are slowly
growing tumors that may mimic adenomas but
grow locally invasive. They spread via
lymphatics and hematogenously in 30% of
cases,

Carcinomas

CT Morphology
An adenoma is a well-defined soft tissue lesion
that is hypodense relative to the thyroid (Fig.
8.30), Some 25% or adenomas enhance. Sensitivity of CT is however only 60-70%.The
diagnosis using 99mTc-sestamibi scintigraphy is
much more sensitive. Carcinomas can only be
differentiated if local invasion or metastases
are visible.

Inflammatory Thyroid Lesions

Acute infective (suppurative)

thyroiditis is a rare cause for swelling with
pain, fever and dysphagia. Commonest
pathogens
are
Streptococcus
hemoly- Licus, Staphylococcus
aureus and Streptococcus pneumoniae.

It can be associated with a fourth branchial

cleft anomaly and may be the result of piriform
sinus
or
thyroglossal
duct
fistulae.
)
is a chronic autoimmune
disorder with inflammation that leads to a
symmetric nodular enlargement of the gland. It
occurs
in
middle-aged
women
with
hypothyroidism and predisposes to non-Hodgkin's lymphoma. It is associated with Graves'
disease and other autoimmune disorders.

Hashimoto's
thyroiditis

Cellulitis and Abscess 271

thyroiditis

Kiede/'s
is a variant chronic
inflammation giving extensive fibrosis leading
to a hypodense, enlarged gland at CT. It may
compress the esophagus and is associated with
mediastinal and retroperitoneal Fibrosis. Slight
contrast enhancement may be seen.

De
Quervain's
(granulomatous)
thyroiditis
is a
(lymphocytic
subacute disease of middle-aged women. It is
associated with viral infections of the upper
respiratory tract. Patients may progress from
hyperthyroidism through hypothyroidism to
euthyroid ism in 1 -2 months. At CT the gland is
symmetrically enlarged or may show a
dominant mass.

Infectious Diseases

Cellulitis and Abscess

Most localized infections are treated by antibiotics. CT is only required in nonresponsive
cases, and can differentiate cellulitis from
suppurative adenitis with edema and abscess
formation.
Infections from
dental origin are common and may spread to
the sublingual/submandibular, parapharyngeal,
or masticator spaces. Abscess formation is
seen frequently and there may be cortical
erosion of adjacent bone.
Mucosal lesions: Infections of the nasopharynx, oropharynx, tonsils, and middle ear
can extend into the retropharyngeal space via
spread to the retropharyngeal lymph nodes.
Cellulitis or suppurative adenitis may occur and
associated swelling may cause bowing of the
pharyngeal wall. Abscesses can occur locally
([peri]tonsillar^ 01 flS a complication of an abscessed adenitis (retropharyngeal). In this age
of broad-spectrum antibiotics, retropharyngeal
abscess formation is more often caused by
penetrating trauma, diskitis, or surgery. In the
larynx, acute supraglottis can spread locally to
involve the glottic or subglottic larynx and
hypopharynx and may cause life-threatening
swelling of these structures.
Ludwig's angina is an extensive, acute
cellulitis of the floor of the mouth that can be

Dental infections:

life threatening. It is generally seen in middleaged men with infected molars. Streptococci or
staphylococci are the causative agents and the
infection involves the sublingual and submandibular spaces bilaterally. Abscess formation is
infrequent If not controlled, rapid spread to the
suprahyoid soft tissues can ensue.
Cellulitis can easily spread to adjacent
facial spaces or extend along fascial planes,
upward or downward. It may extend into the
mediastinum via the visceral and posterior
cervical spaces. Abscesses conform to fascial
spaces and can occur anywhere in the neck.
Localized abscess collections may give a clue
to their origin by their location, Extensive
infections may be complicated by venous
thrombosis,
osteomyelitis,
and
airway
narrowing from mass effect.

CT Morphology
Cellulitis may present with a soft tissue mass
showing marked contrast enhancement. There
is infiltration and edema with thickening of the
skin, obliteration of normal fat planes and irregular thickening of fasciae (Fig. 8 .3t a}. Gas
inclusions are indicative of infection with gasproducing bacteria (Fig. 8.31 b). Myosins may
cause enlargement of muscles.

Infective
(suppurative)
adenitis is characterized by enlarged lymph
nodes

with

low-attenuation

center,

19 8 Neck
suggestive
of
liquefaction
necrosis.
Surrounding edema leads to a smooth
expansion of the structures within the space
with displacement of the pharyngeal wall anteriorly. Abscesses are masses with low attenua

tion that show enhancing peripheral

capsules (Fig. 8.31 c). Abscesses may contain
air and
often
show

nopathy, commonly in the upper cervical

nodes.

Fig. 8.31 (a) Cervical cellulitis appears as an inflamb

matory mass that obscures the sternocleidomastoid
muscle and the intrinsic neck muscles, (b) Gas-forming
cellulitic inflammation of the cervical soft tissues on the
right side, with significant soft-tissue swelling and mycotic
aneurysm of the common carotid artery due to salmonella
sepsis. The inflammatory process shows pe-

ripheral enhancement (arrow), (c) Incipient parapharyngeal abscess (arrow) contains a very small area of
liquefaction partially surrounded by an enhancing wall.
There is significant concomitant soft-tissue swelling with
slight displacement and narrowing of the pharyngeal
lumen.

Necrotizing Fasciitis
surrounding edema.
Severe complications of neck infections
include septic jugular vein thrombosis with or
without distant embolization and mediastinals
(see Fig.8.32). Arterial rupture is a very severe
complication of disseminated neck infection. It
is preceded by small hemorrhages with hematoma formation and has a protracted course. It
usually affects the internal carotid artery.

Necrotizing
fasciitis
causes
a
rapidly
progressive infection of subcutaneous tissue
and deep fascia. It can be caused by
anaerobes or streptococci and leads to
widespread
necrosis,
especially
in
immunocompromised patients.
CT Morphology

Gas may be present, but otherwise distinction

from cellulitis is difficult.

Tuberculous Adenitis (Scrofula)

This accounts for 5% of cases of cervical lymphadenopathy. The disease is caused by Mycobacterium tuberculosis or atypical
mycobacteria, is usually painless and seen
especially in young adults. In tuberculosis, it
may or may not be a manifestation of a
systemic disease. In AIDS-patients there may
be co-existence of tuberculous adenitis and
Kaposi's sarcoma.

Miscellaneous Diseases with Adenopathy

CT Morphology

node hyperplasia) originates in the mediastinum but can be multicentric in 10% of

cases. Most often this affects male patients in
their

Nodes can be homogeneous or show central

necrosis with rim enhancement or calcification.
A multilocLilar complex of nodes is a specific
sign. The posterior triangle or jugular nodes are
involved without surrounding inflammatory
changes. Infections with atypical mycobacteria
are more often seen in children and usually involve a more localized, unilateral lymphade-

Infectious mononucleosis is primarily caused

by the Epstein-Barr virus, it is associated with
lymphadenopathy. and most often
the
posterior
cervical
nodes
are
involved.
Hyperplasia of the lymphatic tissue of
Waldeyer's ring is common.

Castleman's disease (angiofollicular lymph-

Arterial Thrombosis and Dissection

21 8 Neck
50s or 60s. The nodes show an early dense uniform enhancement following contrast administration.
Sarcoidosis
gives
rise
to
diffuse
adenopathy. The nodes are homogenous and
do not show necrosis. Theft is often
involvement of Wal- cleyer's ring and the
salivary glands.
Cat-scratch disease is a granulomatous
infection in young patients caused by
Bartonella henselae. It can be associated
with painful cervical adenopathy. Usually one
node group is involved. hut multiple sites can
be found in disseminated disease (in 5-10%).
Kimttra and Kikuchi disease are rare
causes for cervical adenopathy in oriental
patients. Kimura occurs in young males and
shows enhancing nodes and salivary gland
infiltration.

Kikuchi is more frequent in young females,

showing a necrotizing lymphatlenopathy.

Fungal Infections
Histoplasmosis is ubiquitous in the central US.
Rarely, it may show granulomatous masses in
the
larynx,
oropharynx,
or
trachea.
Cryptococcosis
is
usually
seen
in
immunocompromised patients that in rare
cases may show a neck mass originating from
suppurative adenitis. In South-America, acute
or chronic paracoccidioidomycosis (Sotd/i
American
blastomycosis)
can
be
encountered which shows mucosal infection of
the oral cavity or lymph adenopathy.

Vascular Lesions
Jugular Venous Thrombosis
Thrombosis of the internal jugular vein can be
the result of infection, obstruction, advanced
tumors, IV drug abuse, or sinus thrombosis,
postoperative or after insertion of central
venous catheters.
CT Morphology

A fresh thrombus is hyperattenuating. The

acute thrombophlebitic phase shows an
enlarged thrombus-filled vein with loss of
adjacent soft tissue planes and enhancing vasa
vasorum (fig. 8.32). This is often associated
with fluid (venous transudate) in the
retropharyngeal space. In the thrombosed
phase perivascular changes have resolved, but
enlarged collaterals are shown.

Arterial Thrombosis and Dissection

Thrombosis is often associated with pseudoaneurysm formation and leads to ischemic

symptoms or 1 lorner's syndrome.
Dissections of the large arteries of the
neck can be post-traumatic, part of an aortic
dissection, or spontaneous. They are an
important cause of ischemic cerebral lesions in
young patients.

CT Morphology
7'firombos/s: The imaging features are comparable to venous thrombosis
Dissections: CTA can show an endoluminal
membrane separating the false (often bigger)
and true lumen (often smaller). If one lumen is
thrombosed, the only sign of dissection may be
a long narrowing of the artery (Fig. 8.33).

273

Fig. 8,32 Fresh thrombosis of the internal jugular vein (arrow). Mote the Inflammation in the anterior parapharyngeal space.

Fig, 8,33 Traumatic dissection of

the carotid artery in a young
man
following a motor vehicle
accident
The false channel is
completely
thrombosed (a) making a
diagno
sis
from axial sections a most
im
possible.
There is, however,
occlu
sion of the medial cerebral
artery
on the right side, seen on
coronal
thin-slab M1P from a multislice
CT set (b). The distal
data
the internal
portion
of carotid artery
(arrow)
and
the A1 segment ot the
ante
rior cerebral artery are
stenosed.
Note the excellent
collateral
supply of the right-sided
cortex.

Trauma

Spiral CT has become the primary investigation

aneurysms. Due to a higher incidence of spinal

CT Morphology
lesions, vertebra artery

lesions

die

more

used for soft tissue, vascular, pharyngeal, and

for important soft tissue trauma and can be
laryngeal lesions.
occurring m

frequent than carotid lesions, with most lesions

the C1-C2 and CS-C7 segments.

These patients are often asymptomatic.

Edema and Hematoma

Direct findings ot vessel injury include irregular
in traumatic lesions of the Cervical spine or associated ligaments, prevertebral space edema oi

margins, contrast extravasation, caliber changes,

lack of enhancement. Indirect signs like

hematomas may develop that can extend up oi

hematomas are
Retropharyngeal
downward.
much less frequenL, but can result in significant

carotid space hematoma or bone or metal rragments close to vessels can be evaluated at the
same time. In blunt trauma, there are frequently

Aii- can dissect retroairway

compromise.

signs of vertebral fractures.

alter

laryngeal

trauma

pharyngeals

barotrauma from assisted ventilation alter

or

<ii

Laryngotracheal
Injuries

t ubation.

Vascular Injuries
Vascular injuries are most frequently caused by
penetrating trauma such as stab or shot
wounds and are preferentially diagnosed by CT
angiography. The source images can also
visualize the trajectory of the penetrating
injury in the soft tissues. Penetrating injuries
lead most frequently to carotid occlusion
(35%), pseudoaneurysm formation (35%) and
much less frequently to arterial dissections.
Vertebral artery injury is usually associated
with spinal fractures.
Blum* trauma leads to stretching of
vessels and is more often associated with
occlusions (35%) and dissections (35%) than
pseudoThese injuries are frequently a complication of
penetrating trauma and seen only seldom after
blunt trauma. The mortality rare of these injuries, especially major dislocations, is high, CT
provides the best evaluation of the extent of
fractures, dislocations and hematomas.

CT Morphology

Fractures: cricoid ring fractures are often

multiple with the anterior fragment collapsed
posteriorly. There may be associated tears at
the petiole of the epiglottis due to shearing
forces. Exposed fragments in the airway are
prone to infection and must be removed.
Thyroid fractures are either horizontal (more
often in adults), vertical (more in children), or
com

Larynx Surgery 275

pound. It can sometimes be difficult to detect
horizontal ones by CI". There is associated soft
tissue swelling and hematoma formation, all
leading to airway compromise.
Dislocations; cricoarytenoid dislocations
can be caused by relative minor trauma such
as intubation. There is usually a ventral dislocation. Vocal cord paralysis and aryepiglottic fold
hematoma can serve as indicators of such
dislocations. Cricothyroid dislocations require
much greater forces and are associated with

cricoid or thyroid fractures in most cases. The

distance between the cricoid and thyroid is
enlarged and the cricoid can be rotated relative
to the thyroid. There is a large risk of recurrent
laryngeal nerve injury in these dislocations.
Hematomas: hemorrhage in the soft
tissues is associated with fractures, but can
also occur independently. The paraglottic fat
and subglottic region are the most likely
regions involved.

Post-Treatment Neck

Because of the changed morphology of the

treated neck, a thorough knowledge of the
therapy undertaken and its expected changes
is very important in the evaluation of patients
after surgical or radiation therapy, liven so,
post- treatment imaging remains a significant
challenge and is often associated with a limited
sensitivity for diagnosing local recurrence.

larynx Surgery
The goal of oncologic surgery in the larynx^
pharynx is complete resection of tumor with
preservation of speech and deglutition. In the
larynx, the most frequent conservational pro-

cedures and their resulting morphology are reviewed below (Fig.8.34; Table 8.30).

Vertical Hemilaryngectomy

In this procedure the ipsilateral vocal cord,

para- glottic space and part of the thyroid
cartilage are resected. Variations include
resection of one arytenoid for posterior
spreading lesions or the anterior aspect of the
opposite true cord in anterior extensions. These
procedures are indicated for limited glottic
carcinomas with norma! cord mobility and no
supra/subglottic extension. Contraindications
are extension to the false cord or in the
subglottic as well as para- glottic or cartilage
invasion.

Fig. 8.34 Lines of resection of procedures used in

conservation SLirgeryof the larynx, (a) horizontal
supraglot- tic laryngectomy (HSL). (b) vertical
hemilaryngectomy

(VH), (c) supidcricoid laryngectomy with cricohyoidopexy (SL + CHP), and (d) stipracricoid
laryngectomy with cricohyoidoepiglottopexy (SL +
CHFP).

 CT Morphology
The laryngeal axis is tilted and the thyroid on
the side of resection is shortened, often with a
paramedian plane of section. The adjacent car

Table 8.30 CT landmarks after conservative laryngeal surgery (Maroldi, 1997)

Hyoid bone
Epiglottis
Thyroid
Cricoid
Arythenoid"
Horizontal supraglottic laryngectomy

Present
(resected)

Resected

Upper third Mot

modified
resected

Present
(resected)

Present

Vertical hemilaryngectomy

Present

Present

I psi lateral Mot

modified
a la
resected

Resected

Present

Supracricoid laryngectomy + CHP

Present

Resected

Resected

Shifted closer
to hyoid bone

Resected
(present)

Present

Supracricoid laryngectomy + CHEP

Present
Suprahyoid

Present

Resected

Shifted closer
to hyoid bone

Resected
(present)

Present

' Ipsilateral,

Contralateral, CHP = cricohyoidopexy, CHEP = cricohyoidoepigloltopexy

tilage often becomes irregular and sclerotic.

Glottic symmetry is usually distorted from scar
tissue between the thyroid and arytenoid and
often a laryngocele is present.

Supracrkoid Laryngectomy

Supracricoid
cricohyoido-

Arytenoid'

laryngectomy
epiglottapexy

apex of the preserved arytenoid is regular, but

a soft tissue pseudocord is seen extending
downwards into the subglottis. The axis of the
asymmetric larynx is often oriented in the
transverse plane and pharyngeal pouches with
air or fluid can be observed lateral to the preserved arytenoid.

with

entails
resection of the thyroid cartilage (except the
cornu inferior), one arytenoid, paraglottic
tissue, both true and false vocal cords and the
lower portion of the epiglottis including the
preepiglottic space. The epiglottic tip and hyoid
are sutured to the anterior arch of the cricoid.
This is the procedure chosen for more
advanced glottic carcinomas. Contraindications
are arytenoid fixation, invasion of preepiglottic
fat, or massive extralaryngeai growth.

Supracricoid
laryngectomy
with
cricohyoidopexy differs in the fact that the
entire epiglottis and its preepiglottic fat are
resected, followed by pexis of the hyoid to the
anterior cricoid. It is performed for advanced
supraglottic carcinomas extending into the
ventricle as well as for trans- glottic
carcinomas with limited cartilage invasion.
Arytenoid fixation, invasion of cricoid or extension beyond the larynx (tongue base or valleculae) are contraindications.

CT Morphology

The thyroid and (part of) the epiglottis are absent while the hyoid and cricoid are adjacent in
the midline. The redundant mucosa around the

Horizontal Supraglottic Laryngectomy

In this procedure, the false cords, epiglottis and
preepiglottic space and upper part of the
thyroid are resected, although variations exist
in which part of the tongue base, piriform sinus
or one arytenoid are also resected. It is
performed for selected supraglottic carcinomas
with normal cord mobility and without
extension to the ventricle. Contraindications
are lesions that involve both arytenoids,
postcricoid area, tongue base, cartilage or
glottic region (crossing of ventricle),

CT Morphology
The anterior glottis is elevated just below the
tongue base with hyoid and thyroid remnant
close together and often irregular. The residual
mucosa around the preserved arytenoids used
for reconstruction is often thickened and
redundant resulting in asymmetry of this
neovestibule.

Radiation Therapy 277

Total Laryngectomy
Total laryngectomy has to be performed if lesions cannot be treated conservatively as in
subglottic extension or extensive cartilage
invasion by the tumor. This is also the
procedure
for
local
recurrences
or
if
radiotherapy
has
failed
or
produced
osteoradionecrosis. All laryngeal structures,
the hyoid bone, the piriform sinus, and strap
muscles are resected and the defect is reconstructed in a tube-like neopharynx connecting the base of the tongue with esophagus.
Contraindications are synchronous tumors or
hematogenous distant metastases.
CT Morphology

The resected structures are absent resulting in

a collapsed, irregular aspect of the mucosa.
The neopharynx is a tubular structure with a
regular wall thickness and smooth external
margins. Also, the walls of the tracheostoma
are thin and regular.

Neck Dissections
Surgery to the head and neck is often
associated with some form of neck dissection
for resection of (possible) positive lymph
nodes. The terminology has recently been
standardized and several forms are practiced.
Radical neck dissection: In the
classical radical dissection, all lymph nodes at
levels l-V are resected, and the spinal
accessory nerve, the sternocleidomastoid
muscle and the internal jugular vein removed.
Sometimes the superior belly of the omohyoid
muscle is also removed.
Modified radical neck dissection: in
this procedure all lymph nodes of the radical
dissection are removed but one or more major
non-lymphatic structures are preserved.
Se/ecrive neck dissections: Beside
preservation
of
major
non-lymphatic
structures, selected lymph node levels are also
preserved. There are four subtypes:
supraomohyoid: resection of alt lymph
nodes at levels l-lll located above the
superior belly of the omohyoid and
anterior to the posterior margin of the
sternocleidomastoid;

posterolateral: resection of all lymph

nodes at levels Il-V as well as suboccipital
and
retroauricular lymph nodes (especially
used for melanoma of the scalp);
/arera/.1 removal or all lymph nodes at
levels IIIV along the internal jugular vein;
anterior compartment: resection of all
lymph nodes at level V! from the hyoid
bone ievel down to the suprasternal notch
level.

Extended radical neck dissection: In this

procedure one or more additional lymph node
groups and/or nonlymphatic structures are resected compared to the radical neck
dissection. Examples can include level V),
suboccipital
or
periparotid
nodes
and
nonlymphatic structures like the carotid artery,
vagus or hypoglossal nerve, or paraspinous
muscles.
Because the post-surgical neck is usually
evaluated by a combination of clinical and endoscopic means, the role of CT in diagnosing
recurrence is not clear. It is probably best
reserved for patients with a high risk of
recurrence based on pretreatment findings and
clinical follow-up and for evaluation of late
complications. It can evaluate deep extension
or guide biopsy. For these high-risk patients, an
early post-treatment baseline study may be
beneficial. Tumor recurrence is suspected by
the presence of an irregular, enhancing soft
tissue mass >lcm, thickened commissure or
lysis of residual cartilage.

CT Morphology
With radical dissections the neck is markedly
asymmetric with absence of lymph nodes and
characteristic nonlymphatic structures. The
trapezius muscle is atrophied with concomitant
hypertrophy of the levator scapulae muscle. In
selective dissections only minor differences
may be present, especially with regard to
lymph nodes and surrounding fat.

Radiation Therapy
Primary radiation therapy is generally possible
for T1 and T2 tumors as well as selected T3
tumors of the neck. It is the primary modality
for nasopharyngeal and small glottic tumors
but for other tumors there is an institutional

variability based on local experience. In

general, large volume tumors or tumors with
massive invasion of the pre-epiglottic fat are a
contraindication

8 Neck
for primary radiation therapy. Secondary radiotherapy is often performed in T3 and T4 tumors
as an adjunct to conservation or radical
surgery to get a better local control. Successful
radiation therapy will lead to considerable
shrinkage of the tumor within months after its
institution. Failure of radiation therapy is
suspicious when at 4 months after therapy
50% or more of the tumor mass is still visible.
However, the high doses (>60 Gy) used in
radiation therapy lead to diffuse changes in the
tissues in the neck, mainly as a result of
inflammatory reaction with edema, fat
infiltration, and fibrosis. The high doses can
also be associated with complications like softtissue necrosis with ulceration or fistulae and
osteochon- dronecrosis.
Radiation treatment can cause a progressive inflammatory mucositis with edema.
Severity varies with the type of treatment. The
process is most severe 2-4 weeks after treatment and often involves the pharynx or larynx.
There may be associated swelling of the retropharyngeal structures and airway narrowing. In
doses of 45 Gy and larger, the salivary gland is
affected too, resulting in a chronic sialadenitis
with hypoplastic glands and xerostomia.
Postradiation surveillance by palpation or
endoscopy is often difficult. Therefore, it would
be preferable to rely on imaging. Costeffectiveness issues limit routine follow-up with
imaging studies in high-risk patients. Pre

treatment factors like tumor volume, cTNMstaging and cartilage invasion can identify
patients at high risk of treatment failure and in
these patients a baseline study at 4 months is
advisable. Patients at low risk or those where
there is clinical suspicion of complications can
be imaged as needed.
Early results of FDG-PRT and especially 201
Thailium-SPECr are promising, resulting in an
improved accuracy for distinguishing between
recurrence and radiation changes,

CT Morphology
Expected changes after radiation therapy can
be manifold and depend on the dose given,
type of therapy and irradiated portals. The
changes are often symmetric, start within
weeks, and may resolve within 12-24 months
or persist indefinitely.
Usually, the skin and platysma are
thickened with reticulation of subcutaneous
and deep fat structures. The mucosal
structures and pharyngeal wall may thicken
also, with surrounding edema and increased
enhancement. Salivary glands show a chronic
adenitis with increased enhancement and
atrophy and normal lymph nodes will atrophy.
In the larynx, specific changes include
infiltration of preepiglottic and paragjottic fat,
thickening of vocal cords and epiglottis, and
mucosal thickening at the glottic commissures
and subglottic region. Cartilage is usually
unaffected by the radiation.

8 Neck

Acknowledgments
We are grateful for the advice of Jonas A. chapter and who have given us permission to Castelijns,
MD PhD and Suresh K. Mukherji, MD incorporate their material, who have helped to organize and
write this