ACS Surgery: Principles and Practice

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1 HEAD AND NECK DIAGNOSTIC PROCEDURES 1

HEAD AND NECK DIAGNOSTIC

PROCEDURES

Adam S. Jacobson, M.D., Mark L. Urken, M.D., F.A.C.S., and Marita S.Teng, M.D.

Head and neck surgery deals with a wide range of pathologic conditions affecting the upper aerodigestive tract and the endocrine
organs of the head and neck. As in other areas of the body, the
causes of these conditions can be inflammatory, infectious, congenital, neoplastic, or traumatic. This chapter discusses the diagnostic approach to head and neck disorders, with particular
attention to cancer.
Anatomic Considerations

The head and neck can be conceptualized by dividing it into

the following segments: (1) nasal cavity and paranasal sinuses, (2)
oral cavity, (3) pharynx, (4) larynx, (5) salivary glands, and (6)
thyroid [see Figure 1].
NASAL CAVITY AND PARANASAL SINUSES

The nasal vault and paranasal sinuses are a complex labyrinth

of interconnected cavities. These cavities are lined with mucous
membranes and are normally well aerated. The nasal vault itself
is divided into two equal halves by the nasal septum. There are
three paired turbinates in the nasal cavity, which further subdivide the nasal vault from cephalad to caudal, creating the superior, middle, and inferior meatuses.
The ethmoid sinus is the most complicated of the paranasal
sinuses; it is also known as the ethmoid labyrinth [see Figure 2].
The maxillary sinus lies within the body of the maxilla and is the
largest of the paranasal sinuses. The frontal sinus lies within the
frontal bone and is divided into two asymmetrical halves by an
intersinus septum. The sphenoid sinus lies posterior to the nasal
cavity and superior to the nasopharynx. It too is an asymmetrically paired structure that is divided by an intersinus septum.The
sphenoid sinus remains the most dangerous sinus to manipulate
surgically because of the surrounding vital structures (i.e., the
carotid artery, the optic nerve, the trigeminal nerve, and the vidian nerve).
Tumors within the nasal vault or the paranasal sinuses present
as nasal airway obstruction, epistaxis, pain, and nasal discharge.
They can originate in any of the paranasal sinuses or the nasal
cavity proper and often remain silent or are mistakenly treated as
an infectious or inflammatory condition, with a consequent delay
in the diagnosis.
ORAL CAVITY

Anatomically, the oral cavity extends from the vermilion border to the junction of the hard and soft palates and the circumvallate papillae. It includes the lips, the buccal mucosa, the upper
and lower alveolar ridges, the retromolar trigones, the oral tongue
(anterior to circumvallate papillae), the hard palate, and the floor
of the mouth.
PHARYNX

The pharynx is a tubular structure extending from the base of

the skull to the esophageal inlet. Superiorly, it opens into the nasal
and oral cavities; inferiorly, it opens into the larynx and the

esophagus. The pharynx is subdivided into the nasopharynx, the

oropharynx, and the hypopharynx.
Nasopharynx
The nasopharynx extends from the posterior choanae to the
inferior surface of the soft palate. Malignancies of the nasopharynx can present as nasal obstruction, epistaxis, tinnitus,
headache, diminished hearing, and facial pain.
Oropharynx
The oropharynx extends from the junction of the hard and soft
palates and the circumvallate papillae to the valleculae. It includes the
soft palate and uvula, the base of the tongue, the pharyngoepiglottic
and glossoepiglottic folds, the palatine arch (which includes the tonsils and the tonsillar fossae and pillars), the valleculae, and the lateral and posterior oropharyngeal walls. Carcinomas of the oropharynx
can present as pain, sore throat, dysphagia, and referred otalgia.
Hypopharynx
The hypopharynx extends from the superior border of the
hyoid bone to the inferior border of the cricoid cartilage. It includes
the pyriform sinuses, the hypopharyngeal walls, and the postcricoid region (i.e., the area of the pharyngoesophageal junction).
Malignancies of the hypopharynx can present as odynophagia,
dysphagia, hoarseness, referred otalgia, and excessive salivation.
LARYNX

The larynx is subdivided into the supraglottis, the glottis, and

the subglottis [see Figure 3]. It consists of a framework of cartilages that are held together by extrinsic and intrinsic musculature
and lined with a mucous membrane that is topographically
arranged into two characteristic folds (the false and true vocal
cords). Neoplasms of the larynx can present as hoarseness, dyspnea, stridor, hemoptysis, odynophagia, dysphagia, and otalgia.
Supraglottis
The supraglottis extends from the tip of the epiglottis to the
junction between respiratory and squamous epithelium on the
floor of the ventricle (the space between the false and true cords).
Carcinomas of the supraglottis can present as sore throat,
odynophagia, dysphagia, and otalgia.
Glottis
The space between the free margin of the true vocal cords is
the glottis.This structure is bounded by the anterior commissure,
the true vocal cords, and the posterior commissure. The most
common symptom of carcinoma of the glottis is hoarseness.
Subglottis
The subglottis extends from the junction of squamous and respiratory epithelium on the undersurface of the true vocal cords
(approximately 5 to 10 mm below the true vocal cords) to the
inferior edge of the cricoid cartilage. The most common symptom of carcinoma of the subglottis is hoarseness.

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Sphenoidal Sinus

Superior Sagittal Sinus

Concha Suprema
Frontal Sinus
Superior Concha
Falx Cerebri
Middle Concha
Pharyngeal Orifice
of Auditory Tube
Inferior Concha

Straight Sinus
Oral Part
of Tongue
Sublingual Fold
Pharyngeal Recess
Pharyngeal Part
of Tongue
Salpingopharyngeal Fold
Palatine Tonsil

Epiglottis
Hyoid Bone

Oral Part of Pharynx

Laryngeal Part
of Pharynx
Vocal Fold
Thyroid Cartilage

Figure 1 The anatomic structures of

the head and neck are shown.

Esophagus

SALIVARY GLANDS

Clinical Evaluation

Salivary glands are subdivided into major and minor salivary

glands.The major salivary glands consist of the parotid glands, the
submandibular glands, and the sublingual glands. The minor salivary glands are dispersed throughout the submucosa of the upper
aerodigestive tract. Classically, benign neoplasms present as painless, slow-growing masses. A sudden increase in size is usually the
result of infection, cystic degeneration, hemorrhage into the mass,
or malignant transformation. Malignant neoplasms also usually
present as a painless swelling or mass. However, certain features
are strongly suspicious for a malignancy, such as overlying skin
involvement, fixation of the mass to the underlying structures,
pain, facial nerve paralysis, ipsilateral weakness or numbness of the
tongue, and cervical lymphadenopathy.

The diagnostic approach to the upper aerodigestive tract begins

with a thorough history, starting with a detailed evaluation of the
chief complaint. Once the chief complaint has been defined (e.g.,
neck mass, hoarseness, hemoptysis, or nasal obstruction), it must be
further characterized. The physician must determine how long the
problem has been present and whether the patient has any associated symptoms (e.g., pain, paresthesias, discharge, change in voice,
dyspnea, hemoptysis). In addition, it is important to ask about recent infection (e.g., of the ear, mouth, teeth, or lungs) and previous
medical treatment. Once a complete history of the chief complaint
has been obtained, the physician should elicit a more comprehensive general medical history from the patient, including pertinent
past medical history, past surgical history, medications, allergies,
social history (tobacco, ethanol, I.V. drug use), and family history.
After completion of the history, the next step is to perform a
comprehensive physical examination. This begins with a thorough inspection of the entire surface of the head and neck, with
a focus on gross lesions, areas that are topographically abnormal, and old scars from previous injuries or procedures. The
examination should proceed in an orderly fashion from superior to inferior. Next, the inspection focuses on the mucosal surfaces of the upper aerodigestive tract.
Although an accurate history and careful physical examination of
the head, neck, and mucosal surfaces are the most important steps
in evaluating a lesion in this part of the body, this clinical evaluation

THYROID

The thyroid gland performs a vital role in regulating metabolic function. It is susceptible to benign conditions (e.g., nodule,
goiter, and cyst), inflammatory disease (e.g., thyroiditis), and malignancies. Additionally, congenital anomalies of the thyroid, such
as a thyroglossal duct cyst, can present later in life.Thyroid lesions
can present as pain, hoarseness, dyspnea, or dysphagia.
On the posterior aspect of the thyroid gland reside the four
parathyroid glands. These glands play a vital role in maintaining
calcium balance. Parathyroid adenomas and, rarely, carcinomas
can develop.

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Frontal Sinus

Ethmoid Sinuses

Ostium

Turbinate
Bones

Maxillary
Sinus

Nasal
Airway

usually provides only a working diagnosis.The head and neck surgeon must then proceed in a stepwise fashion to further clarify the
diagnosis and, in the case of neoplasm, to perform an accurate staging.
Radiographic techniques allow the head and neck surgeon to visualize the mass and determine its characteristics (i.e., to differentiate between solid and cystic lesions), as well as determine its
anatomic associations. Ultrasonography, magnetic resonance imaging, and computed tomography each provides a unique view of the
pathology in question and thereby helps narrow the differential diagnosis. Acquisition of a tissue specimen for cytologic or histologic
analysis, or both, is the next step. Fine-needle aspiration (FNA) is
often utilized at this stage in the workup, provided that the location
of the mass lends itself to a safe procedure. If the lesion is located
deep in the neck near vital structures, image-guided FNA can be attempted before resorting to an open biopsy. If the lesion is on a mucosal surface of the upper aerodigestive tract, an endoscopic biopsy
is performed. Often, a panendoscopic procedure is performed at
this point to accurately map the lesion, obtain a tissue specimen,
and, in patients with cancer, assess the rest of the upper aerodigestive tract for a synchronous primary tumor.
After a histologic diagnosis has been made and correlated with
the imaging information, the patient and physician can have a comprehensive discussion of the pathology, the stage of the disease, and
the selection of therapy.
Nasal Diagnostic Procedures
ANTERIOR RHINOSCOPY

Using a variety of different light sources that provide both illumination and coaxial vision, the head and neck surgeon can view
the nasal vault through a nasal speculum [see Figure 4].This technique is performed both before and after nasal decongestion, with
particular attention to mucosal color, edema, and discharge and
the effect of vasoconstriction. Limited visualization of the nasal
septum, the turbinates, and the vault is also possible with this
technique.
RIGID NASAL ENDOSCOPY

The rigid nasal endoscope comes with a variety of lens angles (0,

Figure 2 The paranasal

sinuses are shown.

60, and 90), which allow for visualization of structures that are inaccessible by simple anterior rhinoscopy. Rigid nasal endoscopy is
especially useful for visualizing deeper structures and structures that
are not in a straight axis from the nasal aperture.
Indirect Laryngoscopy

Indirect laryngoscopy has been used since the 1800s for visualizing the pharynx and larynx. In this technique, the head light source
illuminates the mirror, which in turn illuminates the laryngopharynx [see Figure 5].The patient is seated in the sniffing position and
protrudes the tongue while a warmed laryngeal mirror is introduced firmly against the soft palate in the midline to elevate the
uvula out of the field (gently, so as not to elicit the gag reflex).The
image seen on the mirror can be used to assess vocal cord mobility,
as well as to inspect for a mass or foreign body of the larynx or pharynx.This technique can be performed rapidly and is inexpensive.
Endoscopic Procedures

Endoscopic evaluation of the upper aerodigestive tract is crucial in establishing a definitive diagnosis. The equipment used
consists of both rigid and flexible laryngoscopes, bronchoscopes,
and esophagoscopes. Many of these techniques can be performed
in the office setting, providing the surgeon with an array of methods for gaining the information necessary for a working diagnosis
and, in some cases, for performing a therapeutic intervention.
Operative endoscopy is performed to obtain a definitive diagnosis, to stage tumors, and to rule out synchronous lesions.There is
no substitute for thorough examination and biopsy of a lesion
with the patient under general anesthesia. Regardless of the endoscopic method used, an adequate biopsy specimen must be
obtained for a histologic diagnosis.
FLEXIBLE RHINOLARYNGOSCOPY

Flexible rhinolaryngoscopy is currently one of the most commonly used techniques for visualizing the nasal cavity, the sinuses, the pharynx, and the larynx. The technique utilizes a smallcaliber flexible endoscope and can be performed in an office setting [see Figure 6]. Before the procedure, the patients nasal cavity

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Epiglottis

ESOPHAGOSCOPY

Esophagoscopy plays an important role in the evaluation of

patients with dysphagia, odynophagia, caustic ingestion, trauma,
ingested foreign bodies, suspected anomalies, and upper aerodigestive tract malignancies. This procedure may be performed
with either a flexible or a rigid scope.

Vestibule of
the Larynx

Hyoid
Bone

Vestibular
Fold

Vocal
Fold
Thyroid
Cartilage

Vocal
Muscle

Infraglottic
Space

Cricoid
Cartilage

Trachea

Figure 3

Cross-sectional anatomy of the larynx is shown.

is decongested and anesthetized for maximum visualization and

minimal discomfort. In the procedure, the examiner threads the
end of the scope into the nasal aperture along the floor of the
nasal cavity. As the scope is advanced, the examiner can visualize
the nasal cavity proper for any evidence of lesions or masses.
Once the scope approaches the nasopharynx, it is directed inferiorly and advanced slowly, allowing direct visualization of the
entire pharynx and larynx.

Flexible Esophagoscopy
The primary application for flexible esophagoscopy is diagnosis. The procedure is particularly useful in elderly patients with
limited spinal mobility and in patients with short, thick necks.
The flexible esophagoscope is used with local anesthesia and
sedation in a monitored setting.To facilitate control of secretions
and the passage of the instrument, the patient is placed in a flexed
position and lying on one side. Using insufflation, the surgeon
visualizes and enters the cricopharyngeus and carries out a safe
and detailed visual study of the esophagus. If a malignancy is suspected, either a brush specimen is sent for cytology or a cup forceps is used to acquire a specimen for histologic analysis.
Rigid Esophagoscopy
Rigid esophagoscopy can be used to treat a variety of problems,
including foreign bodies, hemorrhage (e.g., from esophageal
varices), and endobronchial tumors. Rigid esophagoscopes [see Figure 8] are used with the patient under general anesthesia.The patient is placed in the supine position with the neck extended. The
esophagoscope is then passed along the right side of the tongue,
with the endoscopist using the left hand to cradle the instrument.
The right hand is used for stabilization of the proximal end of the
scope, suctioning, and insertion of instruments through the lumen
of the esophagoscope. The lip of the esophagoscope is positioned
anteriorly for manipulation of the epiglottis and visualization of the
pyriform sinus and the arytenoids.The scope is then passed along
the pyriform sinus into the cricopharyngeus (i.e., the superior
esophageal valve). The left thumb is then used to advance the instrument down the esophagus. If no major lesions are noted on insertion of the esophagoscope, a careful inspection of the mucosa
should be made during withdrawal of the instrument.

DIRECT LARYNGOSCOPY

Direct laryngoscopy has the advantage of permitting both diagnostic and therapeutic intervention [see Figure 7]. It is performed
with the patient under general anesthesia and intubated.The procedure allows for direct visualization of the pharynx and the larynx
and permits the surgeon to perform biopsies and remove small lesions. At the same time, the surgeon has the opportunity to palpate
the structures of the oral cavity, the oropharynx, and the hypopharynx, which cannot be properly palpated in an awake patient.
The laryngoscope can also be suspended from a table-mounted Mayo stand (for hands-free use), and a microscope can be
maneuvered into focal distance to allow magnified visualization of
the glottis and subglottis. During a microscopic direct laryngoscopy, small lesions or topographic abnormalities can be better
characterized and removed if desired. Some examples of lesions
that can be diagnosed by direct laryngoscopy are vocal cord
polyps, leukoplakia, intubation granulomas, contact ulcers, webs,
nodules, hematomas, and papillomatosis. Additionally, small
malignant lesions of the vocal cords can be examined and ablated or extirpated by using a CO2 laser under direct microlaryngoscopic guidance.

Figure 4

Shown is an assortment of nasal specula.

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Figure 5 Shown is a laryngeal mirror.

Such an instrument is used for indirect
laryngoscopy.
BRONCHOSCOPY

Bronchoscopy provides clinically useful information by direct

inspection of the tracheobronchial tree. Like esophagoscopes,
bronchoscopes come in both flexible and rigid forms. The flexible bronchoscope is used primarily for diagnosis.The value of the
rigid bronchoscope lies in its therapeutic applications, which
include foreign-body removal, removal of bulky tumors, introduction of radioactive materials, and placement of stents.
Flexible Bronchoscopy
The flexible fiberoptic bronchoscope is usually used with local
anesthesia and sedation in a monitored setting (e.g., an operating
suite). After local anesthesia and decongestion of the nasal vault
with topical tetracaine and 1% phenylephrine, the flexible scope is
gently passed along the nasal floor into the nasopharynx, where
the tip of the scope is angled inferiorly to permit visualization of
the pharynx.The instrument is then advanced slowly into the glottis (between the true vocal folds) and into the tracheobronchial
tree. After a visual inspection of the airway has been completed, a
specimen can be retrieved by means of brush biopsy, bronchoalveolar lavage, or a biopsy forceps.
Rigid Bronchoscopy
Rigid bronchoscopy [see Figure 9] is performed with the patient
under general anesthesia. The patient is placed in the supine position with the neck hyperextended. The bronchoscope is then
passed along the right side of the tongue, with the endoscopist
using the left hand to cradle the instrument.The instrument is initially held almost vertically until it reaches the posterior pharyngeal
wall, at which point it is slowly guided into a more horizontal position.While advancing the scope, the endoscopist cradles the instrument with the fingers of the left hand, providing guidance and protecting the patients lips and teeth. Once the tip of the epiglottis is

Figure 6 A small-caliber flexible laryngoscope is used for rhinolaryngoscopy.

visualized, the instrument is threaded anteriorly to allow visualization of the glottis. The bronchoscope is then passed between the
vocal cords and into the trachea. At this point, ventilation may be
resumed either by positive pressure or by jet ventilation techniques
(ventilating bronchoscopes have a side port for attachment of the
tubing from the ventilator).The patients head is manipulated with
the endoscopists right hand so as to direct the tip of the bronchoscope and permit bilateral exploration of the major airways.
PANENDOSCOPY

The term panendoscopy refers to the combination of direct

laryngoscopy (with or without microscopic assistance), esophagoscopy, and bronchoscopy. Together, these three procedures
provide a complete examination of the entire upper aerodigestive
tract. In cancer patients, this combination of procedures allows
the examiner to create a detailed map of the tumor, as well as to
rule out synchronous primary tumors.
Biopsy Procedures
FINE-NEEDLE ASPIRATION

FNA is often used to make an initial tissue diagnosis of a neck

mass. The advantages of this technique include high sensitivity
and specificity; however, 5% to 17% of FNAs are nondiagnostic.
Another advantage of FNA is speed: If a cytologist or a pathologist is available, diagnosis can often be made within minutes of
the biopsy.
FNA is performed with a 10 ml syringe with an attached 21to 25-gauge needle. Larger needles are more likely to result in
tumor seeding.The patient is positioned to allow for optimal palpation of the mass. The skin overlying the mass is prepared with
a sterile alcohol prep sponge. Local anesthesia is not necessary.
The mass is grasped and held in a fixed and stable position. The
needle is introduced just under the skin surface. As the needle is
advanced, the plunger of the syringe is pulled back, to create suction. Once the mass is entered, multiple passes are made without
exiting the skin surface; this maneuver is critical in maximizing
specimen yield. After the final pass is completed, the suction on
the syringe is released and the needle withdrawn from the skin. If
a cyst is encountered, it should be completely evacuated and the
fluid sent for cytologic analysis.
A drop of aspirated fluid is placed on a glass slide. A smear is
made by laying another glass slide on top of the drop of fluid and
pulling the slides apart to spread the fluid. Fixative spray is then
applied. Alternatively, wet smears are placed in 95% ethyl alcohol
and treated with the Papanicolaou technique and stains.
FNA has several advantages over excisional biopsy. An FNA
requires only an office visit, with minimal loss of time from work
for the patient. In contrast, excisional biopsy is commonly performed in an operating room, so the patient must undergo preoperative testing. Patients with a significant medical history may
require formal medical clearance. An excisional biopsy exposes
the patient to the risks of anesthesia, postoperative wound infection, and tumor seeding.

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Figure 7

Shown are (a) normal vocal folds directly visualized via (b) a rigid laryngoscope.

ULTRASOUND-GUIDED FNA

Ultrasonographic guidance of FNA enables the surgeon to obtain a cytologic specimen of deeper or nonpalpable masses that are
not amenable to standard FNA. Real-time imaging of the needles
passage allows the surgeon to plot a more accurate trajectory and
avoid underlying vital structures. Furthermore, it provides an image
of the mass, allowing its characterization as solid, cystic, or heterogeneous.With cystic or complex masses, it is imperative to place the
tip of the needle into the wall to increase specimen yield.

neck. Palpable masses in the neck [see 2:3 Neck Mass] can be
assessed for changes in size, for association with other local structures, and for character (i.e., solid, cystic, or complex). Applications of ultrasonography include assessment of masses such as
thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, salivary gland tumors, abscesses, carotid body tumors, vascular
tumors, and thyroid masses. Additionally, ultrasonography combined with FNA and cytologic evaluation can provide both a
detailed visual description and an accurate cytologic evaluation of
masses in the neck [see Ultrasound-Guided FNA, above].

CT-GUIDED FNA

CT-guided FNA is most commonly employed to diagnose poorly accessible or deep-seated lesions of the head and neck. Like ultrasound-guided FNA, CT-guided FNA provides visualization of the
needle as it is passed through the tissue and into the underlying
structures, thus allowing a more accurate needle trajectory and
avoidance of underlying vital structures. Additionally, visual guidance of the needle greatly increases the likelihood of obtaining a
specimen from the mass rather than the surrounding tissues.
Imaging Procedures

Because many of the deep structures of the head and neck are
inaccessible to either direct evaluation by palpation or indirect
evaluation via endoscopy, further information must be obtained
by radiography. Imaging procedures such as CT, MRI, ultrasound, and positron emission tomography (PET) scanning permit the diagnosis and analysis of pathologic conditions affecting
these deep structures, including the temporal bone, skull base,
paranasal sinuses, soft tissues of the neck, and larynx.
ULTRASONOGRAPHY

Ultrasonography is a safe and inexpensive method of gaining

high-resolution real-time images of the structures of the head and

Figure 8

Shown is a rigid endoscope.

COMPUTED TOMOGRAPHY

A CT scan with intravenous contrast is often the first-line

imaging technique used to evaluate a mass of the neck and to assess for pathologic adenopathy. CT has proved to be an effective
method for primary staging of tumors and lymph nodes. Additionally, it has been shown to be effective in studying capsular penetration and extranodal extension. It is clearly superior to MRI in
evaluating bone cortex erosion, given that MRI cannot assess
bone cortex status at all. CT scans are also widely used for posttreatment surveillance in cancer patients.
MAGNETIC RESONANCE IMAGING

MRI avoids exposing the patient to radiation and provides the

investigator with superior definition of soft tissue. For example,
MRI can differentiate mucous membrane from tumor, as well as
detect neoplastic invasion of bone marrow. In patients with nasal
cavity tumors, MRI can distinguish between neoplastic, inflammatory, and obstructive processes. MRI is also valuable in assessing the superior extent of metastatic cervical lymphadenopathy
(i.e., intracranial extension). A disadvantage of MRI is its limited
ability to show bone detail; it therefore cannot detect invasion of
bone cortex by a neoplasm. Furthermore, an MRI scan is significantly more expensive than a CT scan.

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Figure 9 (a) Rigid bronchoscopes incorporate stainless-steel tubes of varying length and
diameter. The beveled distal end of this Hopkins bronchoscope facilitates mobilization of the
epiglottis during intubation; the side ports permit ventilation and use of suction catheters.
(b) Illumination is provided by fiberoptic rods that are inserted into the bronchoscope.
POSITRON EMISSION TOMOGRAPHY

PET scanning is a functional imaging technique that measures

tissue metabolic activity through the use of radioisotopically
tagged cellular building blocks, such as glucose precursors. A
range of physiologic tracers has been developed for PET imaging, with the glucose analogue 2-deoxy-2-[(18)F]fluoro-D-glucose (FDG) the most commonly used. FDG has a half-life of 110
minutes. Once given to the patient, FDG is taken up by glucose
transporters and is phosphorylated by hexokinase to become
FDG-6-phosphate (FDG-6-P). Further metabolism of FDG-6P is blocked by the presence of an extra hydroxyl moiety, which
allows FDG-6-P to accumulate in the cell and serve as a marker
for glucose metabolism and utilization.
Because neoplastic cells have higher rates of glycolysis, localized
areas of increased cellular activity on PET scans may represent neoplastic tissue. In this respect, PET is very different from CT and MRI,
which depict tissue structure rather than tissue metabolic activity.
Because FDG is nonspecifically accumulated in glycolytically
active cells, it demarcates areas of inflammation as well as neoplastic tissue, which can lead to a false positive scan. Muscular
activity during the scan can also lead to areas of increased uptake
in nonneoplastic tissue. Furthermore, healing bone, foreign body
granulomas, and paranasal sinus inflammation can produce false
positive results.

False negative scans occur when tumor deposits are very small
(i.e., 3 to 4 mm or less in diameter). Thus, micrometastases are
not reliably detected using an FDG-PET image. Furthermore, a
false negative scan can occur if the PET scan is performed too
soon after radiation therapy.
The role of PET imaging in head and neck oncology is rapidly expanding. Currently, the majority of PET imaging used in
head and neck oncology is FDG based. FDG-PET is actively
being used to look for unknown primary lesions and second primaries, to stage disease before therapy, to detect residual or
recurrent disease after surgery or radiation therapy, to assess the
response to organ preservation therapy, and to detect distant
metastases. Because false positive and false negative PET scans
do occur, accurate interpretation of PET scans requires a thorough understanding of the potential confounding factors.
PET/CT

PET/CT is essentially an FDG-PET scan that has been coregistered with a simultaneous CT scan to allow the radiologist to
precisely correlate the area of increased cellular activity with the
anatomic structure. This technique removes some of the guesswork involved with interpreting an area of increased activity on a
simple PET scan and provides the physician with a morphologic
correlate for the area of increased uptake.

Recommended Reading
AJCC Cancer Staging Manual, 5th ed. Lippincott
Raven, Philadelphia, 1997

Cummings C: Otolaryngology Head and Neck

Surgery, 3rd ed. Mosby Year Book St. Louis, 1998

Bailey B: Head and Neck Surgery Otolaryngology,

3rd ed. Lippincott Williams & Wilkins, Philadelphia,
2001

Som P: Head and Neck Imaging, 4th ed. Mosby, St.

Louis, 2003
Surveillance Epidemiology and End Results. National

Cancer Institute, National Institutes of Health, 2004.

http://seer.cancer.gov/

Acknowledgments
Figure 1 Tom Moore.
Figures 2 and 3 Alice Y. Chen.