Otolaryngol Clin N Am 41 (2008) 77101

Imaging of the Parapharyngeal Space

Hilda E. Stambuk, MDa,b,*, Snehal G. Patel, MDb,c
a

Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA b Weill Cornell Medical College, New York, NY, USA c Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA

The parapharyngeal space (PPS) is a fascial space of the suprahyoid neck that largely contains fat and is surrounded by several other important fascial spaces. Surgeons may be familiar with the older nomenclature of the prestyloid and post-styloid parapharyngeal spaces. The post-styloid compartment of the PPS is now designated as the carotid space, whereas the prestyloid compartment is now considered the true PPS. The presence of fat in the PPS allows the radiologist to identify displacement patterns of the PPS and to use a logical algorithm in identifying the anatomic origin of tumors in this region. A clear understanding of spatial anatomy is essential for accurate diagnosis and appropriate treatment of pathology arising from this region. This article covers the basic anatomy of the PPS and surrounding spaces to describe the spatial approach to the dierential diagnosis of lesions in this area. Other spaces in the suprahyoid neck, including the retropharyngeal space, the perivertebral space, and the posterior cervical space, are not discussed. Boxes and gures are used to list and illustrate some common conditions in the dierential diagnosis pertaining to each space but the reader is referred elsewhere for a more detailed discussion of pathology [1,2].

Spatial approach to dierential diagnosis The PPS is an inverted cone-shaped space that extends from the skull base to the level of the hyoid bone on either side of the pharynx (Fig. 1).

* Corresponding author. Department of Radiology C-278, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021. E-mail address: stambukh@mskcc.org (H.E. Stambuk). 0030-6665/08/$ - see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.10.012

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Fig. 1. The PPS is an inverted cone-shaped space that extends from the skull base to the hyoid bone. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.)

The anatomic boundaries of the PPS are listed in Box 1. The PPS is surrounded by other spaces that are bound by the supercial (investing), middle (buccopharyngeal), and deep (prevertebral) layers of the deep cervical fascia. The reader is referred to other sources for detailed anatomy of the facial layers [3,4]. An understanding of the fascial anatomy and spaces of the neck allows a logical approach to dierential diagnosis of lesions arising from the PPS or surrounding spaces. The carotid space is actually the designation given to the previously named post-styloid space and is separated from the prestyloid space, or PPS, by the tensor-vascular-styloid fascia overlying the tensor veli palatini muscle (Fig. 2). Unlike squamous cell carcinoma (SCC) that is locally inltrative and tends to spread across fascial boundaries in the neck, other tumors tend to be limited in local extent by fascial compartments. The PPS is centrally located in relation to surrounding spaces that are enclosed by the layers of the deep cervical fascia (Fig. 3). The PPS is a relatively rare site of primary pathology but its signicance is that it predominantly contains fat and therefore has a distinct appearance on CT and MRI. The displacement pattern of the PPS fat is an excellent indicator of the possible space of origin of a lesion (Fig. 4) and helps limit the dierential

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Box 1. Anatomic boundaries of the parapharyngeal space Superior Temporal bone lateral to the attachment of the pharyngobasilar fascia and medial to the foramen ovale and foramen spinosum. Note that none of the skull base foramina are included within the boundaries of the PPS. Inferior The greater cornu of the hyoid bone and the posterior belly of the digastric muscle. The PPS blends into the posterior aspect of the submandibular space at this level. Medial The buccopharyngeal fascia that covers the pharyngobasilar fascia and constrictor muscles. Lateral The fascia overlying the pterygoid muscles and the sphenomandibular ligament. The parotid space communicates with the PPS laterally through the stylomandibular tunnel. This tunnel is enclosed by the stylomandibular ligament which extends from the styloid process to the angle of the mandible, the ascending ramus, and the skull base. Anterior The pterygomandibular raphe that extends from the hamulus of the medial pterygoid plate to the posterior aspect of the mylohyoid line on the lingual surface of the mandible. Posterior The tensor-vascular-styloid fascia overlying the tensor veli palatini muscle from the medial pterygoid plate to the styloid process.

diagnosis based on the contents of that space. For example, a tumor arising from the deep lobe of the parotid gland grows medially and thus displaces the adjacent PPS fat anteromedially (see Fig. 4C). The displacement patterns typical of each space along with some common lesions are described under separate sections.

The pharyngeal mucosal space The pharyngeal mucosal space (PMS) is the nasopharyngeal and oropharyngeal mucosal lining on the luminal side of the middle layer of the deep

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Fig. 2. The prestyloid parapharyngeal space (now designated PPS) is separated from the poststyloid parapharyngeal space (now designated CS) by the tensor-vascular-styloid fascia (white line) that overlies the tensor veli palatini muscle and extends medially toward the pharynx from the styloid process (S). (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.)

Fig. 3. The PPS contains fat and is surrounded by several fascial-bound spaces. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.)

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Fig. 4. Displacement patterns of PPS fat from tumors of the (A) pharyngeal mucosal space (PMS), (B) masticator space (MS), (C) parotid space (PS), (D) carotid space (CS). (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.)

cervical fascia. It is lined on the outside by the pharyngeal constrictor muscles and on the inside by squamous mucosa. The space contains minor salivary glands and lymphoid tissue of the Waldeyer ring. Since the PMS is lined by squamous mucosa, squamous cell carcinoma (SCC) is the most common tumor but other tumors, such as minor salivary gland tumors, lymphoma (Fig. 5), and sarcoma, can also occur.

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Fig. 5. (A) Precontrast T1-weighted magnetic resonance image (T1WI) shows lymphoma (M) involving the left PPS. The lesion presents as a homogeneous lesion that is isointense to muscle. The lesion arises from the PMS as evidenced by the absence of a fat plane between the lesion and the PMS. (B) The lesion is hyperintense on T2-weighted magnetic resonance image (T2WI) making it easier to delineate from adjacent normal soft tissue.

Tumors of the PMS are based on the mucosa or wall of the space with no clear delineating plane between it and the tumor. They may inltrate the PPS diusely and replace it (Fig. 6). Alternatively, with benign or less aggressive tumors the PPS fat is displaced posteriorly and laterally (Fig. 7). The masticator space The masticator space (MS) is enclosed by the split layers of the supercial layer of the deep cervical fascia and extends from the skull base to the

Fig. 6. SCC of the left base of tongue (T) that extends into and inltrates the adjacent PPS fat. SCC does not respect fascial boundaries in the neck and inltrates across compartments.

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Fig. 7. (A) Displacement of PPS fat by a tumor of the PMS. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.) (B) Precontrast axial T1WI of a patient who has a tumor (T) of the right tonsil that displaces the PPS fat posterolaterally (arrow).

inferior border of the mandible. It contains the ascending ramus, the posterior body of the mandible, and the muscles of mastication (masseter, medial and lateral pterygoids, and temporalis), the motor and sensory branches of mandibular branch of the trigeminal nerve (V3), and the inferior alveolar artery and vein. The MS extends superolaterally along the lateral surface of the temporalis muscle, divided by the zygoma into supra and infrazygomatic portions (Fig. 8). Anteriorly it is continuous with the buccal space where there is no discrete fascial boundary so that disease processes have free access from one space to the other. The PPS is located posteromedial to the MS so that lesions of the MS tend to displace the PPS fat posteromedially (Fig. 9). Infectious or inammatory lesions are the most common lesions arising within the MS (Box 2). If imaging is required for evaluation of infectious or inammatory lesions of the MS, CT should be the initial modality of choice because inammation, abscess, dental infection, and osteomyelitis are more easily identied on CT compared with MRI. Malignant tumors of adjoining mucosal sites, such as the oral cavity, oropharynx, or maxillary sinus, not infrequently invade the muscles of the MS causing trismus. Lymphoma is an exception to this rule since trismus may not occur despite gross inltration of the MS (Fig. 10). Radiologic imaging may be able to identify early inltration of the MS before the onset of trismus. Tumor invasion of the MS places the branches of V3 at risk for perineural spread, which is a particular feature with some tumors, such as adenoid cystic carcinoma. Perineural spread can occur contiguous to the primary tumor mass or as skip areas and can occur in retrograde and

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Fig. 8. Coronal T1WI demonstrates the normal anatomy of the MS. Note that the space extends from the superior attachment of temporalis muscle (upper white arrow) to the inferior border of the mandible (lower white arrow). The MS is divided into suprazygomatic and infrazygomatic compartments by the zygoma (white arrowhead). The contents of the MS include the mandible (*) which is anked on either side by the muscles of mastication: T, temporalis; M, masseter; LP, lateral pterygoid muscle; MP, medial pterygoid muscle.

antegrade directions along the nerve at risk. Radiologic ndings with early perineural spread may be minimal, and conclusive diagnosis requires both abnormal enlargement and enhancement of the nerve (Fig. 11). Perineural spread may not always be readily apparent and it is helpful for the radiologist to look for certain indirect signs, such as an enlarged foramen ovale (Fig. 12), abnormal soft tissue in the Meckels cave, and denervation atrophy of the masticatory muscles. MRI is superior to CT for the evaluation of perineural spread (see article by Drs. Ahmad and Branstetter, elsewhere in this issue). Primary tumors of the MS are rare in adults but a solid tumor in the MS in a child should prompt the diagnosis of rhabdomyosarcoma until proven otherwise. Although these tumors can be restricted to the MS, extension across fascial compartments can occur with destruction of the mandible or erosion of the skull base (Fig. 13). The parotid space The supercial layer of the deep cervical fascia splits to enclose the parotid space (PS), which is located posterolateral to the PPS. In addition to the parotid gland, the PS contains the facial nerve that divides the parotid into a supercial and deep lobe. Since the parotid gland is encapsulated late

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Fig. 9. (A) Lesions originating in the MS tend to displace the fat of the PPS in a posteromedial direction. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.) (B) Axial precontrast CT scan shows a soft tissue mass originating from the ascending ramus of the left mandible with extraosseous extension into the pterygoid muscles. The fat in the left PPS is displaced posteromedially by the MS mass. (C) Bone window of axial CT scan shows sunburst-like periosteal new bone formation which is classically found in osteosarcoma.

in embryonic development, it contains intraparenchymal lymph nodes. Common lesions of the PS are listed in Box 3. As might be expected, the most common lesions in the PS arise from the parotid gland. Since the majority of the parotid gland parenchyma is located supercial to the plane of the facial nerve, lesions arise more commonly from the supercial lobe of the parotid compared with the deep lobe. This

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Box 2. Common lesions of the masticator space Inammatory/infectious Odontogenic infection: cellulitis, abscess Myositis Congenital/developmental Hemangioma Venolymphatic malformation Neoplastic Benign tumor of muscle or bone Rhabdomyosarcoma Osteosarcoma Nerve sheath tumor Non-Hodgkin lymphoma Deep extension of mucosal carcinoma Metastatic disease distinction is helpful in surgical planning, but imaging is generally not able to delineate the normal facial nerve. However, the plane of the facial nerve can be estimated by identifying the retromandibular vein on imaging since the nerve lies lateral to the vein after exiting the stylomastoid foramen.

Fig. 10. (A) Inltrative lesion of the right MS that had inltrated the pterygoid muscles on imaging but had not produced trismus. (B) The lesion was accessed by transfacial CT-guided FNA, which conrmed the diagnosis of lymphoma.

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Fig. 11. Coronal postcontrast T1WI shows abnormal enlargement and enhancement of left V3 (*) from foramen ovale at the skull base into the MS. These features are consistent with perineural spread of tumor in this patient who had a history of melanoma.

If a lesion of the PS comes into relation to the PPS, such as a tumor of the deep lobe of the parotid gland, it displaces the PPS fat anteromedially (Fig. 14). The most common deep lobe parotid lesion is a pleomorphic adenoma or benign mixed tumor. Unlike most solitary well-dened lesions

Fig. 12. Bone window of axial CT of the skull base in the patient shown in Fig. 11 demonstrates widening of the left foramen ovale (arrowheads) compared with the normal right side (*). Nerves involved by perineural spread tend to cause uniform enlargement of the bony canal or foramen without osseous destruction as demonstrated in this case.

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Fig. 13. (A) Axial CT scan of a patient who has rhabdomyosarcoma shows a large, multicompartmental soft tissue mass occupying the right MS. The mass (M) inltrates the pterygoid muscles, surrounding fat, including the PPS, with extension into the right maxillary sinus (S), nasal cavity, nasopharynx, and destruction of the pterygoid plates (arrow). Note the normal fat in the contralateral PPS that is labeled for comparison. (B) There is destruction of the skull base (arrows) with extension of tumor into the right sphenoid sinus and the right cavernous sinus (*). On MRI, rhabdomyosarcomas are generally isointense to muscle on T1WI, of intermediate signal on T2WI, and are generally homogenous on postcontrast images, but can have variable enhancement depending on the extent of necrosis.

of the parotid, this tumor classically is intensely T2-bright matching the intensity of cerebrospinal uid (CSF) (Fig. 15). MRI is therefore the preferred modality to evaluate the parotid bed for recurrent lesions after surgical excision of benign mixed tumor (Fig. 16). This is not a consistent, nor an exclusive, characteristic of pleomorphic adenomas, however, because other tumors, such as lymphangioma/hemangioma (Fig. 17), lymphoepithelial cysts, and occasionally mucoepidermoid carcinoma (Fig. 18) can also be hyperintense on T2-weighted MRI. Malignant tumors of the deep lobe of the parotid gland are uncommon and are dicult to dierentiate from the more common benign lesions in the absence of certain features, such as extraparenchymal extension, perineural invasion, regional lymph node metastases, skull base erosion (Fig. 19), or distant metastases.

The parapharyngeal space The PPS is an inverted, cone-shaped, fat-lled space that is surrounded by several fascia-dened spaces (see Figs. 3 and 4). Adipose tissue is the primary content of the PPS. Other contents include arteries, veins, and minor salivary gland rests. Primary lesions of the PPS are therefore rare, although lipoma or minor salivary gland tumors can occur. Small lesions arising from the PPS are recognizable by the presence of fat around their periphery rather

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Box 3. Common lesions of the parotid space Neoplastic Pleomorphic adenoma Warthin tumor Lipoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Acinic cell carcinoma Carcinoma ex pleomorphic adenoma Squamous cell carcinoma Extranodal or nodal non-Hodgkin lymphoma Nodal metastases, commonly skin cancers of the face and scalp. Inammatory/infectious Parotitis/parotid abscess Reactive lymphadenopathy Lymphoepithelial cysts/lesions Congenital/developmental Hemangioma Venolymphatic malformation First branchial cleft cyst

than displacement of the fat. Most lesions arising from the PPS itself are benign and therefore well-dened. Malignant tumors can occasionally arise from the minor salivary gland rests and are also generally well-dened so that dierential diagnosis from benign tumors is not possible on imaging (Fig. 20). An ill-dened lesion of the PPS, however, should raise suspicion for malignancy. Conversely, tumors from the surrounding spaces more commonly aect the PPS and cause eccentric displacement of the PPS fat. Some malignant tumors, such as low-grade salivary tumors, can also displace fat making dierential diagnosis dicult, but obvious inltration of the PPS fat is a reliable indicator of malignancy. Most malignant tumors that invade the PPS are squamous cell carcinomas of PMS (see Fig. 6) or lymph node origin (Fig. 21), but occasionally lymphomas of the PMS or PS can also be inltrative (see Fig. 5).

The carotid space The carotid space (CS) is contained by the carotid sheath and is formed from all three layers of the deep cervical fascia. It spans the entire neck and extends from the skull base to the aortic arch. The suprahyoid portion of the

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Fig. 14. (A) A lesion of the PS displaces the PPS fat in an anteromedial direction. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.) (B) Anteromedial displacement of the PPS fat (arrow) on this axial T1WI from a tumor (T) of the deep lobe of the left parotid gland (P). (C) The tumor is intermediate signal on T2WI and (D) the tumor enhances homogeneously on the post-contrast T1W fat-saturated sequence. Histopathology of the resected deep lobe parotid tumor was low-grade myoepithelial carcinoma.

CS is anatomically related to the PPS and is located posterior to it (see Fig. 3). The CS communicates with the carotid canal and jugular foramen superiorly at the skull base and contains the carotid artery, internal jugular vein, cranial nerves IX through XII, and the sympathetic chain. Cranial nerve X lies posterior and lateral to the carotid artery, whereas the sympathetic chain lies posterior and medial to the artery. The anatomic relationships of the contents of the CS to each other are often helpful in discerning the precise anatomic origin of tumors within this space. Vascular

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Fig. 15. (A) Axial T1WI shows a well-dened hypointense lesion (T) arising from the deep lobe of the left parotid gland. The tumor is distinct from the normal surrounding fatty parotid tissue (P). (B) The lesion is extremely hyperintense on T2WI similar to the CSF signal. (C) The lesion does not enhance signicantly on postcontrast T1WI. Pleomorphic adenomas exhibit variable enhancement after gadolinium administration and may enhance increasingly on delayed imaging so that dierentiating the lesion from surrounding normal parotid tissue may become dicult.

and neurogenic tumors are therefore the most common lesions in this space (Box 4). Common anatomic variations, such as a dominant jugular vein or tortuous carotid artery, may be mistaken for a lesion of the CS if care is not taken in examining contiguous slices on CT or MRI. Specic studies, such as MR angiography (MRA) or CT angiography (CTA), can easily resolve the issue if required. Tumors of the suprahyoid CS cause anterior displacement of the PPS fat and the internal carotid artery with lateral displacement of the internal jugular vein (Fig. 22). The two most common soft tissue masses in the CS are paragangliomas and nerve sheath tumors. These tumors are most commonly asymptomatic and are often incidentally detected on imaging studies performed for investigation of unrelated conditions. When symptomatic, clinical ndings may

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Fig. 16. Recurrent pleomorphic adenoma in the right parotid bed following previous surgical excision. (A) T1WI shows a mass (arrow) in the right parotidectomy bed that is isointense to muscle. Dierentiating postoperative scar from recurrent pleomorphic adenoma is extremely dicult on this sequence. T2WI shows intensely bright clusters of nodules that represent recurrent tumor in the parotidectomy bed on axial (B) and coronal (C) sequence.

include a pulsatile neck mass, submucosal lateral pharyngeal wall mass, or very rarely lower cranial neuropathy or Horners syndrome. Radiographic distinction between paragangliomas and nerve sheath tumors is generally easy because paragangliomas are very vascular tumors. They arise from the neural crest and are most commonly located within the bifurcation of the common carotid artery (carotid body tumors), in the perineurium of the vagus nerve (glomus vagale), at the jugular bulb (glomus jugulare), or in the middle ear cavity (glomus tympanicum). Of these four common sites, only glomus vagale and glomus jugulare are in direct relationship to the PPS. They enhance intensely on CT and MRI and have ow voids (Fig. 23). Flow voids are diagnostic of paragangliomas, but

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Fig. 17. (A) Lymphangioma of the parotid gland can be hyperintense on T2WI but unlike pleomorphic adenoma, these tumors tend to be trans-spatial and compressible on palpation. (B) The inferior PPS communicates directly with the submandibular and sublingual spaces. Note the anterior extension of the lymphangioma from the PPS into the right sublingual space (*).

may not be readily apparent on MRI if the tumor is 2 cm in diameter or smaller. Contrast-enhanced CT scan can help make the diagnosis because paragangliomas enhance intensely compared to nerve sheath tumors that may or may not enhance (Fig. 24). The classic carotid body tumor is located

Fig. 18. Mucoepidermoid carcinoma of the supercial lobe of the right parotid gland, which appears as a well-circumscribed, hyperintense lesion (arrow) on T2WI. This nding is important to consider in the dierential diagnosis of parotid tumors since pleomorphic adenomas also exhibit this characteristic, making precise histologic diagnosis dicult.

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Fig. 19. Several radiographic features of malignancy are illustrated in this patient who has an adenosquamous carcinoma of the deep lobe of the left parotid gland. (A) T1WI sequence shows extraparotid extension with the tumor invading the posterior belly of the digastric muscle (arrow). The contralateral normal muscle (M) is labeled for comparison. (B) Postcontrast fatsaturated T1WI demonstrates the ill-dened lateral border (arrow) of the tumor within the parenchyma of the left parotid gland. (C) A more caudal axial postcontrast fat-saturated T1W image shows invasion (arrow) of the mastoid portion of the temporal bone. The contralateral normal mastoid air cells (M) are normal.

within the carotid bifurcation in the infrahyoid neck and is not in immediate proximity to the PPS. It tends to splay the internal and external carotid arteries (Fig. 25) and this nding helps dierentiate a carotid body tumor from a glomus vagale that tends to displace the carotid artery anteriorly (Fig. 26). Another distinction between other paragangliomas and carotid body tumors is that unlike carotid body tumors, other paragangliomas often have demonstrable feeder vessels that most commonly arise from the ascending

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Fig. 20. (A) Precontrast axial CT scan shows a well-dened mass centered in the left PPS. Note the clear rind of PPS fat around the periphery of the lesion (arrows). The styloid process is marked S and the opposite PPS fat is labeled (*) for comparison. (B) A large PPS tumor may be dicult to dierentiate from a tumor originating in the deep lobe of the parotid gland. In this patient, however, the contrast-enhanced CT clearly demonstrates a fat plane (arrow) between the PPS lesion and the deep lobe of the left parotid gland (P). The tumor was a polymorphous low-grade adenocarcinoma of minor salivary gland origin.

Fig. 21. (A) Axial contrast-enhanced CT shows a new necrotic nodal mass (arrow) at high-level V in the right neck in this patient who had been previously treated for SCC of the right palatine tonsil. (B) This nodal mass extends cephalad and inltrates diusely into the right PPS fat (arrow).

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Box 4. Common lesions of the carotid space Neoplastic Paraganglioma Schwannoma Meningioma (from posterior fossa via the jugular foramen) Direct extension of mucosal carcinoma or nodal metastases Vascular Internal jugular vein thrombosis Carotid artery thrombosis Carotid artery aneurysm, dissection, or pseudoaneurysm Inammatory/infectious Abscess

pharyngeal artery. Conventional angiography can demonstrate vascular anatomy and is useful if embolization is part of the treatment plan, such as for paragangliomas at the skull base. Radiologic dierential diagnosis of schwannoma versus neurobroma may not be easy. Heterogeneity within the lesion is more commonly seen in

Fig. 22. Schematic of the relationship of the suprahyoid CS to the PPS fat showing a tumor of the CS displacing the PPS fat and ICA anteriorly, and the IJV laterally. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.)

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Fig. 23. (A) Contrast-enhanced axial CT scan demonstrates a densely enhancing mass in the left CS. Note the anteromedial displacement of the internal carotid artery (arrow). The internal jugular vein is eaced by the lesion and is therefore not visible on this section. (B) Axial post-gadolinium T1WI at a slightly more cephalad level shows intense enhancement of the mass. The internal jugular vein is displaced posterolaterally (black arrow) and the internal carotid artery is displaced anteromedially (white arrow). (C) Multiple low-signal ow voids are visible within the lesion on the T1WI, and a cluster is labeled (white arrow), conrming the diagnosis of vagal paraganglioma.

schwannomas because of cystic change or hemorrhage. Schwannomas arise from the Schwann cells of the peripheral nerve sheath and in the CS, the vagus nerve and the sympathetic chain are the common nerves of origin. These wellencapsulated tumors appear as a round or ovoid mass that is isointense to

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Fig. 24. (A) Postcontrast axial T1WI scan shows a fairly large right CS mass without ow voids. The absence of ow voids is suggestive of nerve sheath tumor rather than paraganglioma. (B) Relative non-enhancement of the mass on contrast-enhanced CT scan is consistent with schwannoma. (C) Immediate delayed postcontrast image shows slightly more enhancement of the schwannoma. Note that the degree of enhancement is not as intense as that seen in paraganglioma (Fig. 23A).

muscle on T1-weighted images, hyperintense on T2-weighted images, and enhance following contrast administration (Fig. 27). These imaging characteristics are by no means unique to schwannomas, and paragangliomas can appear similar. However, schwannomas do not have ow voids even when they are large. Additionally, schwannomas at the skull base cause regressive remodeling of bone, whereas permeative changes are seen with paraganglioma.

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Fig. 25. (A) Schematic showing the classic location of a carotid body tumor that causes splaying of the internal and external carotid arteries. (Courtesy of Memorial Sloan-Kettering Cancer Center, New York, NY; with permission. Copyright 2007 MSKCC.) (B) Sagittal precontrast T1WI shows a soft tissue mass (M) nestled in the bifurcation of the common carotid artery with splaying of the internal and external carotids. (C) Axial T2WI shows bilateral hyperintense lesions in the carotid bifurcations. Flow voids are visible in these lesions that displace the external carotid arteries (arrows) anteriorly and the internal carotid arteries (arrowheads) posteromedially. This patient has bilateral carotid body tumors.

Squamous cell carcinoma of the adjacent PMS or extracapsular spread from metastatic lymphadenopathy can involve the CS (see Fig. 21). The radiographic nding of SCC in the CS is of importance in determining surgical resectability of the primary or metastatic disease. Inltration of the carotid artery and unresectability are features of tumors that encircle the carotid artery by 270 or greater.

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Fig. 26. Postcontrast axial T1WI shows a densely enhancing lesion of the CS that displaces the internal (arrow) and external carotid arteries anteriorly instead of splaying them. The lesion has the characteristic ow voids of paraganglioma, and the diagnosis of glomus vagale was conrmed at surgery.

Fig. 27. (A) Axial T2WI shows a heterogeneous mass in the left CS with focal central marked hyperintensity. (B) The lesion enhances heterogeneously with focal low signal centrally on postcontrast T1WI. A heterogeneous mass in the CS without ow voids is most indicative of schwannoma.

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Summary The PPS is a suprahyoid space that largely contains fat and is surrounded by several other spaces dened by the fascial layers of the neck. A clear understanding of the spatial anatomy of the PPS and of the displacement patterns of the PPS fat are essential for accurate diagnosis and appropriate treatment for pathology arising in this region.

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