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Imaging of Head and Neck

Imaging of Head and Neck

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Published by Marwan M.
موضوع مهم جدا
موضوع مهم جدا

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Published by: Marwan M. on Nov 27, 2009
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Imaging o the Headand Neck
Edited by Michael Forsting
Colin S. Poon Michael Abrahams James Abrahams
 The sot tissue structures o the orbit are contained withina bony cavity. These sot tissue structures include the globe,the extraocular muscles, the optic nerve–sheath complex,the lacrimal apparatus, and various vascular and nervestructures.
Bony Anatomy
 The bony orbit is a conical structure with the apex pointing posteriorly. The orbital roo is composed o the rontalbone and is thinner anteriorly. The medial wall is com-posed o the rontal process o the maxillary bone anteri-orly, the lamina papyracea o the ethmoid air cells at themidportion, and the sphenoid bone posteriorly. Thelamina papyracea is very thin, and not surprisingly it is acommon site o orbital blowout racture and spontaneousdehiscence o orbital at. The lateral orbital wall is ormedby the orbital surace o the zygomatic bone. The orbitaloor is ormed by the orbital plate o the maxilla, theorbital process o the palatine bone, and the orbital suraceo the zygomatic bone. The orbital plate o the maxilla isthin and a common site o inerior blowout racture.Multiple oramina and canals go through the bony orbits (Box 11-1). The optic canal (also called
optic oramen
)is located at the orbital apex. It is bordered by two bony spikes o the lesser wing o the sphenoid bone, commonly reerred as the
optic struts
. The canal contains the optic nerve and the ophthalmic artery, both o which are con-tained within a dural sheath. The superior orbital fssure is located at the marginbetween the lateral wall and the orbital roo. The greater  wing o the sphenoid bone orms its lateral boundary, while the lesser wing orms its medial boundary. The supe-rior orbital fssure contains the superior ophthalmic vein;the oculomotor (III), trochlear (IV), and abducens (VI)nerves; and the ophthalmic division o trigeminal nerve(V 
). The superior orbital fssure orms the largest com-munication between the orbit and intracranial structuresand thereore orms a conduit or inectious or neoplastic processes between the orbital apex and the cavernoussinus. The inerior orbital fssure is located at the marginbetween the lateral wall and the orbital oor. It containsthe inraorbital (branch o V 
) and zygomatic nerves, thenerve branches rom the pterygopalatine ganglion, and venous connection between the inerior ophthalmic veinand the pterygoid plexus. The inerior orbital fssure con-nects with the pterygopalatine ossa and the masticator space/inratemporal ossa, allowing the spread o deepacial inection and neoplasm to the orbital apex. The globe is essentially a spherical structure, with the wall consisting o three layers: retina (innermost), choroids(middle), and sclera (outermost). These layers cannot beresolved with current clinical imaging technology, unlessthey are separated by pathologic processes (e.g., retinaldetachment). The globe is divided into three uid-flledcavities: anterior chamber, posterior chamber, and vitreouscavity.
The anterior chamber and posterior chamber constitute the anterior segment, while the vitreous cavity constitutes the posterior segment. The anterior chamber extends rom the cornea to the iris. The posterior chamber extends rom the posterior surace o the iris to the anterior surace o the vitreous. The vitreous cavity is posterior tothe posterior chamber. The anterior border o the orbit is ormed by theorbital septum, a fbrous structure adherent to the inner margin o the orbital rim with central portions that extend
Box 11-1.
Major Foramina o the Orbit and Their NeurovascularContents
Optic Canal
Optic nerveOphthalmic artery
Superior Orbital Fissure
Cranial nerves: III, IV, VI, V
Lacrimal and rontal nervesSuperior and inerior ophthalmic veins
Inerior Orbital Fissure
Cranial nerve: V
Zygomatic nerveInraorbital vessels
II Imaging of the Head and Neck
into the tarsus o the eyelids. Although there are a ew ori-fces or passage o vessels, nerves, and ducts, the septumorms an eective barrier to prevent superfcial processesrom extending into the orbit proper. A pathologic processsuch as cellulitis may be designated as
post- septal
. A postseptal process signals the involvement o morecritical structures o the orbit, the possibility o extensioninto the cavernous sinus and intracranial structures.
Sot Tissue Anatomy
 There are seven extraocular muscles: the superior, inerior,medial and lateral rectus; the superior and inerior oblique;and the levator palpebrae superioris muscles. The levator palpebrae muscle can be seen immediately above the supe-rior rectus muscle. With the exception o the inerior oblique muscle, all extraocular muscles originate rom theannulus o Zinn, a tendinous ring in the orbital apex. They pass anteriorly and insert on the globe just behind thecorneoscleral border. The our rectus muscles and thefbrous septa connecting between them orm the musclecone o the orbit. The intraconal space is flled with orbitalat. Orbital vessels, sensory and motor nerves to the extra-conal muscles, and the optic nerve–sheath complex alsotraverse the intraconal space. The optic nerve may appear straight or slightly tortu-ous depending on the eye position. It consists o threesegments: orbital, canalicular, and intracranial. The orbitalsegment is covered by the same meningeal sheaths as thebrain. The normal diameter o the optic nerve is up to4mm. A layer o cerebrospinal uid can be seen betweenthe meningeal sheath and the optic nerve. The extraconal space represents the area between themuscle cone and the bony orbit. This space contains orbitalat and the lacrimal gland. The lacrimal gland is locatedsuperolateral to the globe. The upper margin o the glandis convex. The lower margin is concave and lies on thelevator palpebrae and lateral rectus muscles. The lacrimalsystem drains through the lacrimal ductal system near themedial canthus. It consists o the superior and inerior puncta, their associated ducts, the lacrimal sac, lacrimalduct, and the valve o Hasner, which is a draining orifceinerolateral to the inerior nasal turbinate. The vascular anatomy o the orbits can be well dem-onstrated on high-resolution magnetic resonance imaging (MRI)
and computed tomography (CT) angiography. Theprimary arterial supply to the orbit is the ophthalmic artery. It is superior to the optic nerve and can be seencrossing the optic nerve almost perpendicularly (see Fig.11-4). The ophthalmic artery most oten originates romthe internal carotid artery. The origin is usually at theanteromedial aspect o the internal carotid artery as it exitsthe cavernous sinus. Variants o its origin include the cav-ernous segment o the internal carotid artery and themiddle meningeal artery (i.e., external carotid artery branch). Secondary arterial supply to the orbits comesrom the external carotid artery. Because the orbits receiveblood supply rom both the internal and external carotidarteries, orbital arteries may serve as anastomosis betweenthe two arterial systems. The largest orbital vein visualized on CT or MRI isthe superior ophthalmic vein. It can be seen arising near the base o the nose, coursing anteromedially to postero-laterally, and draining into the cavernous sinus. It crossesover the optic nerve in its mid course, at approximately 20degrees (see Fig. 11-4). The midportion o the superior ophthalmic vein is an intraconal structure that lies betweenthe superior rectus muscle and the ophthalmic artery. Theinerior ophthalmic vein is much smaller than the superior ophthalmic vein. It is usually not well visualized on CT or MRI studies. Both the superior ophthalmic vein and ine-rior ophthalmic vein receive tributaries rom the veins o ace and nose.
Imaging Techniques
 The major modalities or imaging o the orbits include CT and MRI. The abundance o intraorbital at provides goodintrinsic sot tissue contrast on CT or most clinical applica-tions. The advances o multidetector CT technology nowmake high-resolution CT imaging possible. The sourceimages can be reormatted in dierent planes, providing high-resolution isotropic imaging. This renders the previ-ous advantage o multiplanar capability o MRI obsolete.CT is superior to MRI or delineation o osseous structuresand calcifcations. It requires short imaging time and isthereore less sensitive to motion o the globe and eyelid.CT imaging can be completed quickly and requires lesspatient cooperation, making it ideal or imaging orbitaltrauma.Compared to CT, MRI provides superior sot tissuecontrast. It also provides better imaging details o the intra-cranial structures. When it is important to assess intracra-nial abnormalities, either as direct extension o orbitallesions or as associated lesions in certain diseases (e.g., inmultiple sclerosis), MRI is superior to CT.In the past, evaluation o suspected vascular lesions o the orbits required conventional angiography. The advancesin CT angiography and MR angiography now allow many  vascular lesions to be evaluated noninvasively. In somecases, conventional angiography can be oregone.CT and MRI oten provide complementary roles inorbital imaging. The choice o CT versus MRI or initialimaging o the orbits depends on the clinical problem. CT is usually preerred or trauma, or evaluation o the bony orbits or calcifed lesions, and when MRI is contraindi-cated. For other applications, MRI is generally preerredbecause o the absence o radiation risks and its high sot tissue contrast. MRI is the initial imaging o choice or evaluation o the optic nerve, other cranial nerves, andintracranial lesions. Exceptions can be ound in a smallnumber o optic nerve meningiomas, which are very small

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