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Jo

Computed

tomography

Carlos

M.D.*t

R. Martinez,

Bob

z

W.

Gayler,

of the neck

M.D.*

#{149}m

Haskins
0.

Stanley

t.
A

vOrth

Kashima,

M.D.

S. Siegelman,

M.D.*

Ae

Computed
choice”

tomography
for the evaluation

interpretation
cross

has

ofsuch

sectional

become
ofneck

images,

anatomy

“the
masses.

is a detailed

imaging

modality

Here,

of

to facilitate

exposition

the

of the normal

of the neck.

THIS
EXHIBIT,
A SELECTION
OF THE GENERAL RADIOLOGY
PANEL,
WAS DISPLAYED
AT THE
67Th
SCIENTIFIC
ASSEMBLY
AND
ANNUAL
MEFI’INC
OF THE RADIOLOGICAL
SOCIETY
OF NORTH
AMERICA,
NOVEMBER
15-20,
1981, CHICAGO,
ILLINOIS.

Introduction
Computed
and
uation

airway

tomography,
detail,

of patients
with
communication

neck

This
*

From

the

Russell

H.

as depicted
the thoracic

Morgan

Department
of Radiology
and Radiological
Science,
The Johns
Hopkins
Medical Institutions,
Baltimore,
Maryland.
t Presently,
Radiological
Services,
Tampa General Hospital, Davis Islands,
Tampa,
Florida.
From the Department
of Laryngology and Otology, The Johns Hopkins
Medical
Institutions,
Baltimore,
Maryland.
Address

reprints

requests

to Carlos

R. Martinez,

M.D., Radiological
vices, Tampa
General
Hospital,
Islands, Tampa,
Florida 33606.

Volume

3, Number

1

March

SerDavis

1983

with

has rapidly

its unique

become

capacity

the imaging

for displaying

soft

tissue

of choice

in the eval-

sectional

anatomy

of the neck

masses.
reviews

by CT using fifteen
inlet. The capabilities

the normal

cross

reference
levels
and limitations

extending
from
of this technique

and interesting
cases that illustrate
the use of CT in the diagnosis
of patients
with head and neck tumors
will be presented.

Material
This report
is derived
of head and neck tumors.
500) unit. The examinations

bone,

modality

and

the mastoid
tip to
will be discussed,
and

management

Methods

from the study of 140 patients
referred
Scans were obtained
with a high resolution
were carried
out in the supine
position

for evaluation
(AS&E Pfizer
with the neck

slightly
hyperextended
and during
quiet breathing.
The scanning
plane was parallel
to the infraorbitomeatal
line. In most instances
10 mm sections
were obtained
at
10 mm intervals
using a 10 second
exposure,
20 mA, and 120 kVp. In specific
instances,
such as the evaluation
of the larynx
and trachea
or the examination
of an
uncooperative
patient,
a shorter
(5 second)
scanning
time and higher
(50) mA setting

RadioGraphics

9

CT

of the

were
used.
pharyngeal,
tumors,

For the
laryngeal

5 mm

iodinated

contrast

were

We
infusion

found
the
of a 30%

material

to

infused

be

of neck

approximately
infusion
rate

at the

rate

if a 19 gauge

of

structures,

an

with

a short

neck.

additional

in order
to improve
the
reducing
artifacts.
Scans at
of the thoracic
inlet are frecompromised
by
beam

larities

This

in the

outline

of the

from

dental

Motion

fillings

artifacts

lowing
patient
tongue.

by
two
successive
scans
the area of interest.
We
utilized
a few
technical

“tricks”
image
by
the level
quently

This alirregu-

my,

the

of 25 cc of a 60% contrast
mawas injected,
followed
imme-

diately
through

H.U.) level.
of minor

problem
can be partially
solved
by
using
a “swimmer’s”
position
and
increasing
the tube current.
Artifacts

was
of

were used. Whenever
there
need
for greater
enhancement
vascular

et al.

that might
be obscured
tissue settings
were used.

nee-

dle

bolus
terial

patient

and a low (-200
lows visualization

the humeral
true in an

can be avoided

obtaining
open
mouth
views
slight changes
in the scanning

20 cc per minute.
This
was usually
achieved

difficulty

hardening
artifacts
from
heads.
This is particularly
obese

hundred
cc were given
first scan; an additional

cc were

without

of
small

obtained

in the CT evaluation

masses.
One
prior
to the
200

examination
or other

sections

at 5 mm
intervals.
rapid
intravenous
helpful

Martinez

neck

partially

tip

of

should

be

at different

levels. Soft
photographed

window
window
Bone

viewed

window

the

to

level

of approximately

structures

400

H.U.)

and
widths

structures

to

not
scans

at each

level.

visualized

on the

ref-

are included

in the

line

because
and

of

their

constant

demonstrable

clinical

relationship

anatomical

land-

marks.

a

In general,

40
lowing

are best studied

to simplify

the

fol-

structures

that

are

discussion,

bilaterally
symmetrical
anatomic
relationships
scribed
in terms of the

with a wide window
(1000 or more if
an expanded
scale is available).
The
airway
should
be viewed
with a very
wide
window
(1000 H.U. or more)

one side

Upper

Nasopharynx

! Lower

Nasopharynx

..per

Alveolar
Cavity

Ridge

Angles

Border

of

1Valleculae
Hyoid

Body

only.

Palate

Submandibular

-

-

Carotid

-

Sup.

Glands
Horns

of

Hyoid

Bifurcations

Aryepiglottic

-

Cartilages

jVocal

Soft

-

Epiglottis

Notch

Arytenoid

neck

Hypopharynx

-

Thyroid

of the

and
their
will be destructures
of

Uvula

-

Mandibular
;Free

thoracic
depicts

drawings
have
been
derived
each
scan;
some
anatomical

importance

Oral

to the
diagram

of the

drawings

and

of the nasophar-

Line
from
erence

tissues are best viewed
at a relatively
wide

(250

level

some

structures

studied

H.U.

extruded

at the

ynx and extending
inlet. This reference

by swal-

soft

To represent
the normal
anato15 scans have been selected,
be-

ginning

can be avoided
by asking the
to bite gently
with the lips on

Scans
and
and

produced

by

or by
plane.

airway

if only

-

Folds

Laryngeal

Vestibule

Cords

Subglottis
1Cricoid

Ring

‘Upper

Trachea

First

Ribs

ISTRUCTU

Figure

10

-

Laryngotrachea

-

-

Lower

Thyroid
Thyroid

Isthmus
Gland

RES

1

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT

LEVEL

1-UPPER

of the

neck

NASOPHARYNX

Figures

2A & 2B

section
demonstrates
the relationship
of the nasopharynx
to the
prevertebral
and pharyngeal
muscuIature
and to the anterior
arch of C 1.
It also demonstrates
the torus tubarius at the opening
of the eustachian
tube. The nasopharyngeal
air shadow
may be asymmetrical
because
of the
asymmetric
distribution
of lymphoid
tissue. The deep soft tissue planes in
the parapharyngeal
space should be
This

symmetrical,

however.

The

close

re-

lationship
of the nasopharynx
to the
carotid
sheath
clarifies
the basis for
the
from

Figure

complex
disease

syndromes
in this region.

that

arise

2A

Antrum
nt.

Carotid

.

Mandibular
Condyle

Facial N.

Mastoid

Jugular

nt. Carotid

Cranial

x, xi, xii
nt.

Volume

Torus

Odontoid
Post.

Styloid

Figure

V.

A.
Eustachjan

ix

Tip

Jugular

Arch

Cranial

Cl

Nerves

V.

2B

3, Number

1

March

1983

RadioGraphics

11

CT

of the

Martinez

neck

LEVEL

Figures

2-LOWER

et al.

NASOPHARYNX

3A & 3B

Here, the infratemporal
fossa is well
seen. It is limited
laterally,
by the
mandibular
ramus
and the parotid
gland;
and anteriorly,
by the posterolateral
wall of the maxillary
antrum.
The external
carotid
artery
proximal
to the origin of the internal
maxillary
artery
is surrounded
by
parotid
gland tissue at this level. A
zone of low attenuation
tissue (fat) is
normally
present
between
the pharyngeal
musculature
and the pterygoid muscles.
These zones are bilaterally symmetrical.

Figure

3A

Mandibular

Retromandibula
Facial
Parotid

Figure

12

Glan

3B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT of the neck

LEVEL

3-UPPER

ALVEOLAR

RIDGE-SOVr

PALATE

Figures

Figure

4A & 4B

The oral cavity and the isthmus of the
pharynx
are seen in this section.
The
midportion
of the parotid
gland
is
demonstrated.
In adults, the parotid
gland is usually
of relatively
low attenuation
(less
than
surrounding
muscles
and vascular
structures)
because
of variable
amounts
of fatty
infiltration
of the parenchyma.
The
retromandibular
vein is commonly
visualized
just posterior
to the mandibular ramus. The main trunk of the
facial nerve, although
not visualized
on the CT image,
lies just lateral
to
the retromandibular
vein.

4A

Soft

Palate

Cavity
Antrum

Oropharynx

Masseter
Pharyngeal

Constrictor

Int. Carotid

M.

M.

A.

Retromandibular

(Post.
Carotid

A..

Post. Auricular

V.

Ext.

Sternocleidomastoid

Figure

Volume

Facial

V.

V.)

M.

4B

3, Number

1

March

1983

RadioGraphics

13

CT

of the

neck

Martinez

LEVEL

Figures

4-ORAL

CAVITY-UVULA

5A & 5B

The tip of the uvula appears here as a
punctate
structure
in the middle
of
the oropharynx.
It is surrounded
by
palatine
tonsils
and the oropharyngeal musculature
(pharyngeal
constrictor,
palatoglossus
and palatopharyngeus
muscles).
The posterior
belly of the digastric
muscle is an important
anatomical
landmark.
It lies
lateral to the carotid
sheath and the
external
carotid
artery.
The retromandibular
vein becomes
the external jugular vein after exiting from the
parotid
gland.

Figure

5A

)ular

Figure

Ramus

Carotid

A.

:Jugular

V.

I

14

et al.

5B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT of the neck

LEVEL

5-MANDIBULAR

ANGLE-SUBMANDIBULAR

GLAND

Figures

Figure

6A & 6B

The oropharynx,
the base of the
tongue,
and the upper portion
of the
submandibular
gland are well visualized at this level. The internal
and
external
carotid
arteries
and the jugular veins are in close proximity
to the
oropharynx.
The most inferior portion
of the parotid gland is separated
from
the adjacent
submandibular
gland by
the stylomandibular
ligament.
The
stylohyoid
and digastric
muscles
separate
the structures
of the carotid
sheath
from
the
submandibular
gland.
The attenuation
of the submandibular
gland is usually
greater
than that of the parotid
gland.

6A

haryngeal
Constrictor

M.

Carotid A.
us N.

V.

Figure

Volume

6B

3, Number

1

March

1983

RadioGraphics

15

CT

of the

LEVEL

Figures

Martinez

neck

6-FREE

BORDER

OF

EPIGLOUIS-SUPERIOR

HORN

OF

et al.

HYOID

7A & 7B

This section
demonstrates
the relationship
of the submandibular
gland
to the base of the tongue and to the
free border
of the epiglottis.
The superior horn of the hyoid is adjacent
to
the internal
and external
carotid
arteries.
The suprahyoid
group
of
muscles
(stylohyoid,
mylohyoid,
and
geniohyoid)
is visualized
as a group in
this section.

Figure

7A

Epiglottis
Mandible
Submandibular

Gland

and

.Sternoclejdomastoid

Int. Carotid

A.

nt. Jugular

Vertebral

Figure

16

V.

Semispinalis
Capitis
Levator Scapulae

Semispinalis

M.

and
Mm.

Body C3

7B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT

LEVEL

8A & 8B

The valleculae,
epiglottis
and median
glossoepiglottic
fold are seen at this
level. The asymmetry
of the valleculae in Figure 8A is accounted
for by
secretions
on the right side. The vallecular spaces are best seen if scans
are obtained
while the tongue is protruding.
The fat layer deep to the
sternocleidomastoid
muscle
is regularly seen irrespective
of the body
habitus of the patient.
Muscle definition is dependent
on intermuscular
fat rather
than on muscle
size. The
hyoid
bone
is a useful
reference
structure.

8A

Hypoglossal

N’

mt. Carotid

,8

Int.

onstrictor

Jugular

?idomastoid

Figure

Volume

neck

7-VALLECULAE-HYPOPHARYNX

Figures

Figure

of the

M.

M.

8B

3, Number

1

March

1983

RadioGraphics

17

CT

of the

Martinez

neck

LEVEL

Figures

8-HYOID

BODY-CAROTID

et al.

BIFURCATION

9A & 9B

The pre-epiglottic
space is well demonstrated
because
of its low (fat) attenuation.
A portion
of the aryepiglottic fold is seen laterally. The carotid
artery bifurcates
at this level in most
individuals,
usually at the level of the
fourth or fifth cervical vertebral
body.
Note the relationship
of the internal
jugular
vein to the carotid
bifurcation.

Figure

9A

Sternocleidon

Figure

18

9B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

CT

et al.

LEVEL

9-THYROID

NOTCH-ARYEPIGLOTHC

neck

FOLDS

Figures

Figure

of the

1OA & lOB

The alae of the thyroid
cartilage
are
seen at the level of the thyroid
notch
in this section. The pattern and extent
of ossification
of the thyroid
cartilage
is variable,
but usually symmetrical.
On each side, the aryepiglottic
fold
separates
the
laryngeal
vestibule
from the pyriform
sinus. The common carotid
artery
and the jugular
vein lie under the sternocleidomastoid muscle
posterolateral
to the
thyroid
lamina.

1OA

Thyroid
Aryepiglottic

Ext. Jugular

Fold

V.

C5

Levator
Semispinalis

Figure

Volume

Capitis

M.

lOB

3, Number

1

March

1983

RadioGraphics

19

CT

Martinez

of the neck

LEVEL

Figures

hA

lO-ARYTENOID

CARTILAGES-LARYNGEAL

et al.

VESTIBULES

& 11B

Here the upper portions
of the arytenoid
cartilages
are present
posteroinferior
to the aryepiglottic
folds.
The corniculate
cartilages
are very
seldom calcified
and cannot be identified within
the aryepiglottic
folds.
Visualization
of the pyriform
sinuses
may be improved
by phonation
(EE-E) or by a modified
Valsalva
maneuver during the scanning
period.

Figure

11A

al Constrictor

Neural
Ext.

Foramen

Jugular’

Figure

20

M.

llB

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT of the neck

LEVEL

11-VOCAL

CORDS

Figures

Figure

12A & l2B

The level of the true vocal cords is
identified
by the close apposition
of
the anterior
commissure
to the inner
surface
of the thyroid
cartilages,
as
well as by the presence
of the vocal
process
of the arytenoid
cartilage.
The uppermost
portion
of the cricoid
ring is seen at this level forming
the
posterior
boundary
of the glottic
space.

12A

Anterior

Arytenoid

Int. Jugular

Commissure

Cartilage

V.

Middle and
Post. Scalene Mm.

Vertebral

Figure

Volume

12B

3, Number

1

March

1983

RadioGraphics

21

CT

of the

Martinez

neck

LEVEL

Figures

et al.

12-SUBGLOTFIS

13A & 13B

Here the mucosa
of the subglottis
is
closely applied to the cricoid ring and
thyroid
cartilage.
The
cervical

esophagus

is posterior

to the poste-

nor lamina
of the cricoid.
Note the
relationship
of the cricoid
lamina to
the inferior
cornu of the thyroid
cartilage. In children
and young adults,
the carotid
arteries
and jugular veins
may be difficult
to separate
from the
adjacent
muscles
unless a rapid infusion of contrast
material
is employed
during
the
examination.
Normal
lymph
nodes
usually
measure
less
than 5 mm in diameter.

Figure

Horn Thyroid

l3A

Cartilage

Cartilage
.Cricoid
lnt. Jugular

Cartilage

V.
Vagus N.

.

Deep

Figure

22

Longus

Vertebral

Colli

M.

Body

C7

13B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

CT of the neck

et al.

LEVEL

Figure

Middle

13-CRICOID

RING-LARYNGOTRACHEA

Figures 14A & 14B
The cricoid ring surrounds
the airway.
The upper pole of the thyroid gland is
readily
identified
because
of its high
attenuation
which
results
from the
vascularity
and iodine content
of the
gland. The common
carotid
artery is
usually
found
posterior
to the thyroid.

14A

anc,

l Cervical

V.

Post. ScalenE

tor Scapulae

Figure

Volume

l4B

3, Number

1

March

1983

RadioGraphics

23

CT

Martinez

of the neck

LEVEL

14-UPPER

Figuresl5A&15B
The thyroid
isthmus
is seen anterior
to the trachea
at this level. The Carotid artery
lies posterior
to the thyroid gland while the jugular
vein is
more
laterally
placed
between
the
anterior
scalene
and the sternocleidomastoid
muscles.
The jugular veins
are frequently
asymmetrical,
the
right being larger in most subjects.

Figure

TRACHEA-THYROID

ISTHMUS

15A

Vertebral Body

Figure

24

et al.

Ti

l5B

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

CT

et al.

LEVEL

Figure

15-FIRST

RIB-LOWER

THYROID

of the

neck

GLAND

Figures 16A & l6B
This section,
just above the thoracic
inlet, is at the level of the first rib. Individual
tracheal
rings are visible
in
older individuals
if they have become
calcified.
The esophagus
is commonly
just to the left of the midline
at this
level. The lower cervical
nerves may
be seen directed
inferolaterally
between the anterior
scalene
and the
middle and posterior
scalene muscle
group. The anterior
scalenes
may be
prominent
in patients
with chronic
obstructive
pulmonary
disease
and
should not be mistaken
for masses or

16A

adenopathy.

Vertebral

Figure

Volume

Body

Ti

l6B

3, Number

1

March

1983

RadioGraphics

25

CT

of the

neck

Martinez

Case

history
thyroid.
because

This 35 year
of papillary

old man had
carcinoma

et al.

One

a past
of the

He consulted
a physician
of a right
parapharyngeal

mass.

Figure 17
A 2.5 cm partially
cystic mass (arrowheads)
space displaces
the styloid process
(arrow)

DIAGNOSIS
Metastatic
of the

26

thyroid

papillary
gland.

carcinoma

in the right
anteriorly

parapharyngeal
and laterally.

Figure 18
Section
obtained
2 cm caudad.
The lateral pharyngeal
wall is distorted
and the right submandibular
gland is displaced
anteriorly.
The relationship
of the cystic
mass to the carotid
artery
and jugular
vein is
demonstrated
(arrow).

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

CT

et al.

Case

of the

neck

Two

This
palpable
region.

68 year
masses

old
in the

man
right

had

two

parotid

1%

Figure 19
This sialogram
showing
traparotid
mass lesion

displacement
(arrowheads).

of the ducts

suggests

a single

Figure 20
Two sharply
defined
masses (arrowheads)
are present
in the right
otid. Note the clear visualization
of the posterior
facial vein within
normal
parotid
tissue between
the two masses.
The study was
formed
during the infusion
of a contrast
medium.

Volume

3, Number

1

March

1983

RadioGraphics

in-

parthe
per-

DIAGNOSIS
Adenopathy-Hodgkin’s

dis-

ease.

27

CT

Martinez

of the neck

Case

This
mitted
glottic

53

year

old

man

was

Three

ad-

for the evaluation
of a supralesion.
An asymptomatic
left

parotid
mass
examination.

was

noted

on physical

Figure 21
A laryngogram
shows
of the valleculae.

a thickened

epiglottis

Figure 22
This scan shows a thickened
epiglottis,
infiltration
of the pre-epiglottic
space

28

et al.

RadioGraphics

(arrowheads)

obliteration
(arrow).

March

and distortion

of the valleculae

1983

Volume

and

3, Number

1

Martinez

et al.

CT of the neck

.

Figure

23

In this
perficial

sialogram,
ductal
displacement
lobe suggests
an intraparotid

Figure

24

This

scan

Moderate
density

Volume

shows

a sharply

fatty
of both

3, Number

infiltration
parotid

1

March

defined

of the

in the
mass.

mass

within

parenchyma

lower

the

portion

left

accounts

of the

parotid

for

su-

DIAGNOSIS

gland.

the

low
left

glands.

1983

RadioGraphics

Carcinoma
of the epiglottis
parotid
Warthin’s
tumor.

and

29

CT

of the neck

Martinez

Case
This
slowly

26

enlarging

year

old
left

neck

man

had

Four

a

mass.

Figure 25
A cystic mass is seen between
submandibular
gland (arrow).
to the floor of the mouth.

Left
(ranula).

30

DIAGNOSIS
submandibular

et al.

Figure 26
At this level,
gland

cyst

portion

gland

of the

the hyoid
mass.

the mylohyoid
muscle and deformed
left
The anterior
portion
of the mass extends

is seen to be displaced

Note

the

lateral

displacement

to the right
of the

by the lower
submandibular

(arrow).

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT

Case

of the neck

Five

This

49 year

subglottic

old

carcinoma

treated

with

radiotherapy

woman

with

had

been

five

years

earlier.
At this time, she had wheezing
and a palpable
lesion of the left lobe
of the

Figure 27
In this scan, a soft tissue mass (arrowheads)
partially
obliterates
subglottic
airway.
Note the well defined
soft tissue plane between
cricoid
and the mass in the left lobe of the thyroid
(arrows).

thyroid.

the
the

Figure 28
Pathology
Specimen.
Laryngectomy
and thyroidectomy
were performed
after partial laser excision
of the subglottic
mass. The residual
lesion of the left subglottis
(arrowheads)
and the lesion of the left lobe
of the thyroid
(arrows)
are demonstrated.

DIAGNOSIS
Recurrent
carcinoma.

subglottic
Colloid

cyst

squamous
of the

thy-

roid.

Volume

3, Number

1

March

1983

RadioGraphics

31

CT

Martinez

of the neck

Case

This
lump

39 year

in the

old

woman

had

et al.

Six

a

throat.

Figure 29
A lateral radiograph
of the soft tissues of the neck shows a smooth
mass
(arrowheads)
in the base of the tongue displacing
the epiglottis
posteriorly.

Figure 30
In this CT scan (without
contrast
agent), there is a high
uation)
mass’ (arrowheads)
in the base of the tongue.
of this lesion is the same as that of the normal thyroid
high because
of its iodine content.
The superior
horns
rows) are seen in either side of the mass.
‘ ‘

DIAGNOSIS
Lingual

32

thyroid.

RadioGraphics

March

1983

density
(attenThe attenuation
tissue, which is
of the hyoid (ar-

Volume

3, Number

1

Martinez

et al.

CT

Case

of the

neck

Seven

This
two year

76 year
history

old

woman

of progressive

had

a

airway

obstruction.

Figure 31
A CT scan at ‘Level 8’ shows a partially
from the inner lamina of the cricoid.
cartilage
appears
intact.

calcified
subglottic
The outer lamina

mass arising
of the cricoid

Figure 32
A follow up study after an interval
of 4 months
and after partial
laser
excision
of the tumor shows unequivocal
decrease
in the size of the lesion which coincided
with clinical improvement.

Volume

3, Number

1

March

1983

RadioGraphics

DIAGNOSIS
Chondrosarcoma

of the

larynx.

33

CT

of the

Martinez

neck

Case

This
enlarging

48

year

goiter

old
and

man

had

Eight

an

stridor.

Figure 33
A lateral xeroradiograph
demonstrates
with erosion
of the cricoid ring (arrow)
airway.

DIAGNOSIS

Carcinoma
of the thyroid
transmural
subglottic
extension.

34

et al.

with

a large neck mass (arrowheads)
and narrowing
of the subglottic

Figure 34
This CT scan shows a large mass (arrowheads)
of the thyroid,
erosion
of the cricoid
ring
transmural
extension.

RadioGraphics

March

arising from
posteriorly

1983

the right
(arrow)

Volume

lobe
and

3, Number

1

Martinez

et al.

CT

Case

of the

neck

Nine

This

29

year

slowly
enlarging
had previously
a glomus

old

man

had

a

left neck mass. He
been operated
on for

tympanicum.

Figure 35
A sharply
defined
enhancing
mass (arrowheads)
under the sternocleidomastoid
muscle
displaces
the left submandibular
gland anteriorly.
The carotid
bifurcation
is usually
located
at the level of the hyoid
horns.

I
r

DIAGNOSIS
Figure

36

In this

left

common

at the carotid
imal internal

Volume

3, Number

carotid

bifurcation.
and external

1

March

angiogram,

Multiple
carotid

1983

a highly

vascular

mass

small feeders
arising from
arteries
are demonstrated.

RadioGraphics

is seen

Carotid
caroticum).

body

tumor

(glomus

the prox-

35

CT

of the

neck

Martinez

Case

This
pable

34 year

masses

old

man

in the upper

had
and

et al.

Ten

pallower

neck.

Figure 37
An oblique
view of the
neural foramen
(arrow)

cervical
spine
on the left.

shows

enlargement

of the

C2-3

Figure 38
A small, well defined,
lobulated
mass (arrowheads)
is seen anterior
to
the scalene muscles in this CT scan. It minimally
displaces the left carotid
artery and the left jugular vein. Note the asymmetry
of the jugular veins
with a very large right jugular vein, a normal variant.

36

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT

of the

neck

Figure 39
In this CT scan, a large lobulated
parapharyngeal
mass
is seen (arrowheads).
The internal
carotid
artery is displaced
(white
arrow)
and
there is distortion
of the lateral pharyngeal
wall on the left. The C2-3
neural foramen
(black arrow) on the
left is enlarged,
corresponding
to the
radiographic
finding.

DIAGNOSIS
Neurofibromatosis.

Volume

3, Number

1

March

1983

RadioGraphics

37

CT

of the

Martinez

neck

Case

This

plained

62

year

old

man

et al.

Eleven

com-

of hoarseness.

Figure 40
A CT section
at the level of the vocal cords demonstrates
of the margin
of the enlarged
left vocal cord (arrowheads).

excellent

Figure
Normal

definition

41
subglottic

irregularity
Note the

of the laryngeal cartilages.

region

5 mm

below

the vocal

cords.

DIAGNOSIS

Squamous
vocal
cord.

38

carcinoma

of the left

RadioGraphics

March

1983

Volume

3, Number

1

Martinez

et al.

CT of the neck

Case

Twelve

This

50 year

in the posterior

Figure 42
A sharply
defined
mass
tween
the semispinalis
muscle.

with very
capitis

low (fat)
muscle

attenuation
and the

old man

had a mass

neck.

is visualized
besplenius
capitis

DIAGNOSIS
Lipoma.

Volume

3, Number

1

March

1983

RadioGraphics

39

CT

of the neck

Conclusions
1. Computed
tomography
is helpful
in
the evaluation
of neck masses. Specifically,
it is capable
of documenting
tumor size, location and relationship
to
adjacent
structures;
it can demonstrate
routes of tumor spread and provide
clues supporting
a specific diagnosis.
2. Thorough
knowledge
of the normal
cross sectional
anatomy
of the neck
and meticulous
tomographic
technique are mandatory.
The examination should be planned
on the basis of
the clinical presentation.
3. Intravenous
contrast material
given as
a rapid infusion during the examination provides
the best enhancement
of
the vessels,
and thereby
improves
recognition
of key vascular
structures.

4. The exact location
and extent of tumors in the infratemporal
fossa and
parapharyngeal
space is best evaluated
by CT. The detection
of parapharyngeal tumors depends
more on asymmetry, and distortion
of deep soft tissue compartments
than on asymmetry
of the airway. CT does not provide a
histologic
diagnosis
or permit differentiation
between
benign and malignant
processes.
An inflammatory
process
may mimic
tumor
infiltration.
5. CT is very useful in the evaluation
of
parotid
tumors and will probably
replace conventional
sialography
for the
assessment
of tumor pathology
of the
parotid.
Sialography,
however,
remains the procedure
of choice for the
evaluation
of inflammatory
diseases of
the salivary glands.
6. CT is extremely
valuable
for the
evaluation
and staging
of laryngeal
carcinoma.
It is the best imaging
modality for the evaluation
of cartilage
erosion and tumor extension
into the
pre-epiglottic,
paraglottic
and
subglottic
spaces.
7. Current
limitations
of CT of the larynx
are: (a) motion
artifacts,
(b) lack of
dynamic
information,
(c) inability
to
differentiate
edema
from tumor infiltration
and (d) lack of adequate

40

Martinez

characterization
of mucosal surfaces.
8. CT is most helpful in the detection
of
metastatic
adenopathy,
especially
in
obese patients.
Reactive
nodes, however, cannot
be differentiated
from
metastatic
nodes Normal lymph nodes
usually measure
fewer than 5 mm in
diameter
and reactive
nodes usually
measure
fewer than 15 mm in diameter. Large nodes with central necrosis
usually
indicate
metastatic
involvement.
9. The role of CT in the evaluation
of
thyroid nodules is limited because of
the accuracy of nuclear medicine and
ultrasound
techniques.
CT, however,
is helpful
in defining
the extent of
paratracheal
and thyroid
masses by
defining
the extent of tracheal
cornpression
and transmural
airway invasion.

Additional

133:145-149.

8. Sons PM, ShugarJMA.
Combined
CT
sialogram.
Radiology
1980;
135:
387-390.
9. Som PM, Shugar JMA, Train JS et al.
Manifestations
of parotid
gland enlargernent:
Radiographic,
pathologic
and clinical correlations
Part I-The
autoimmune
pseudosialectasis.
Part
Il-The
diseases of Mikulicz’
syndrome.
Radiology
1981; 141:415426.
10. Stove DN, Mancuso AA, Rice D et al.
Parotid
CT sialography.
1981; 138:393-397.

Radiology

11. Mancuso
AA, Hanafee
WN. Cornputed tomography
of the head and
neck.
Williams
& Wilkins
Baltimore/London:

1982.

Readings

1. Carter BL, Karmody
CS, Blickman
JR, et al. Computed
tomography
and
sialography
Part I-Normal
anatomy
Part Il-Pathology.
J Comput
Assist
Tornogr 1981; 5:42-53.
2. Doubleday
LC, Jing BS, Wallace
S.
Computed
tomography
of the infratemporal
fossa.
Radiology
1981;
138:619-624.

included here that previously appeared in Martinez
BW, et al. COmputed tomography of
the neck. Ann Otol Rhinol Laryngol 1982; 91:Supplement
99 are reproduced with permission.
Figtres

CR. Kashima H, Gayler

acknowledge
the cooperation of ow colleagues in the Departments of Otolaryngology and Radiolo.
gy and the expert assistance of the technical staff. We appredate the typing of Ms. Agnes Bridges and Ms. Rose
We gratefully

3. Larsson 5, Mancuso AA, Hoover L et
al. Differentiation
of pyriform
sinus
cancer from supraglottic
laryngeal
cancer
by CT. Radiology
1981;
141:427-432.
4. Mancuso
AA,
nafee

et al.

WN.

Calcaterra

Computed

of the larynx.

TC,

Walker.

The

photoaphy

of Mr. Henri Hessels is

much ap-

preoated.

Ha-

tomography

Rad Clin N Am 1978;

XVI:195-208.

5. Mancuso
AA, Bohman
L, Hanafee
WN et al. Computed
tomography
of
the nasopharynx:
Normal
and vanants

of

normal.

Radiology

1980;

137:113-121.
6. Mancuso AA, Macen D, Rice D et al.
CT. of cervical lymph node cancer.
AJR

1981; 136:381-385.

7. Miller

EM,

computed
ation

Normal
D. The role of
tomography
in the evalu-

of neck

masses.

Radiology

1979;

RadioGraphics

March

1983

Volume

3, Number

1