DEEP SPACES, PARANASAL SINUSES, AND NASOPHARYNX Wade Wong, D.O.

Evaluation of the head and neck has developed significantly with the advent of CT and MRI. These modalities have greatly complimented the physical and endoscopic examinations by revealing possible blind areas such as nonpalpable adenopathy, cartilage invasion, bone marrow invasion, contralateral involvement, and distant metastases. MRI has some major advantages over CT. Superior soft tissue contrast is possible with MRI leading to better definition between tumor and adjacent structures. Multiplanar imaging can be extremely helpful in appreciating and confirming the extent of disease. There is a lack of beam hardening artifacts which are encountered with CT when dental fillings are present. In patients who can not tolerate intravenous iodine contrast, MRI with gadolinium can still be performed. In order to optimally evaluate the head and neck for pathological processes, one must first have a clear understanding of the anatomy of the head and neck. Anatomical Considerations: In addition to understanding basic anatomical structures such as the tongue, the tonsilar fossa, the epiglottis, the paranasal sinuses, the nasal cavity, and the larynx, one must also be aware of certain anatomical spaces which are delineated by fascial planes. These anatomical spaces throughout the head and neck represent potential vertical highways for tumor spread of pathological processes. Pharyngeal Mucosal Space: This space is located very superficially along the pharyngeal mucosal walls. It includes the mucosa of the pharynx, Waldeyer's ring, the cartilaginous eustachian tube, the pharyngobasilar fascia, the levator and constrictor muscles. Common tumors seen in this space would include squamous cell cancer, lymphoma, and sometimes adenocarcinoma, adenoid cystic carcinoma, and juvenile angiofibromas. Thornwaldt cysts and mucous retention cysts can also be found along this space. It represents a very superficial layer for which tumors often will develop before they spread to deeper layers. This space is probably less important from an imaging standpoint than the deeper spaces as an endoscopist can usually detect tumor spread along this space without difficulty. Pharyngeal Mucosal Space * Most superficial layer includes the pharyngeal mucosa, Waldeyer's Ring, eustachian tube, constrictor and levator muscles. * Common masses: Squamous Cell Carcinoma Adenoid Cystic Carcinoma Lymphoma Juvenile Nasal Angiofibroma Thornwaldt's Cyst

and the pterygoid veins. and larynx. Lipomas may arise denovo from the fat within this space. The parapharyngeal space contains primarily fat. * METS (squamous cell cancer). pleomorphic adenomas. . branchial cleft cysts. Once in the parapharyngeal space. can spread to the next deeper layer which is often the parapharyngeal space. Parapharyngeal Space * Fat filled space with some twigs of the fifth nerve and pterygoid veins.Parapharyngeal Space: This is an important vertical highway which extends from the skull base to the hyoid bone. it can spread in a vertical manner very quickly. lipomas. Infections can also run rampant in this space in a very rapid manner. tonsilar fossa. infection. Tumors that may arise along the pharyngeal mucosal space such as squamous cell cancer of the tonsilar fossa. Lesions that are frequently encountered in this space include metastatic lesions from squamous cell cancer. particularly from the base of the tongue. * Extends from skull base down to the hyoid bone. Salivary gland tumors may also be encountered in this space as a result of direct extension. branches of the trigeminal nerves. Branchial cleft cysts can develop or cross through this space.

Involvement of the carotid space may be an indicator for nonresectability. Major verticle highway. paragangliomas. particularly in the internal jugular nodes.Carotid Space: This is another major highway through which tumors can race vertically up and down from the skull base down to the aortic arch. . Other lesions that can be found in the carotid space would include neurofibromas. * Common tumors: Metastatic squamous cell cancer Lymphoma Schwannomas/Neurofibromas Paraganglioma * Encasement of the carotid artery may mean inoperability. Popular sites of origin for squamous cell cancer to invade the carotid space include the larynx. the jugular vein. This space includes the extracranial carotid artery. the tongue base. Carotid Space * Includes carotid artery. internal. jugular chain of nodes. Metastatic lesions from squamous cell cancer can frequently be found in this space.. internal jugular vein. and the nasal pharynx. the internal jugular chain of nodes. * Extends from skull base down to aortic arch. and lymphomas. the tonsilar fossa. Infections which may be harbored. cranial nerves 9-11. can also be detected in the carotid space. particularly if the carotid artery is encased. Schwannomas. portions of cranial nerves 9 through 11.

Infections from vertebral osteomyelitis and/or prevertebral abscesses may also be encountered in this area. and the base of the tongue. Chordomas can also be found in this space. It includes not only the longus coli muscles. * Common masses METS Chordoma Infection . close scrutiny of tumor extension to the prevertebral space is very important. Prevertebral Space * Longus colli muscles. Common neoplasms that are found in the prevertebral space include metastatic lesions particularly from squamous cell carcinoma of the tonsilar fossa. spinal cord. the larynx. the vertebral artery. spine. but also the paraspinous muscles. the vertebra. Metastatic lesions to the prevertebral space as well as to the carotid space can potentially determine inoperability. the nasopharynx. For that reason. vertebral bodies. paraspinus muscles. and the spinal cord.Prevertebral Space: This is a complex space which is enveloped by a deep layer of cervical fascia. * METS involving the prevertebral space may also mean inoperability as a tumor-free margin can not be obtained.

Submandibular Space: This space contains the submandibular gland. Other types of tumors involving this space may include the variety of salivary gland tumors ranging from mucoepidermoid to adenoid cystic to pleomorphic adenomas. Submandibular Space * Includes submandibular gland. facial vein nerve and artery. Mucoepidermoid carcinomas. Lymphoma Adenoid Cystic Carcinoma. * Benign: Pleomorphic adenoma Warthin's Tumor Hemangioma Branchial Cleft Cysts Epidermoid . nodes. submandibular nodes. and portions of the facial vein and artery as well as the inferior loop of cranial nerve 7. Squamous cell cancer from the base of the tongue and floor of the mouth can extend into this space. * Malignancies: Squamous cell cancer from oral cavity and face.

Parotid Space * Includes parotid gland. * Common Tumors: Pleomorphic adenoma. and squamous cell carcinomas. mucoepidermoid carcinomas. adenoid cystic carcinomas. Warthin's Tumors. Common tumors in this location would include pleomorphic adenomas.Parotid Space: This space contains the parotid gland and the parotid segment of cranial nerve 7. hemangiomas. Warthin's tumors. mucoepidermoid carcinoma Adenoid cystic carcinoma Squamous cell cancer carcinoma Hemangioma . cranial nerve 7. retromandibular vein. external carotid artery. The retromandibular vein in external carotid arteries also pass through this space.

If neoplasm is discovered in this space. Salivary gland tumors can also extend into this space. and nasopharynx can be found extending into this space.Masticator Space: This space contains the muscles of mastication. particularly along the course of the mandibular division of cranial nerve 5. Metastatic extensions of squamous cell carcinoma. Lymphomas and hemangiomas as well as cellulitis or abscesses can also be found in this compartment. tonsilar fossa. These include the masticator. temporalis. * Common Masses: Squamous Cell Carcinoma Salivary Gland Tumors Lymphoma Hemangioma Abscess Rhabdomyosarcoma * Warning checks: Perineural spread along V3 (foramen ovale) . medial lateral pterygoid muscles. One should also check for possible perineural spread. particularly from the floor of the mouth. Masticator Space * Masseter. one should check for extension to the side of the skull as the masticator space extends very high into the suprazygomatic region along the temporalis muscle. the medial and lateral pterygoids. temporalis.

Retropharyngeal Space * Posterior mid-line potential space extending from skull base to approximately T3. * Common Masses: METS Lymphomas Infections . and infections. particularly from squamous cell cancer.Pterygopalatine fossa to orbital apex and cavernous sinus Retropharyngeal Space: This is a posterior potential midline space which can also present a major highway extending cephalad to the skull base or caudad down to approximately the T3 level. metastatic tumors. Common lesions which can involve this space would include lymphomas.

Nodes in all other levels of the neck exceeding 1 centimeter in size. should be considered abnormal. 2. or supraglottic larynx. * Check for extra capsular extension as this carries a very poor prognosis. breast. tongue. Lymph Nodes * Suspicious for malignancy if greater than 1. pharynx. esophagus. Abnormal supraclavicular nodes may represent metastasis from any source. parotid gland. Submandibular adenopathy may be related to metastasis from adjacent skin.5 centimeters in juglo-digastric region. * Central necrosis makes lymph nodes suspicious for malignancy regardless of size. tonsilar fossa. tongue base. Abnormal adenopathy in the midjugular chain may be related to metastasis from tongue. or supraglottic larynx cancers. but lung. submaxillary gland. In the jugular digastric region (levels 1. tonsil. 1 centimeter or greater elsewhere. or base of the tongue. and esophagus are particularly common sources.Lymph Node Evaluation: We consider nodes to be suspicious for metastatic disease by size.5 centimeters in diameter should be considered very suspicious for metastasis. Posterior triangle nodes may be seen with metastasis from the pharynx. One should also pay attention to nodes that have ill defined borders as there may be extracapsular extension with infiltration of the surrounding fat planes or encasement of vessels such as the carotid. Nodes with necrosis should also be considered abnormal regardless of size. Those along the jugular digastric region are often related to metastasis from the pharynx. Abnormal adenopathy along the inferior jugular chain may be due to metastatic disease from the supraglottic larynx. or thyroid. and 3 or submandibular and upper internal jugular chain) nodes that are larger than 1. the nasopharynx. . or thyroid. tonsilar fossa.

bone changes (erosion or thickening) may be present. hiatus semilunaris. * Olfactory cleft: obstruction may be a cause of anosmia. ethmoid bulla. * Haller cell: laterally situated ethmoid cell which can potentially cause structural obstruction of outflow to maxillary sinus. Relentless. and salivary malignancies. . Nasal Pharyngeal Squamous Cell Carcinoma * Warning sign: Unilateral otitis media/mastoiditis in adult. Obstructs sinuses. Fungiform papilloma: Arises from nasal septum. * Mucocele: an obstructed sinus. and maxillary). the finding of unilateral otitismedia and/or mastoiditis in an adult. Nasopharyngeal carcinoma tends to have a predilection for the fossa of Rosenmueller and therefore often presents with unilateral otitismedia or unilateral mastoiditis in adults. The osteomeatal complex represents a common drainage point for the anterior sinuses (frontal.PATHOLOGY BY LOCATION Paranasal Sinuses. This tumor likes to spread along the spinal accessory chain of nodes and the suspicious node in the posterior triangle may therefore alert one to the presence of nasopharyngeal carcinoma. Slow growth. * Concha Bullosum may act as an ethmoid air cell and should be reported. A mucocele is an obstructed sinus. In severe or complicated cases. non-hodgkins lymphoma. Likewise. and Nasal Cavity: Coronal CT is usually the most functional projection for evaluating the paranasal sinuses. should direct one to the nasopharynx to be sure that there is not an early nasopharyngeal cancer lurking. middle turbinate. fluid or airfluid levels filling the paranasal sinuses. * Papilloma: Neoplastic (benign) related to HP virus exposure.) Inverted papilloma: Arises from lateral wall adjacent to middle neatus. * Mucus retention cysts: obstructed mucus gland. Osteomeatal Complex: (Strategic point which a lesion can obstruct the anterior sinuses. A mucus retention cyst represents an obstructed gland. uncinate process. Inflammatory and/or allergic processes are usually seen as areas of mucoperiosteal thickening. Malignancies that affect the paranasal sinuses include squamous cell carcinoma. (Potential malignant transformation in 10 to 20 percent. Polyps and Papillomas * Polyps: Inflammatory or allergic etiology. Usually well-rounded and arises from side wall of sinus. A lesion placed at the osteomeatal complex can strategically obstruct the anterior sinuses. May cause bone destruction and epistaxes. It is usually seen as a rounded soft tissue mass attached to the wall of a sinus. middle meatus. Bone expansion can be present with mucoceles. Nasopharynx.) * Components: Infundibulum. ethnoid.

orbit. * Low grade malignancy. Other malignancies that occur in the nasopharynx and paranasal sinuses can include tumors of the minor salivary glands which line the mucosal surfaces of the nasopharynx and paranasal sinuses. Hodgkin's lymphoma is very uncommon in the head and neck. particularly into the maxillary sinuses. Non-Hodgkin's Lymphoma * Bulky masses. orbit. Juvenile Nasal Angiofibroma * Juvenile nasal angiofibroma: * Teenage males. * Arises from pterygopalatine fossa with frequent destruction of pterygoid plates. but invaginates inwardly into the underlying stroma. Juvenile nasal angiofibroma s tend to be seen in teenage males and usually originate along the pterygopalatine fossa. * May metastasize to spinal accessory nodes in posterior triangle. * May be accompanied by large cervical nodes. The inverted papilloma is a benign. * Cross fascial plains easily. slow growing lesion. It tends to grow inwardly. and possibly also into the middle cranial fossa.* Arises at fossa of Rosenmuller. * Tends to be destructive rather than blastic. They are extremely vascular and can follow blood vessels commonly out to the infratemporal fossa. The common place for an inverted papilloma to arise would be the lateral nasal wall at the middle meatus. Cervical lymph node involvement is common in non-Hodgkin's lymphomas of the head and neck and involvement of Waldeyer's ring is often seen. Adenocarcinomas and rhabdomyosarcomas are also a possibility. Most are histiocytic or lymphocytic types of lymphomas. . * Epistaxes and/or nasal obstruction. * May spread to infratemporal fossa. One should check for numerous flow voids and widening of the pterytopalatine foramen. Do not biopsy unless the tumor has been embolized. Non-Hodgkin's lymphoma is the second most common nasopharyngeal malignancy. * May involve a solitary gland such as the thyroid gland with or with out adjacent adenopathy and may arise very rapidly. Benign tumors would include inverted papilloma which arises from the mucous membranes. skull base. which tends to remottle and enlarge the nasal fossa. causing obstruction and possibly bone destruction. Epistasis can also be associated with this tumor. These would include adenoid cystic carcinomas and mucoepidermoid carcinomas. * May have thickening of Waldeyer's Ring. They can represent with nasal obstruction and epistasis. These tumors tend to be very bulky and can easily cross fascial planes. * Extremely vascular: Check for flow voids on MRI.

July 1991. Osborn A. AJR 159:278. Norbash AM. February 1993. Osborn A. * Slow growing. eds. Hesselink JR. 1st ed.. Hansberger H. Fibrosarcoma * Low grade malignancy. Pediatric sinonasal tumors.. Differential diagnosis of head and neck lesions based on their space of origin. * Very aggressive and malignant. Harnsberger H. March 1989. and recurrent. superior turbenates. St. Som P. Hudgins PA. vol. Differential diagnosis of head and neck lesions based on their space of origin. Buetow P. AJR 157:147-154. * Destroys adjacent architecture by direct invasion. 2005. Brown J. Nasopharynx and Deep Facial Compartments. * May present as cystic mass intracranially. Smoker W. 5. Som PM. July 1991. Philadelphia. Wenig B. Wiggins RH. nasal septum. The infrahyoid portion of the neck. * A form of PNET like medulloblastoma and pineoblastoma. SaundersElsevier. Applied Radiology 21-28. Differential diagnosis of head and neck lesions based on their space of origin. I. Radiologic Clinics NA. 2. 6. pp 2048-84. References: 1. Davidson HC: Diagnostic Imaging � Head and Neck. #2. Inverted papilloma. Saunders. The suprahyoid part of the neck. 2006. Zlatkin & Crues. Curtain HD. 1300-1549.. Head and Neck Imaging. ethmoid air cells. Shapiro M. Clinical Magnetic Resonance Imaging. AJR 157:147-154. Harnsberger HR. 7. * Relentless Esthesioneuroblastoma * Arises from neuroectodermal cells along cribriform plate. The suprahyoid part of the neck. August 1992. MRI of head and neck. Mosby-Year Book. AJR 155:159. in Edelman. 8. . 1996. relentless. 3. pp. July 1991. 3rd edition. Hesselink. 4. Smirniotopoulos J. Drawings adapted from: Harnsberger H. Louis. I. 9. Philadelphia. eds. Chew F. extends through the cribriform plate and may see the CSF. 27.* Usually slow growing.

Sign up to vote on this title
UsefulNot useful