3

Head and Neck Imaging

BERNARD B. O’MALLEY, MD

Imaging the neck is unlike imaging any region of the mented to improve upon the accuracy of clinical
torso or brain since maximal contrast resolution is lymph node staging. This is true of either computed
necessary to differentiate lesions in cross-sectional tomography (CT), magnetic resonance imaging
exams of those solid organs. Because of the various (MRI) or sonography and nuclear imaging including
organ systems, the neck has very good native con- fluorodeoxyglucose-positron emission tomography
trast resolution between lesions and adjacent normal (FDG-PET). Intravenous contrast is necessary to
structures and at the interface with the skull base characterize internal lymph node architecture on CT,
and thoracic inlet. Intravenous contrast is necessary, but less important on MRI. Careful attention to
however, to differentiate veins (and arteries) from lymph node sub-sites is needed at the lateral
adenopathy and masses (Figure 3–1). Once a base- retropharyngeal (Figure 3–3) and tracheo-esophageal
line scan has been obtained, contrast is less impor- groove (Figure 3–4) when appropriate. The added
tant for this particular consideration. Intravenous value of sonography is the capacity to perform fine-
contrast also helps characterize internal lymph node needle aspiration (FNA) of suspicious lymph
architecture for necrosis. Bolus timing parameters nodes,5 which might otherwise look unremarkable
are dependent on the equipment used1 and the med- on other imaging modalities or feel unimportant to
ical condition of the patient. Oral contrast in the the examiner. With proper attention to technique,
form of barium paste is helpful for lesions of the
hypopharyngo-esophageal complex. The throat,
being a semi-collapsed tube, is difficult to evaluate
on cross-sectional images. The importance of cross-
sectional imaging is in evaluating the submucosal 2
component of lesions (Figure 3–2), complementing
the clinical and endoscopic exam. Imaging is there-
fore not valuable for detection of mucosal disease 1
and cannot be a substitute for clinical inspection.
Evaluating a palpable neck mass2 and staging a
known mucosal or sinonasal lesion is the primary
role for imaging of the neck and head. Lesions of the
nasopharynx, parapharyngeal space, sinonasal tract
and subglottic space are better staged by the cross-
sectional exam, however. Familiarity with the imag-
ing of lymphomas and benign3 or inflammatory
lesions of the neck can prevent unnecessary surgical
Figure 3–1. Enhanced axial CT image through the oropharynx. (1)
explorations in this functionally and cosmetically Partially necrotic pathologic lymph node (level II). (2) Normal sub-
sensitive region.4 Imaging exams have been docu- mandibular node (level I-b) with fatty hilum.

57
58 CANCER OF THE HEAD AND NECK
1
2
Figure 3–2. Enhanced axial CT images through the oropharynx. (1) Base of tongue
squamous cancer extending to lateral pharyngeal wall. (2) Early extra-pharyngeal exten-
sion into parapharyngeal space.
both the neck and the primary lesion can be ade-
quately scanned at one imaging visit. Whether or not
there is a known primary tumor, the contrast bolus
should be peak for the axial survey of the neck. The
primary site, if it is known, can be scanned in what-
ever plane necessary in the post-bolus phase of the
scan. These issues are less important in MRI. As
many as one-third of all N0 neck dissections show
histologically positive metastatic adenopathy.6
Imaging may demonstrate some of these occult
metastases and thus improves upon the clinical
exam.7 In the N0 neck, FDG-PET (Figure 3–5) has
been reported to be more sensitive than CT or MRI8
and to have a sensitivity and specificity of approxi-
mately 90 percent.9 However, true micro-metastases
will remain below the resolution of cross-sectional
exams and current FDG-PET technology, but
enlarged lymph nodes should not be overlooked.
One half of all missed lymph nodes are less than or
equal to one centimeter in size. Careful analysis of
high quality scans is necessary to maintain a
respectable accuracy rate for staging the neck. Both
1
CT and MRI improve upon the clinical accuracy of
71 percent.7 Conventional MR is not adequate10 and
has no benefit over CT.11 The neck can be adequately
staged if MR is chosen for staging of the primary
site. FDG-PET is very accurate in the post-treatment
setting compared to either CT or MRI.12,13
As in other body regions, a diagnosis has often
been established and the imaging is performed to
round out the TNM staging. While radiology is com-
plementary to the clinical staging, it is responsible
for so-called stage creep,14,15 increasing the T, N, or
M component of the diagnosis. The radiologist and
clinical oncologist need to establish a rapport and
select the modality most appropriate for their collec-
tive expertise and imaging armamentarium. Scan
protocols must be established for consistency within
a practice and at the very least among sequential fol-
low-up surveillance-type scans on a given patient.
Consistent imaging parameters from contrast injec-
tion rates through scan technique16 to photography
facilitate detection of subtle changes lending confi-
dence to the diagnosis of often clinically occult

2 our ability to diagnose mucosal recurrences. Lymph
1 triage previously operated patients into categories
Figure 3–3. Axial T2-weighted MR image through the maxilla. (1)
Metastatic left lateral retropharyngeal lymph node. (2) Palate tumor
(hard and soft palate).
changes. Consistency also allows the other members
of the clinical oncology team to work with reliable
images for treatment planning.
Staging the index lesion involves evaluating for
the possibility of clinical underestimation of the
submucosal extent of disease17 (Figure 3–6), inva-
sion of adjacent vital structures18 (Figure 3–7), and
non-palpable adenopathy. Imaging for determination
of the M stage of disease begins (and usually ends)
with the chest radiograph. Cross-sectional imaging
of the chest should be productive given the preva-
lence of smoking exposure in the head and neck can-
cer population. This would also serve as a baseline
against which any developing apical pulmonary
radiation changes or aspiration infiltrates could be
compared. A well-designed scan of the neck that
covers the superior mediastinum should provide
adequate evaluation of the apical pulmonary region.
Detection and staging of neck lesions are very
important for accurate assignment of initial treatment
pathways for individual patients. High quality CT is
usually adequate for most upper aerodigestive sub-
sites. MRI is useful for skull base, larynx19 and equiv-
ocal CT findings.20 Follow-up imaging is very chal-
lenging, especially for the uninitiated. Distortion of
tissue planes by biopsy, resection, neck dissection,
Head and Neck Imaging 59
flap reconstruction (Figure 3–8) and/or radiation ther-
apy can be very distracting and misleading.21 Inflam-
matory changes related to chemotherapy-induced
mucositis and superimposed radiation changes22 limit
node metastases take unconventional pathways after
neck dissection.23 Different phases of contrast are
beneficial for different modalities. Early phases are
better for MRI1 and later phases are better for CT.24
Metabolic imaging in the form of FDG-PET will find
a more important role for this stage of patient evalua-
tion.13,25,26 This tool, while not perfect,27 will help
such as intervention or continued surveillance. In the
“unresectable” or organ preservation groups, deter-
mining the relative degree of metabolic activity of a
tumor prior to being treated will help determine the
effects of radiation treatment28 or combined thera-
pies.29 These images are best interpreted with some
form of co-registration with a cross-sectional scan.30
Less expensive methods of imaging FDG-PET with-
out a dedicated PET scanner (Figure 3–9) can be
competitive.31 If the PET radionuclides are not avail-
able, SPECT imaging with Tl-201 can be used as an
adjunct to the clinical exam.32,33
The Paranasal Sinuses
Tumors of the nasal cavity and paranasal sinuses are
the most challenging lesions to stage. The cosmetic
1 2
Figure 3–4. Enhanced axial CT through thoracic inlet. (1) Thick-
ened esophagus related to squamous cancer. (2) Necrotic lymph
node in the left tracheo-esophageal groove.
60 CANCER OF THE HEAD AND NECK

ties each provide vital but incomplete information.

Nowhere else than the skull-base margin is per-
ineural extension more problematic.37 Some very
2 small and very peripheral lesions track deep into the
skull base foramina (Figure 3–11) while other larger,
1
more centrally located masses grow in a simple cen-
trifugal manner. The interpretation must be made
with a high index of suspicion while the oncologist
must have a great deal of confidence in the interpre-
tation. A brain imaging protocol is often applied but
is inadequate in its standard form. A standard neck
imaging protocol will not provide adequate spatial
resolution at the skull base. A well-designed CT or
MR imaging protocol with appropriate plane, range
and section thickness is necessary for accurate diag-
nosis. Coronal, axial and sometimes sagittal views
Figure 3–5. Corongal FDG-PET image of torso. (1) Activity related
to unsuspected lymph node metastasis. (2) Activity related to glottic track the deep margin to best advantage. The cav-
squamous cancer. ernous sinus is the most difficult compartment to
confidently pronounce clear of disease with imag-
and functional impact of these tumors is immedi- ing. The vascular channels intermixed with fat are
ately apparent. They rarely present at an early stage. alternately bright and dark on MR imaging and
There are few, if any, discriminating imaging fea- inhomogeneously bright on CT. Tumor extension
tures among the various subtypes of tumors in this within the cavernous sinus can actually be identified
region. The challenge is to accurately predict the tis- on non-contrast images (Figure 3–12). Contrast
sue compartments that have been violated without images are necessary, however, to exclude disease
overestimating the boundaries of the tumor. Unlike
the neck, this region requires multiplanar imaging.
Radiographs and tomographic radiographs no
longer have a role in this work-up. The coronal view
is the single most important imaging plane (Figure
3–10) for the orbital margin and for the cribriform
plate for high naso-ethmoidal lesions.34 Prior to
MRI, high resolution CT was used to evaluate these 2 1
thin osseous barriers. Any distortion of the bone tex-
ture raised the suspicion of involvement of the adja-
cent soft-tissue space. With the advent of MRI, not
only is the coronal plane easier to acquire but also
the soft tissue within any compartment is directly 3
evaluated,35 not inferred from bony change. MRI is
probably the single best baseline-imaging exam for
paranasal neoplasms.36 Certain vagaries of physics
disturb tissue signal at these bone tissue air inter-
faces, but this is less problematic when tumor or
fluid replaces the air of the sinus cavity. The critical
determination of whether or not an orbit should be Figure 3–6. Axial T1-weighted MR image through maxilla in a
patient with squamous cancer of the soft palate. (1) Neurotropic
exenterated demands the application of both modal- extension to the left pterygopalatine fossa (PPF). (2) Normal appear-
ities (CT and MRI). These complementary modali- ance of right PPF. (3) Vidian canals, diseased on the left.

beyond the cavernous sinus, within the basal cisterns
(Figure 3–13). Axial views are familiar to most
observers and easily outline the deep posterolateral
extracranial extension to the masticator and para-
2 consultation with the maxillofacial prosthodontist.
4
3 margin that is neither visible nor palpable. Both
1
A evidence of widening of the corresponding fissure
3 positive margin.
2
1 cial for the above determination. The sagittal view
B
Figure 3–7. A, Enhanced axial CT through lower neck. (1) Left
common carotid artery (CCA). (2) Recurrent squamous cancer sur-
rounding the CCA. (3) Normal right CCA. (4) Normal right internal
jugular vein. B, Nonselective cervical catheter angiogram. (1) Proxi-
mal left CCA. (2) Extrinsic compromise of distal left CCA. (3) Normal
caliber proximal left internal carotid artery.
Head and Neck Imaging 61
pharyngeal spaces. The lateral retropharyngeal
lymph node station can also be cleared in this view.
Extra-paranasal extension into the clinically sus-
pected buccal and pre-maxillary spaces is confirmed
in this plane as well. Involvement of the palate must
be determined to allow appropriate preoperative
Epithelial tumors of the hard palate are best
staged by cross-sectional imaging protocols that
evaluate deep extension such as a paranasal sinus
protocol. The larger lesions are staged for the deep
advanced and apparently early/small lesions are at
risk for central neurotropic extension to and through
the foramina at the skull base (Figure 3–14). Distant
perineural extension is more typical of the minor
salivary histologies but can be seen in squamous
neoplasms, particularly those with desmoplastic fea-
tures. MRI has the distinct advantage over CT by
revealing abnormal perineural enhancement before
or foramen. These images help determine the extent
and appropriateness of skull base resection and por-
tal planning for radiation therapy in anticipation of a
Oral Cavity
Oral cavity lesions rarely require imaging without
clinical suspicion of deep infiltration. Patients with
floor of mouth, retromolar gum and endophytic
lesions of the tongue are imaged to rule out deeper
involvement. Key landmarks are the midline lin-
gual septum, mylohyoid sling, extrinsic muscles
and cortical margin of mandible. Although axial
images are most familiar, the coronal view is cru-
is important to exclude extension of anterior
tongue lesions into the root of the tongue base (Fig-
ure 3–15). As with surgical margins, the confi-
dence in diagnosing involvement of the intrinsic
tongue is limited by the heterogeneous signal of the
interlacing muscle and fat. Pre-contrast and fat-
suppressed post-contrast views must be carefully
matched to improve confidence. Involvement of
the extrinsic muscles must also be carefully
excluded. Determining T stage by measuring size
62 CANCER OF THE HEAD AND NECK
2
1 compartment allows treatment of nasopharyngeal
Figure 3–8. Enhanced axial CT image through reconstructed
hypopharynx. (1) Composite free tissue graft at hypopharynx produces
a pseudo-mass. (2) Partial airway compromise at supraglottic airway.
may be difficult to determine by any means and
any radiographic description must be considered an
estimated margin.
Retromolar lesions sit within one of the most
asymmetrically shaped structures, the trigone. Fur-
thermore, imaging artifacts most often degrade this
area, especially CT. Upward posterior extension
along the lateral pterygoid fascia and neurotropic
extension along the mandibular segment of the Vth
nerve can be clinically silent but should be excluded
in all cases.
Buccal mucosal lesions are not usually imaged
until they become problematic due to multiple recur-
rences and limitations to clinical evaluation due to
trismus. Submucosal, periosteal and perineural
extension is difficult to evaluate and close correla-
tion with the clinical findings is necessary to avoid
over- or underestimating disease which becomes dif-
ficult to stage given the loss of tissue planes after
multiple treatments.
Nasopharynx
Imaging of nasopharyngeal tumor requires the
greatest expenditure of techniques to confirm the
status of bone as well as perineural involvement.38
Confirming that disease is limited to the mucosal
lesions with a standard radiation portal while spar-
ing the cranial nerves (particularly cranial nerve II)
and the temporal lobes is the main goal of imaging.
While one modality may be adequate and efficient
for follow-up surveillance, it is the combination of
CT and MRI that is crucial at the baseline for this
disease. MRI is more sensitive than CT for invasion
of the cancellous bone of the central skull base. CT
is more sensitive to early involvement of the overly-
ing cortical bone of the sphenoid and basi occiput.
The minor change in the bone cortex that is not well
shown with MRI may have prognostic implications,
but will not likely change the treatment portal. MRI
may be the single best staging exam (Figure 3–16)
given the greater sensitivity to perineural exten-
sion,39 cavernous sinus extension4 and the more
accurate estimation of cancellous bone involvement.
MRI is adequate for nodal staging. Treatment plan-
ning is widely performed with CT although MRI-
based planning continues to develop.
Imaging follow-up is best performed with the
modality that is most compatible with the patients’
condition. CT remains an efficient method for fol-
3
2
1
Figure 3–9. Coronal coincidence FDG image of the upper body.
(1) Clinically symptomatic metastatic lower left cervical lymph node.
(2) Primary base of tongue lesion, occult on cross-sectional imaging.
(3) Normal intensity brain activity.
 Head and Neck Imaging 63

1
1

3 3

1
1

2 2

Figure 3–10. MRI images of sinus tumor. Sagittal upper and coronal lower
images with T1 and T2 weighting. (1) Penetration through fovea ethmoidalis into
extradural space. No brain invasion. (2) Displaced lamina papyracea without inva-
sion of orbital fat or muscle cone. (3) Obstructed sphenoid sinus secretions, not
tumor extension.

low-up surveillance imaging of the primary site does require intravenous contrast for detailed
and the neck. It is very reproducible between restaging, however. Patients receiving nephrotoxic
patients’ visits and among different institutions. CT chemotherapeutic agents should be followed with

Figure 3–11. Enhanced coronal T1-weighted MR image

1 through mid-orbits. (1) Thickened first division of left trigem-
inal nerve due to neurotropic skin tumor at forehead. (2)
2
Normal appearing first division of left trigeminal nerve.
64 CANCER OF THE HEAD AND NECK

2 1
3

Figure 3–12. Coronal T2-weighted MR image

through cavernous sinuses. (1) Tumor extension into
left cavernous sinus. (2) Intact dura stretched by
expanding tumor. (3) Normal heterogeneous
appearance of non-contrast MR of cavernous sinus.

MRI if their mucositis doesn’t produce too much
swallowing motion artifact. Scanning of both the
primary site and comprehensive evaluation of the
neck does result in a lengthy exam, however. A
bonus for the MRI cohort is evaluation of the CNS
white matter injury of the spinal cord, brainstem
and optic nerves.
contralateral to the original primary tumor. Misin-
terpretation of this phenomenon could falsely sug-
gest locoregional failure. Imaging artifact can be
avoided in the oropharynx with direct coronal views
behind the dental work that would otherwise obscure
the lesion in the axial plane.

Oropharynx

Most of the oropharyngeal sub-sites are easily eval-

uated in the axial plane with cross-sectional imag-
ing. Pharyngeal wall lesions rarely penetrate the 3

tough pharyngo-basilar fascia in their early stages.

Retropharyngeal extension and adenopathy are clin-
ically occult and must be excluded radiographically.
Invasion of the masticator space by tonsillar lesions
(Figure 3–17) can be detected with a good contrast-
enhanced scan. The index of suspicion must be high
particularly when trismus is present. Axial views
also outline base of tongue lesions across the glosso-
1
tonsillar sulcus, which may be difficult to appreciate
clinically. Base of tongue lesions are best supple-
2
mented by sagittal views to outline the status of the
preepiglottic space. This also determines the extent
of involvement anteriorly into the intrinsic muscles
of the tongue for accurate T staging.
Follow-up images need careful correlation with
pretreatment scans because of the variability of Figure 3–13. Axial contrast T1-weighted MR image through skull
base. (1) Neurotropic intracranial extension along cisternal segment of
native lymphoid tissue during treatment. Often Vth nerve. (2) Leptomeningeal growth along cerebellar folia. (3) Oper-
regrowth of lymphoid tissue produces pseudotumor ative bed of original ethmoid sinus tumor remains free of disease.
 Head and Neck Imaging 65

2
1

2
1 3
Figure 3–14. CT images of palate tumor with centripetal neurotrophic extension.
Upper panel: axial bone (L) and tissue (R) windows through palate. Lower panel:
coronal (L) and para-sagittal (R) tissue windows. (1) Palate tumor involving hard
and soft segments. (2) Extension upward through widened left greater palatine
foramen. (3) Normal bilateral palatine canals.

Soft palate lesions are difficult to discriminate without intravenous contrast. That benefit is not nec-
with conventional imaging because of the curved essary in early larynx cancer but has a bearing on
contour of the structure, the poor conspicuity of prognosis for local recurrence for more locally
these lesions and motion artifact from the soft palate advanced lesions.41 A negative CT is adequate for
resting on the tongue. This organ is best imaged in
the semi-coronal plane (Figure 3–18) with special
attention to the tonsillar margin.

Larynx and Hypopharynx

Imaging findings in the larynx have, in the past,

helped confirm the limited extent of early larynx
cancer allowing patients to decide between radiation
and surgery for primary management. Imaging for
advanced larynx and hypopharynx lesions helps
confirm the need for surgery and single out the 1
patients appropriate for organ preservation. Post- 2
3 4 5
biopsy changes distort the narrow tissue planes Figure 3–15. Midline sagittal MR tongue with undifferentiated
within the larynx and patients should not be scanned carcinoma. (1) Intact bone cortex of buccal plate at symphysis.
(2) Tumor originating at oral tongue. (3) Intact geniohyoid muscle.
prior to any endoscopic manipulation or biopsy. (4) Tumor extension toward base of tongue. (5) Preserved pre-
MRI provides exquisite soft tissue resolution40 even epiglottic space.
66 CANCER OF THE HEAD AND NECK

3 3

5 4

Figure 3–16. Nasopharynx cancer. Clockwise from upper left: semi-coronal T1-
weighted, contrast T1-weighted, and fat-suppressed T2-weighted MR images and
para-sagittal contrast T1-weighted MR images. (1) Mucosal mass. (2) Levator veli
palatini muscles (invaded on the left). (3) Intact skull base (clivus) with normal mar-
row signal. (4) Early invasion of parapharyngeal space. (5) Benign reactive
enhancement at foramen ovale, intracranial extension.

clearance of the paraglottic space and preepiglottic

space42 (Figure 3–19). MRI better evaluates the sub-
glottic extent and is more sensitive to early cartilage
involvement.43 Neither of these features is common
with early glottic cancer. Either modality can con-
firm a locally advanced lesion being restricted to the
supraglottis or hemilarynx permitting a primary sur-
1
gical approach.44,45 Advanced cancers of the larynx 2
cause pain and difficulty managing secretions—lim-
iting the success of MRI for staging. Tracheostomy
alleviates some of these problems. Rapid CT scan-
ners coupled with “slip ring” (helical/spiral) tech-
nology help produce images with less patient motion
artifact.46 Reformatted images can be produced in 3
the sagittal and coronal planes from the original
axial scan plane (Figure 3–20). Either modality pro-
vides adequate surgical planning or baseline infor-
mation prior to treatment. MRI is more sensitive but
Figure 3–17. Squamous cancer tonsillar pillar. (1) Large mass
less specific than CT for cartilage invasion.47 Imag- arising in right palatine tonsil. (2) Right medial pterygoid invaded. (3)
ing of primary tumors of the hypopharynx is per- Right base of tongue extension.
 Head and Neck Imaging 67

2 1

1
3 2

Figure 3–18. CT images of soft palate squamous cancer. Axial (L) and semi-
coronal (R) tissue windows. (1) Soft palate component. (2) Tonsillar pillar exten-
sion. (3) Medial pterygoid muscle (normal).

formed with larynx style protocols. Local extension
to the laryngeal framework is the most important
component of extra-pharyngeal extension. Imaging
detects cartilage invasion that can be clinically
occult.48 CT can detect inferior extension of pyri-
form sinus tumor (Figure 3–21) that cannot be
assessed clinically.49 Surveillance follow-up imag-
ing should take into account the risk for patient
motion with MRI and the ability of the patient to tol-
erate intravenous contrast for CT.
One method to reduce the need for re-biopsy and
avoid the difficulties of follow-up cross-sectional
imaging is PET imaging.13,26 Non-surgical or organ
preservation patients treated by chemo/radiotherapy
frequently have persistent morphologic abnormali-
ties on follow-up clinical evaluation and imaging
despite maximal therapy. Often this represents ster-
ilized tumor and fibrosis. Pain or dysfunction influ-
ence the decision to re-biopsy the primary site. In an
effort to avoid the post-biopsy injury, a baseline

2
1

Figure 3–19. CT images of left transglottic squamous cancer. Clockwise from

upper left panel: axial images through epiglottic, false cord and true cord levels of
larynx and coronal reformatted image of same. (1) Supraglottic lesion. (2) Para-
glottic component at false cord level. (3) Paraglottic extension to true cord level.
68 CANCER OF THE HEAD AND NECK
FDG-PET scan should be obtained and repeated
after treatment.50 If the degree of metabolic activity
has improved, biopsy could be deferred unless cross-
sectional imaging shows a distinct progression and
resection deferred unless the correlation of modali-
ties indicates severe tissue necrosis. Another sec-
ondary benefit of the FDG-PET scan would be sur-
veillance for second primaries. Nuclear scans with
thallium-201 on more conventional equipment with
single photon emission computed tomography
(SPECT) capacity has been shown to be competitive
with CT in the post-treatment larynx population.51
This method had an accuracy of 90 percent and does
not require investment in PET technology.
Follow-up imaging of the reconstructed and irra-
diated laryngopharyngectomy is very important
given the difficulty of examining the irradiated/
operated neck. Familiarity with the type of resec-
tions, flap reconstructions and patterns of recurrence
is essential for accurate interpretation.52,53 Careful
attention should be directed to the anastomotic level
and peristomal region.
Esophagus
The cervical segment of the esophagus is difficult to
evaluate clinically. It remains one of the sites in the
Figure 3–20. Large supraglottic cancer. Upper
panel: sagittal (L) and coronal (R) reformatted CT
images. Lower panel: glottic (L) and epiglottic (R)
axial CT source images. (1) Mucosal lesion at laryn-
geal surface of epiglottis. (2) Inferior preepiglottic
extension.
2
head and neck best evaluated with fluoroscopy (Figure
3–22). Mural and exophytic lesions can be detected
prior to advanced dysphagia, which is usually the
accompanying chief complaint. Like other segments
of the esophagus, complete staging is best performed
with a combination of endo-sonography,54 and cross-
sectional imaging. These techniques are complemen-
tary, with the endoscopic exam providing information
about the depth of invasion relative to the muscularis,
the linear extent of the lesion and characterization of
internal architecture of posterior mediastinal lymph
nodes. Synchronous lesions can be excluded at other
levels of the esophagus at baseline. Cross-sectional
exams provide a more complete locoregional N stag-
ing and can be extended for regional M staging. Nei-
ther CT nor MRI has sufficient negative predictive
value for adenopathy, however.
Salivary Glands
Imaging of cancer of the minor salivary glands is
covered in the corresponding sub-sites. Imaging of
the major salivary gland masses is usually per-
formed when the clinical exam does not provide
accurate assessment of the anatomic extent of the
tumor or when surgical excision is likely to have a
positive margin on a vital structure. Imaging
1
1
2
1
 Head and Neck Imaging 69

1 1

2 2

Figure 3–21. Contrast CT images of left pyriform squa-

mous cell carcinoma. Clockwise from upper left: serial
images through the laryngo-pharynx. (1) Diseased left
pyriform aperture. (2) Preserved left pyriform apex.

should also be considered in the setting of cranial

nerve palsy.55
Parotid lesions are easily outlined with CT when
high quality multiplanar images can be acquired and
intravenous contrast used. Contrast helps outline the
lesion relative to the gland and provides better char-
acterization of the vascular margin at the carotid 1
sheath. The benefits of MRI over CT are better dis-
crimination of the lesion relative to background
parotid tissue (Figure 3–23) and slightly better dis-
crimination of proximal neurotropic extension of 2
disease along the VIIth nerve.
Image-guided biopsy is helpful when there is a
need to establish the diagnosis prior to treatment.
Follow-up imaging is best performed with the
modality that revealed the lesion prior to treatment.
Radiation changes produce extensive regional
hyperintensity22 of the parotid bed and mastoid, lim-
iting the value of T2-weighted images. Contrast-
enhanced fat-suppressed T1-weighted images are
important at this stage.1
Submandibular lesions are often managed without
imaging prior to resection. Imaging of the neck can be
Figure 3–22. Anterior esophagram of squamous cell carcinoma
performed to confirm the completeness of the resec- upper esophagus. (1) Varicoid appearance of squamous cancer cer-
tion and determine whether a limited neck dissection vicothoracic esophagus. (2) Trachea.
70 CANCER OF THE HEAD AND NECK
is appropriate. Both sublingual and submandibular
salivary gland lesions are imaged with an oral cavity-
type imaging protocol with careful attention to the
floor of mouth and the status of Wharton’s duct.
Thyroid
Imaging of the thyroid gland and neck for thyroid
cancer varies because of the variety of disciplines
that manage this disorder. Imaging of the gland is
only part of a comprehensive clinical and labora-
tory evaluation. Whether the imaging is cross-sec-
tional, functional (radioiodine), or metabolic
(FDG-PET) should be determined by the evalua-
tion and the chief complaint. Persons with meta-
bolic complaints should be imaged with radioio-
dine to supplement their work-up, if necessary.
Persons with palpable abnormalities don’t neces-
sarily need radioiodine scanning initially. Sonogra-
phy is often used to confirm multiplicity and con-
sistency of lesions, favoring a benign condition.
Neither CT, MRI, sonography nor radioiodine
scans can confirm or exclude cancer, however.
FNA is essential for lesions considered at risk for
cancer by clinical or imaging grounds. Sonography
preceding or as an adjunct to the FNA may reveal a
cyst, which could be aspirated or followed, as clin-
ically indicated. When cancer has been confirmed,
sonography (Figure 3–24) can establish the size of
the lesion(s), the status of any pseudo-capsule, and
the condition of the capsule of the gland.56 Sono-
graphic staging of the lymph nodes is limited5 and
CT or MRI is better at covering the high level II
nodes and the lower tracheo-esophageal nodes.
Cross-sectional imaging of the neck is not neces-
sary prior to thyroid surgery in the absence of clin-
ical features suspicious for extra-thyroidal or medi-
astinal extension. Since iodinated intravenous
contrast alters the accuracy of radioiodine scans,
CT is a less useful modality for baseline staging.
Imaging artifacts at the thoracic inlet and upper
mediastinum are difficult to sort out in the absence
of contrast with CT. MRI is not prone to these arti-
facts (Figure 3–25) and can be performed with con-
trast without interference with radioiodine scans.
Neck scans by either modality should be extended
to the level of the tracheal carina to cover the lower
tracheoesophageal lymph nodes at risk. Correlation
of the cross-sectional views with the radioiodine
scans is more productive than either scan alone.
Lesions that accumulate iodine less well can be
imaged with thallium57 or FDG-PET.58,59 This
agent accumulates in metabolically active tissue,
and to a greater degree in tumor. Although costly
and less specific, FDG-PET can be used without
interruption of thyroid replacement. Another defi-
nite advantage of PET is the ability to co-register
the images in any plane with cross-sectional exams
in a way that cannot be done with I-131.
Unknown Primary
No discussion of head and neck imaging would be
complete without a discussion of the occult primary
presumed to be within the upper aerodigestive tract.
If one looks at the larger picture of patients with
metastatic adenopathy above the clavicles, the role
of imaging has increasing value. CT of the neck,
chest, abdomen and pelvis usually follows the tradi-
tional method of panendoscopy and exam under
anesthesia after an unproductive office exam. The
advent of FDG-PET can obviate the need for such
comprehensive searching60 and might even be
sequenced between the office exam and any subse-
1
3
2
4
Figure 3–23. Parotid tumor. (1) Parotid tumor along expected course
of facial nerve. (2) Superficial lobe involvement. (3) Deep lobe exten-
sion to paraphayngeal space. (4) Preserved stylomastoid foramen.
 Head and Neck Imaging 71

sectional exam of the neck. The majority of patients

3
with positive FDG-PET scans are found to have a
2 corresponding tumor and most of those with nega-
tive scans never manifest a head or neck primary on
1
follow-up (after treatment).61,62 At the very least,
patients with no identifiable primary or one local-
ized to the head and neck have a better prognosis
than those discovered to have a visceral primary
below the clavicles.63

4
Figure 3–24. Throid cancer sonogram. Transverse sonogram
through right thyroid bed. (1) Solid component of complex mass. (2)
Cystic component of complex mass. (3) Artifact. (4) Intact pseudo-
capsule of lesion.
quent procedure requiring anesthesia. The results of
the PET scan can show other sites of adenopathy and
locate the primary tumor25 (see Figure 3–9). PET
images are best reviewed in correlation with a cross-
Sarcomas
Soft tissue sarcomas and other tumors usually pre-
sent within the lateral neck or paraspinal compart-
ments. These are imaged equally well with MRI64 or
contrast enhanced CT. CT tends to overestimate the
overall size of neck masses65 compared with MRI—
probably because of its multiplanar capacity. Vascu-
lar integrity and margins can also be surveyed at the
initial MRI visit with the help of magnetic resonance
angiography (MRA). Many patients can be spared
catheter angiography. Sarcomas developing within
sub-sites of the aerodigestive tract are imaged
according to those protocols. Combining informa-

Figure 3–25. Throid cancer MRI. Clockwise from

upper left: Coronal and sagittal T1-weighted non-
contrast images and axial T2-weighted images
4 through base of neck and thoracic inlet. Note the lack
1 of imaging artifacts. (1) Left lobe thyroid mass. (2)
Extracapsular extension. (3) Tracheoesophageal
lymph node metastasis. (4) Trachea. (5) Invasion of
prevertebral muscles. (6) Plane of brachiocephalic
vein. (7) Left common carotid artery.

6
2 3

7
7
1

4 5
72 CANCER OF THE HEAD AND NECK
tion from pretreatment MRI with CT based treat-
ment planning lends confidence to those plans.
FUTURE DIRECTIONS
Cross-sectional imaging will continue to develop
computer assisted interactive methods for opera-
tive guidance66 and treatment based on pre-proce-
dure scans. These procedures are best performed
by practitioners with prior experience without the
aid of imaging support. Further development of
interactive types of software should allow trainees
to develop skills on so-called virtual patients, pro-
viding that experience base. Performing proce-
dures under imaging guidance is advancing from
simple biopsies and ablations to realtime guidance
on “fluoroscopic-CT” and “open architecture”
MRI equipment.
Developments in sonography with color flow
imaging of lymph nodes and power Doppler imag-
ing of masses and lymph nodes is being explored to
better characterize for neoplastic features.
Continued improvement in CT scanner technol-
ogy allows for performance of CT angiography in
selected cases for patients that may not be able to
undergo MRA.
Continued development of iron-coated dextran
may provide more accurate evaluation of borderline
sized lymph nodes.11
Nuclear imaging will come to play a greater role
in triage of patients along treatment pathways, pre-
and post-treatment. New ligands, combined with
conventional radionuclides, are being explored for
the detection of squamous cell carcinoma with
cross-sectional nuclear imaging (SPECT).67,68 More
specific isotopes for head and neck neoplasms will
replace FDG for PET imaging.69 The continued
exploration of monoclonal antibodies70 holds
promise for detection of more specific tissue anti-
gens.71,72 Novel combinations of established nuclear
agents are being explored to reduce the need for
obtaining both a nuclear and a cross-sectional exam,
simply for correlation.73
The thrust of much of the past decade of
research has been to find an efficient pathway of
patient management where selection of an imaging
modality provides pertinent and accurate informa-
tion. Ideally the technique would provide anatomic
staging of the primary site, comprehensive lymph
node staging and functional information regarding
nerves and blood vessels. One of the original goals
of MRI was to provide in vivo tissue characteriza-
tion on human subjects. Twenty years after its intro-
duction, MR shows promise for “one-stop shop-
ping” for all vital information: MR imaging, MR
angiography, and now MR spectroscopy.74 Improve-
ments in software have followed necessary
improvements in hardware and magnetic field
strength. Sampling a small volume of tissue from a
cross-sectional image and analyzing for relative
amounts of known metabolites can predict the like-
lihood of neoplasm.75 As with other modalities, a
physician is responsible for determining the pres-
ence of a target on the image for sampling. Like
FDG-PET, this noninvasive technique allows one to
follow a trend during treatment in order to confirm
treatment response.
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