ExpertDDX: Head and Neck, 2e 2nd

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 SECOND EDITION

Koch | Hamilton
ii
 SECOND EDITION

Bernadette L. Koch, MD
Associate Director of Radiology
Cincinnati Children’s Hospital Medical Center
Professor of Clinical Radiology and Pediatrics
University of Cincinnati College of Medicine
Cincinnati, Ohio

Bronwyn E. Hamilton, MD
Professor of Radiology
Director of Head & Neck Radiology
Oregon Health & Science University
Portland, Oregon

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

EXPERTDDX: HEAD AND NECK, SECOND EDITION ISBN: 978-0-323-55405-3

Copyright © 2019 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher.
Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.
elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made. To the fullest extent of the
law, no responsibility is assumed by Elsevier, authors, editors or contributors for any
injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Library of Congress Control Number: 2018953134

Cover Designer: Tom M. Olson, BA

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To Ric, an amazing inspiration to many in the world of head and neck imaging.
Thank you for your unending support and encouragement.
To Bronwyn, my coeditor, whose excellence in editing and passion for getting it
right helped me navigate this journey.
To the Elsevier team, especially Nina Bennett, whose hard work, kind heart, and
encouraging words kept us on task.
BLK

To Gary and Rhiannon, who provide joy and inspiration for my days: Thank you for
embracing my quirks and sharing the ride.
To my loving parents and brother, Mark, without whom life would not be so full
and rich: Thank you for your encouragement and support.

To Ric, you inspired a generation of radiologists to be excellent. We are grateful

for the legacy you leave but will truly miss your thought-provoking teaching and
inimitable turns of phrase.
To Bernadette, grateful thanks for your top notch editorial skills and patience
throughout the process. You made this project fun!
BEH

We have been lucky to maintain an excellent team of leading authors who have
contributed their expertise, updating content throughout this edition.
BLK & BEH

v
vi
 Contributing Authors
Yoshimi Anzai, MD, MPH
Professor
Department of Radiology and Imaging Sciences
University of Utah Health Sciences
Salt Lake City, Utah
Nancy J. Fischbein, MD
Professor of Radiology and, by courtesy, of Neurology,
Neurosurgery, Otolaryngology-Head and
Neck Surgery, and Radiation Oncology
Department of Radiology
Stanford University Medical Center
Stanford, California
Nicholas A. Koontz, MD
Director of Fellowship Programs
Dean D.T. Maglinte Scholar in Radiology Education
Assistant Professor of Radiology and Imaging Sciences,
Otolaryngology-Head & Neck Surgery
Department of Radiology and Imaging Sciences
Indiana University School of Medicine
Indianapolis, Indiana
Luke N. Ledbetter, MD
Assistant Professor
Department of Radiology
The University of Kansas Medical Center
Kansas City, Kansas
Additional Contributors
Susan I. Blaser, MD, FRCPC
Joel K. Curé, MD
H. Christian Davidson, MD
Jolanta M. Dennis, MD
Christine M. Glastonbury, MBBS
H. Coleman Herrod, MD
Chang Yueh Ho, MD
Daniel E. Meltzer, MD
Associate Professor of Radiology
Division of Neuroradiology
Department of Radiology
Icahn School of Medicine at Mount Sinai
New York, New York
Kristine M. Mosier, DMD, PhD
Associate Professor of Radiology and Imaging Sciences
Chief of Head and Neck Imaging, Department of
Radiology and Imaging Sciences
Indiana University School of Medicine
Indianapolis, Indiana
C. Douglas Phillips, MD, FACR
Professor, Department of Radiology
Director of Head and Neck Imaging
Weill Cornell Medical College
NewYork-Presbyterian Hospital
New York, New York
Richard H. Wiggins, III, MD, CIIP, FSIIM
Professor, Director of Head and Neck Imaging
Department of Radiology and Imaging Sciences
University of Utah Health Sciences Center
Salt Lake City, Utah
Blair A. Winegar, MD
Assistant Professor
Department of Medical Imaging
University of Arizona College of Medicine
Tucson, Arizona
Patricia A. Hudgins, MD, FACR
Gregory L. Katzman, MD, MBA
Logan A. McLean, MD
Michelle A. Michel, MD
Anne G. Osborn, MD, FACR
Caroline D. Robson, MBChB
vii
viii
 Preface
This book would not be possible without the incredible foundational work of Dr. Ric
Harnsberger. We are grateful for his passionate and inspiring teaching style. We are confident
that his characteristic style remains in this current revision.

This second edition of the original ExpertDDx: Head and Neck book continues in the same
format as the prior edition, with the primary goal being to help busy radiologists answer
the question, “What is the differential diagnosis for that finding on my scan?” It maintains
the successful style of the former edition and presents 162 expert differential diagnoses in
head and neck pathology. Differential considerations are separated by 4 classic methods used
when constructing a differential diagnosis: Anatomy based, imaging finding based, modality
based, and clinically based.

Each chapter has pertinent key facts, typical imaging findings, and imaging cases that will help
the busy practicing radiologist find relevant and pertinent diagnostic considerations.

There are over 1,450 images in the online content, with over 2,660 images in the print version
of the book. Evolving topics in head and neck radiology are updated throughout, and each
chapter now includes updated references.

We hope that you will enjoy this concise, bullet-point, differential diagnosis-style textbook of
head and neck pathology as much as we enjoyed updating it for you!

Warmly,
Bernadette and Bronwyn

Bernadette L. Koch, MD
Associate Director of Radiology
Cincinnati Children’s Hospital Medical Center
Professor of Clinical Radiology and Pediatrics
University of Cincinnati College of Medicine
Cincinnati, Ohio

Bronwyn E. Hamilton, MD
Professor of Radiology
Director of Head & Neck Radiology
Oregon Health & Science University
Portland, Oregon

ix
x
Acknowledgments
Lead Editor
Nina I. Bennett, BA

Text Editors
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Terry W. Ferrell, MS
Matt W. Hoecherl, BS
Megg Morin, BA
Joshua Reynolds, PhD

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Wissler, MA

Art Direction and Design

Tom M. Olson, BA

Production Coordinators
Emily C. Fassett, BA
Angela M. G. Terry, BA

xi
xii
 Sections
SECTION 1:
Suprahyoid and Infrahyoid

SECTION 2:
Oral Cavity, Mandible and Maxilla

SECTION 3:
Hypopharynx and Larynx

SECTION 4:
Lymph Nodes

SECTION 5:
Transspatial, Multispatial, or
Multilocation in Head and Neck

SECTION 6:
Sinus and Nose

SECTION 7:
Orbit

SECTION 8:
Temporal Bone

SECTION 9:
Skull Base

SECTION 10:
CPA-IAC and Posterior Fossa

SECTION 11:
Cranial Nerves and Brainstem

xiii
 TABLE OF CONTENTS

SECTION 1: SUPRAHYOID AND GENERIC IMAGING PATTERNS

INFRAHYOID 96 Diffuse Parotid Disease
ANATOMICALLY BASED DIFFERENTIALS Bronwyn E. Hamilton, MD
100 Multiple Parotid Masses
4 Parapharyngeal Space Lesion Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
Bronwyn E. Hamilton, MD and Jolanta M. Dennis, MD MBBS
10 Pharyngeal Mucosal Space Lesion, Nasopharynx 102 Focal Retropharyngeal Space Mass
Luke N. Ledbetter, MD and Patricia A. Hudgins, MD, FACR Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
14 Pharyngeal Mucosal Space Lesion, Oropharynx MBBS
Luke N. Ledbetter, MD and Jolanta M. Dennis, MD 106 Diffuse Retropharyngeal Space Disease
18 Masticator Space Lesion Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
Bernadette L. Koch, MD and Christine M. Glastonbury, MBBS
MBBS 110 Diffuse Thyroid Enlargement
24 Buccal Space Lesion Bronwyn E. Hamilton, MD
Bernadette L. Koch, MD and Christine M. Glastonbury, 114 Focal Thyroid Mass
MBBS Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
28 Parotid Space Mass MBBS
Bronwyn E. Hamilton, MD and Christine M. Glastonbury, 118 Invasive Thyroid Mass
MBBS Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
34 Carotid Space Lesion MBBS
C. Douglas Phillips, MD, FACR
38 Carotid Artery Lesion CLINICALLY BASED DIFFERENTIALS
C. Douglas Phillips, MD, FACR
122 Cheek Mass
42 Perivertebral Space Lesion
Bernadette L. Koch, MD and Christine M. Glastonbury,
C. Douglas Phillips, MD, FACR
MBBS
46 Brachial Plexus Lesion
128 Trismus
Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
Bernadette L. Koch, MD and Christine M. Glastonbury,
MBBS
MBBS
52 Visceral Space Lesion
Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
SECTION 2: ORAL CAVITY, MANDIBLE
MBBS
AND MAXILLA
58 Cervical Tracheal Lesion
Bernadette L. Koch, MD and Christine M. Glastonbury, ANATOMICALLY BASED DIFFERENTIALS
MBBS
136 Oral Mucosal Space/Surface Lesion
64 Tracheoesophageal Groove Lesion
Luke N. Ledbetter, MD and Patricia A. Hudgins, MD, FACR
Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
140 Sublingual Space Lesion
MBBS
Bernadette L. Koch, MD and H. Coleman Herrod, MD
68 Posterior Cervical Space Lesion
144 Submandibular Space Lesion
Bernadette L. Koch, MD
Bernadette L. Koch, MD and Logan A. McLean, MD
74 Cervicothoracic Junction Lesion
150 Submandibular Gland Lesion
Bronwyn E. Hamilton, MD and Christine M. Glastonbury,
Richard H. Wiggins, III, MD, CIIP, FSIIM
MBBS
154 Root-of-Tongue Lesion
80 TMJ Mass Lesions
Bernadette L. Koch, MD and Jolanta M. Dennis, MD
Daniel E. Meltzer, MD and Joel K. Curé, MD
158 Hard Palate Lesion
86 Calcified TMJ Lesions
Richard H. Wiggins, III, MD, CIIP, FSIIM
Daniel E. Meltzer, MD and Joel K. Curé, MD
162 Maxillary Bone Lesion
92 TMJ Cysts
Richard H. Wiggins, III, MD, CIIP, FSIIM
Daniel E. Meltzer, MD and Joel K. Curé, MD

xiv
 TABLE OF CONTENTS
GENERIC IMAGING PATTERNS SECTION 5: TRANSSPATIAL,
166 Tooth-Related Mass, Sclerotic MULTISPATIAL, OR MULTILOCATION IN
Luke N. Ledbetter, MD HEAD AND NECK
168 Tooth-Related Mass, Cystic GENERIC IMAGING PATTERNS
Luke N. Ledbetter, MD
240 Air-Containing Lesions in Neck
MODALITY-SPECIFIC IMAGING FINDINGS Bernadette L. Koch, MD
170 Low-Density Jaw Lesion, Sharply Marginated (CT) 242 Solid Neck Mass in Infant
Daniel E. Meltzer, MD and Joel K. Curé, MD Bernadette L. Koch, MD
174 Low-Density Jaw Lesion, Poorly Marginated (CT) 246 Solid Neck Mass in Child
Daniel E. Meltzer, MD and Joel K. Curé, MD Bernadette L. Koch, MD
180 Ground-Glass Lesions of Mandible and Maxilla (CT) 250 Cystic Neck Mass in Child
Daniel E. Meltzer, MD and Joel K. Curé, MD Bernadette L. Koch, MD
254 Cystic-Appearing Neck Masses in Adult
SECTION 3: HYPOPHARYNX AND Yoshimi Anzai, MD, MPH and Patricia A. Hudgins, MD,
LARYNX FACR
258 Transspatial Mass in Child
ANATOMICALLY BASED DIFFERENTIALS Bernadette L. Koch, MD
262 Transspatial Neck Mass
186 Hypopharyngeal Lesion
Richard H. Wiggins, III, MD, CIIP, FSIIM
Daniel E. Meltzer, MD and Patricia A. Hudgins, MD, FACR
190 Laryngeal Lesion MODALITY-SPECIFIC IMAGING FINDINGS
Yoshimi Anzai, MD, MPH and Patricia A. Hudgins, MD,
FACR 268 Hyperdense Neck Lesion (CT)
C. Douglas Phillips, MD, FACR
GENERIC IMAGING PATTERNS 272 Low-Density Neck Lesion (CT)
C. Douglas Phillips, MD, FACR
196 Epiglottic Enlargement
276 Hypervascular Neck Lesion (CT/MR)
Daniel E. Meltzer, MD and Patricia A. Hudgins, MD, FACR
C. Douglas Phillips, MD, FACR
198 Diffuse Laryngeal Swelling
Richard H. Wiggins, III, MD, CIIP, FSIIM CLINICALLY BASED DIFFERENTIALS
202 Subglottic Stenosis
Bernadette L. Koch, MD and Christine M. Glastonbury, 280 Angle of Mandible Mass
MBBS Richard H. Wiggins, III, MD, CIIP, FSIIM
284 Supraclavicular Mass
CLINICALLY BASED DIFFERENTIALS Richard H. Wiggins, III, MD, CIIP, FSIIM
208 Vocal Cord Paralysis (Left) SECTION 6: SINUS AND NOSE
Bronwyn E. Hamilton, MD
214 Vocal Cord Paralysis (Right) ANATOMICALLY BASED DIFFERENTIALS
Bronwyn E. Hamilton, MD
292 Sinonasal Anatomic Variants
218 Stridor in Child
Luke N. Ledbetter, MD and Michelle A. Michel, MD
Bernadette L. Koch, MD
GENERIC IMAGING PATTERNS
SECTION 4: LYMPH NODES
296 Nasal Septal Perforation
GENERIC IMAGING PATTERNS Luke N. Ledbetter, MD and Michelle A. Michel, MD
224 Enlarged Lymph Nodes in Neck of Adult 298 Congenital Midline Nasal Lesion
Yoshimi Anzai, MD, MPH and Patricia A. Hudgins, MD, Luke N. Ledbetter, MD and Michelle A. Michel, MD
FACR 300 Fibroosseous and Cartilaginous Lesions
230 Avidly Enhancing Lymph Nodes Luke N. Ledbetter, MD and Michelle A. Michel, MD
Yoshimi Anzai, MD, MPH and Patricia A. Hudgins, MD, 302 Inflammatory Patterns of Sinusitis
FACR Luke N. Ledbetter, MD and Michelle A. Michel, MD
234 Enlarged Lymph Nodes in Neck of Child 304 Multiple Sinonasal Lesions
Bernadette L. Koch, MD Daniel E. Meltzer, MD and Michelle A. Michel, MD
308 Expansile Sinonasal Lesion
Daniel E. Meltzer, MD and Michelle A. Michel, MD
312 Nasal Lesion With Bone Destruction
Daniel E. Meltzer, MD and Michelle A. Michel, MD
316 Nasal Lesion Without Bone Destruction
Daniel E. Meltzer, MD and Michelle A. Michel, MD

xv
 TABLE OF CONTENTS
320 Sinus Lesion Without Bone Destruction 406 Ill-Defined Orbital Mass
Daniel E. Meltzer, MD and Michelle A. Michel, MD Kristine M. Mosier, DMD, PhD
324 Sinus Lesion With Bone Destruction 410 Cystic Orbital Lesions
Daniel E. Meltzer, MD and Michelle A. Michel, MD Kristine M. Mosier, DMD, PhD
328 Facial Bone Lesion 414 Vascular Lesions of Orbit
Daniel E. Meltzer, MD and Michelle A. Michel, MD Blair A. Winegar, MD and H. Christian Davidson, MD
418 Accidental Foreign Bodies in Orbit
MODALITY-SPECIFIC IMAGING FINDINGS Blair A. Winegar, MD and H. Christian Davidson, MD
332 Hyperdense Disease in Sinus Lumen (CT) 422 Surgical Devices and Treatment Effects in Orbit
Blair A. Winegar, MD Blair A. Winegar, MD
336 Calcified Sinonasal Lesion (CT)
Blair A. Winegar, MD and Michelle A. Michel, MD MODALITY-SPECIFIC IMAGING FINDINGS
340 T2 Hypointense Sinus Lesion (MR) 426 Intraocular Calcifications (CT)
Blair A. Winegar, MD Blair A. Winegar, MD and H. Christian Davidson, MD

CLINICALLY BASED DIFFERENTIALS CLINICALLY BASED DIFFERENTIALS

344 Nasal Obstruction in Newborn 428 Leukocoria
Blair A. Winegar, MD and Michelle A. Michel, MD Bernadette L. Koch, MD
346 Anosmia-Hyposmia 432 Painless Proptosis in Adult
Blair A. Winegar, MD Kristine M. Mosier, DMD, PhD
350 Epistaxis 436 Painful Proptosis in Adult
Blair A. Winegar, MD Kristine M. Mosier, DMD, PhD
354 Traumatic Lesions of Face 440 Rapidly Developing Proptosis in Child
Richard H. Wiggins, III, MD, CIIP, FSIIM and Michelle A. Blair A. Winegar, MD and Bernadette L. Koch, MD
Michel, MD 444 Infectious and Inflammatory Orbital Lesions
Kristine M. Mosier, DMD, PhD
SECTION 7: ORBIT 448 Extraocular Orbital Mass in Child
Bernadette L. Koch, MD
ANATOMICALLY BASED DIFFERENTIALS
360 Preseptal Lesion SECTION 8: TEMPORAL BONE
Kristine M. Mosier, DMD, PhD
364 Ocular Lesion, Adult
ANATOMICALLY BASED DIFFERENTIALS
Kristine M. Mosier, DMD, PhD 454 External Auditory Canal Lesion
368 Ocular Lesion, Child Nicholas A. Koontz, MD
Kristine M. Mosier, DMD, PhD 460 Middle Ear Lesion, Child
372 Optic Nerve Sheath Lesion Bernadette L. Koch, MD
Blair A. Winegar, MD 464 Middle Ear Lesion, Adult
374 Intraconal Mass Bernadette L. Koch, MD
Kristine M. Mosier, DMD, PhD 468 Inner Ear Lesion, Adult
378 Extraconal Mass Bernadette L. Koch, MD
Blair A. Winegar, MD 472 Petrous Apex Lesion
384 Lacrimal Gland Lesion Blair A. Winegar, MD and Logan A. McLean, MD
Blair A. Winegar, MD 476 Inner Ear Lesion, Child
386 Orbital Wall Lesion Bernadette L. Koch, MD
Blair A. Winegar, MD 480 Facial Nerve Lesion, Temporal Bone
Nicholas A. Koontz, MD
GENERIC IMAGING PATTERNS
390 Microphthalmos
GENERIC IMAGING PATTERNS
Bernadette L. Koch, MD 484 Enhancing Middle Ear Lesions
394 Macrophthalmos Nicholas A. Koontz, MD
Bernadette L. Koch, MD 488 Expansile-Destructive Petrous Apex Lesion
398 Optic Nerve Sheath Tram-Track Sign Bronwyn E. Hamilton, MD
Kristine M. Mosier, DMD, PhD 492 Bony Lesions of Temporal Bone
400 Extraocular Muscle Enlargement Nicholas A. Koontz, MD
Blair A. Winegar, MD and H. Christian Davidson, MD
402 Large Superior Ophthalmic Vein(s) CLINICALLY BASED DIFFERENTIALS
Bernadette L. Koch, MD and Christine M. Glastonbury, 496 Conductive Hearing Loss
MBBS Bronwyn E. Hamilton, MD

xvi
 TABLE OF CONTENTS
500 Peripheral Facial Nerve Paralysis 614 Prepontine Cistern Mass
Nicholas A. Koontz, MD Yoshimi Anzai, MD, MPH and Gregory L. Katzman, MD,
506 Vascular Retrotympanic Mass MBA
Bronwyn E. Hamilton, MD and H. Coleman Herrod, MD 620 Cisterna Magna Mass
510 Pulsatile Tinnitus Daniel E. Meltzer, MD and Gregory L. Katzman, MD, MBA
Bronwyn E. Hamilton, MD and H. Coleman Herrod, MD 624 Posterior Fossa Neoplasm, Adult
514 Traumatic Lesions of Temporal Bone Yoshimi Anzai, MD, MPH and Anne G. Osborn, MD, FACR
Bernadette L. Koch, MD 628 Posterior Fossa Neoplasm, Pediatric
520 Secondary (Referred) Otalgia Chang Yueh Ho, MD and Susan I. Blaser, MD, FRCPC
Nicholas A. Koontz, MD
GENERIC IMAGING PATTERNS
SECTION 9: SKULL BASE 634 Cystic CPA Mass
ANATOMICALLY BASED DIFFERENTIALS Bronwyn E. Hamilton, MD

528 Normal Skull Base Venous Variants CLINICALLY BASED DIFFERENTIALS

Bernadette L. Koch, MD and Christine M. Glastonbury, 638 Hemifacial Spasm
MBBS Nicholas A. Koontz, MD
534 Skull Base Foraminal or Canal Variants 642 Sensorineural Hearing Loss in Adult
Bernadette L. Koch, MD Nicholas A. Koontz, MD
538 Congenital Anomalies of Skull Base 646 Sensorineural Hearing Loss in Child
Chang Yueh Ho, MD and Susan I. Blaser, MD, FRCPC Bernadette L. Koch, MD
544 Intrinsic Skull Base Lesion
C. Douglas Phillips, MD, FACR SECTION 11: CRANIAL NERVES AND
550 Anterior Skull Base Lesion BRAINSTEM
C. Douglas Phillips, MD, FACR
554 Cribriform Plate Lesion ANATOMICALLY BASED DIFFERENTIALS
C. Douglas Phillips, MD, FACR
654 Midbrain Lesion
558 Central Skull Base Lesion
Nancy J. Fischbein, MD
C. Douglas Phillips, MD, FACR
658 Pontine Lesion
562 Sellar/Parasellar Mass With Skull Base Invasion
Nancy J. Fischbein, MD
Yoshimi Anzai, MD, MPH and Anne G. Osborn, MD, FACR
664 Medulla Lesion
566 Unilateral Cavernous Sinus Mass
Nancy J. Fischbein, MD
Yoshimi Anzai, MD, MPH and Anne G. Osborn, MD, FACR
570 Bilateral Cavernous Sinus Mass GENERIC IMAGING PATTERNS
Yoshimi Anzai, MD, MPH and Anne G. Osborn, MD, FACR
574 Meckel Cave Lesion 668 Enhancing Cranial Nerve(s)
Yoshimi Anzai, MD, MPH and Anne G. Osborn, MD, FACR Daniel E. Meltzer, MD and Anne G. Osborn, MD, FACR
578 Posterior Skull Base Lesion
CLINICALLY BASED DIFFERENTIALS
C. Douglas Phillips, MD, FACR
582 Clival Lesion 672 Monocular Vision Loss
C. Douglas Phillips, MD, FACR Kristine M. Mosier, DMD, PhD
588 Jugular Foramen Lesion 678 Bitemporal Heteronymous Hemianopsia
C. Douglas Phillips, MD, FACR Kristine M. Mosier, DMD, PhD
592 Dural Sinus Lesion, General 684 Homonymous Hemianopsia
Luke N. Ledbetter, MD Kristine M. Mosier, DMD, PhD
598 Foramen Magnum Mass 688 Oculomotor, Trochlear, or Abducens Neuropathy
Luke N. Ledbetter, MD Nicholas A. Koontz, MD
694 Trigeminal Neuropathy
SECTION 10: CPA-IAC AND POSTERIOR Nancy J. Fischbein, MD
FOSSA 698 Trigeminal Neuralgia
Nicholas A. Koontz, MD
ANATOMICALLY BASED DIFFERENTIALS 702 Complex Cranial Nerve IX-XII Neuropathy
606 Small IAC Nicholas A. Koontz, MD
Bernadette L. Koch, MD and Caroline D. Robson, MBChB 708 Hypoglossal Neuropathy
608 Large IAC Nancy J. Fischbein, MD
Nicholas A. Koontz, MD 714 Horner Syndrome
610 CPA Mass, Adult Nicholas A. Koontz, MD
Bronwyn E. Hamilton, MD

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Koch | Hamilton
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 SECTION 1

Suprahyoid and Infrahyoid

Anatomically Based Differentials

Parapharyngeal Space Lesion 4
Pharyngeal Mucosal Space Lesion, Nasopharynx 10
Pharyngeal Mucosal Space Lesion, Oropharynx 14
Masticator Space Lesion 18
Buccal Space Lesion 24
Parotid Space Mass 28
Carotid Space Lesion 34
Carotid Artery Lesion 38
Perivertebral Space Lesion 42
Brachial Plexus Lesion 46
Visceral Space Lesion 52
Cervical Tracheal Lesion 58
Tracheoesophageal Groove Lesion 64
Posterior Cervical Space Lesion 68
Cervicothoracic Junction Lesion 74
TMJ Mass Lesions 80
Calcified TMJ Lesions 86
TMJ Cysts 92

Generic Imaging Patterns

Diffuse Parotid Disease 96
Multiple Parotid Masses 100
Focal Retropharyngeal Space Mass 102
Diffuse Retropharyngeal Space Disease 106
Diffuse Thyroid Enlargement 110
Focal Thyroid Mass 114
Invasive Thyroid Mass 118

Clinically Based Differentials

Cheek Mass 122
Trismus 128
 Parapharyngeal Space Lesion
Suprahyoid and Infrahyoid
DIFFERENTIAL DIAGNOSIS
Common
• Direct extension into parapharyngeal space from neoplasm
from adjacent space
○ Pharyngeal mucosal space/surface → parapharyngeal
space
– Nasopharyngeal Carcinoma
– Squamous Cell Carcinoma, Palatine Tonsil
– Non-Hodgkin Lymphoma, Pharyngeal Mucosal
Space
○ Masticator space → parapharyngeal space
– Sarcoma, Masticator Space
– Rhabdomyosarcoma, Masticator Space
○ Parotid space → parapharyngeal space
– Benign Mixed Tumor, Parotid Space
– Adenoid Cystic Carcinoma, Parotid Space
– Mucoepidermoid Carcinoma, Parotid Space
• Direct extension into parapharyngeal space from abscess
from adjacent space
○ Abscess, Masticator Space
○ Tonsillar Abscess, Pharyngeal Mucosal Space
○ Parotitis, Acute, Parotid Space
Less Common
• Primary parapharyngeal space lesion
○ Pterygoid Venous Plexus Asymmetry
○ Venolymphatic Malformation
○ Lipoma
Rare but Important
• Benign Mixed Tumor, Parapharyngeal Space
• 2nd Branchial Cleft Cyst, Variant
• Ranula, Diving
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Parapharyngeal space (PPS) lesion is suprahyoid only
○ Some literature separates PPS into pre- & poststyloid
compartments
○ Using this scheme, functional differential considerations
by space can be sorted as
– Prestyloid PPS = PPS (differential considerations here)
– Poststyloid PPS = carotid space (not addressed here)
– Carotid space masses are uncommon but displace PPS
fat anteriorly
□ Considerations include vascular lesions, neurogenic
tumors, & paragangliomas (not addressed here)
• Primary PPS lesions are rare
○ Intact fat plan separates mass from adjacent spaces
• Displacement of PPS fat is useful to determine origin of
masses arising from adjacent suprahyoid head & neck
spaces
• PPS most commonly affected secondarily by direct spread
of local malignancy or infection
Helpful Clues for Common Diagnoses
• Pharyngeal mucosal space/surface (PMS) → PPS
○ PPS fat displaced laterally if mass located in PMS
○ Most common etiologies are infection or malignancy
• Nasopharyngeal Carcinoma
4
○ CT/MR: Lateral pharyngeal recess tumor bulges into
medial PPS
○ PPS fat displaced anteriorly & medially
○ Direct invasion of carotid space or bony skull base
possible
• Squamous Cell Carcinoma, Palatine Tonsil
○ Induration of PPS fat & irregular margin between fat &
tumor are key findings
○ CT/MR: Tumor arises in tonsillar fossa, extends laterally
with either mass effect or direct invasion of PPS
○ Tumor staged as T4 if PPS invaded
• Non-Hodgkin Lymphoma, Pharyngeal Mucosal Space
○ CT/MR: Bulky PMS tumor bulges medial wall of PPS,
without direct invasion
○ Homogeneous density, usually without necrosis
• Masticator space (MS) → PPS
○ PPS fat displaced posteromedially for mass in MS
• Sarcoma, Masticator Space
○ CT/MR: Aggressive MS tumor ± calcific matrix
• Rhabdomyosarcoma, Masticator Space
○ CT/MR: Aggressive noncalcified MS tumor in child
• Parotid space (PS) → PPS
○ PPS fat displaced medially
– Most deep lobe parotid tumors compress &/or involve
PPS
– Fascia less adherent along medial aspect of deep lobe
parotid
○ When tumor is large, may be difficult to determine if site
of origin is PS or PPS
○ Lesion of parotid gland can arise in, or spread to, deep
lobe of parotid & extend medially
– Widening of stylomandibular tunnel characterizes
primary parotid masses extending into (prestyloid)
PPS
• Benign Mixed Tumor, Parotid Space
○ Benign deep lobe tumor often asymptomatic until large
○ May be hard to determine if tumor is from deep lobe of
parotid or primary PPS
○ CT/MR: Large, well-circumscribed mass flattening lateral
aspect of PPS
• Adenoid Cystic Carcinoma, Parotid Space
○ CT/MR: Invasive parotid mass with propensity for
perineural spread (CNVII)
• Mucoepidermoid Carcinoma, Parotid Space
○ CT/MR: Invasive parotid mass; enhances, "feathery"
margins
• Abscess, Masticator Space
○ Odontogenic origins; recent tooth extraction or lucency
around molar
○ CT/MR: Pus pocket in MS; edematous muscles;
induration of PPS from lateral aspect
• Direct extension into PPS from abscess from adjacent space
• Tonsillar Abscess, Pharyngeal Mucosal Space
○ CT/MR: Palatine tonsil pus with surrounding edema &
induration
○ Displaces PPS fat laterally if intratonsillar; abscess may
rupture laterally into PPS
• Parotitis, Acute, Parotid Space
○ CT/MR: Edematous parotid gland with increased
density/enhancement
 Parapharyngeal Space Lesion
○ Swollen, deep lobe causes mass effect on lateral wall of
PPS
○ Look for radiopaque calculus as predisposing cause
○ Unilateral bacterial; bilateral viral
Helpful Clues for Less Common Diagnoses
• Pterygoid Venous Plexus Asymmetry
○ Prominent venous plexus at pterygoid plates involves
PPS & MS
– May simulate venous malformation
– Usually more linear serpiginous than cystic
○ CECT: Asymmetric prominent venous enhancement in
MS & anterior PPS near pterygoid plates
• Venolymphatic Malformation
○ Common congenital suprahyoid transspatial lesion
usually presents in childhood
○ Typically asymptomatic; incidental finding on imaging
○ CT/MR: Can be limited, but typically involves multiple
contiguous spaces, including PPS
– Appearance determined by whether lesion is primarily
venous, lymphatic, or mixed in composition
– Cystic mass with T2 hyperintensity (may be uni- or
multilocular)
– Lymphatic malformations are nonenhancing; venous
& venolymphatic malformations enhance
– Calcified phleboliths on CT are characteristic of venous
malformation
• Lipoma
○ Benign fatty tumor almost always incidental finding
○ CT/MR: Enlarged but otherwise normal-appearing PPS
– Should have no soft tissue component & no
enhancement
Helpful Clues for Rare Diagnoses
• Benign Mixed Tumor, Parapharyngeal Space
○ Arises in PPS from ectopic salivary gland rests
– Primary PPS benign mixed tumor that has no
connection to deep lobe of parotid gland
– Tumor often large when diagnosed
– PPS lesions "silent" & asymptomatic
○ CT/MR: Variable enhancement
Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma
Suprahyoid and Infrahyoid
– Ovoid mass typically low T1, high T2 signal on MR
– If part of mass appears more aggressive or irregular,
think of malignancy arising in benign mixed tumor,
"carcinoma ex pleomorphic adenoma"
• 2nd Branchial Cleft Cyst, Variant
○ Primary cyst in PPS most likely branchial in origin
○ CT/MR: Benign, nonenhancing cyst
– May point towards or be connected to palatine tonsil
• Ranula, Diving
○ Sublingual gland retention cyst ruptures into
submandibular space & PPS
○ CT/MR: Tail sign in sublingual space leads to SMS & PPS
cystic components
– No fascial boundary between submandibular space &
PPS
– PPS component rarest area for pseudocyst to spread
SELECTED REFERENCES
1. Abt NB et al: Plunging ranula with prestyloid parapharyngeal space,
masticator space, and parotid gland extension. B-ENT. 13(1 Suppl 27):57-60,
2017
2. Khatib Y et al: Venolymphatic vascular malformation of the parotid gland
extending into the parapharyngeal space: A rare presentation. J Oral
Maxillofac Pathol. 20(2):308-11, 2016
3. Gamss C et al: Imaging evaluation of the suprahyoid neck. Radiol Clin North
Am. 53(1):133-44, 2015
4. Abrahams JJ et al: Stylomandibular tunnel widening versus narrowing: a
useful tool in evaluating suprahyoid mass lesions. Clin Radiol. 69(11):e450-3,
2014
5. Gupta M et al: A rare parapharyngeal space branchial cleft cyst. BMJ Case
Rep. 2013, 2013
6. Kato H et al: Imaging findings of parapharyngeal space pleomorphic
adenoma in comparison with parotid gland pleomorphic adenoma. Jpn J
Radiol. 31(11):724-30, 2013
7. Varoquaux A et al: Retrostyloid parapharyngeal space tumors: a clinician and
imaging perspective. Eur J Radiol. 82(5):773-82, 2013
8. Ohmann EL et al: The utility of fine needle aspiration to identify unusual
pathology in a parapharyngeal mass. Am J Otolaryngol. 32(1):82-4, 2011
9. Tang LL et al: Prognostic value and staging categories of anatomic
masticator space involvement in nasopharyngeal carcinoma: a study of 924
cases with MR imaging. Radiology. 257(1):151-7, 2010
10. Babbel RW et al: The parapharyngeal space: the key to unlocking the
suprahyoid neck. Semin Ultrasound CT MR. 11(6):444-59, 1990
(Left) Axial T1WI MR shows a
nonkeratinizing EBV(+)
nasopharyngeal carcinoma
filling the pharyngeal mucosal
space ſt. The parapharyngeal
space ﬇ and prevertebral
muscles st are invaded by the
tumor. (Right) Coronal T1WI
MR in the same patient reveals
carcinoma ſt in the
nasopharyngeal mucosal
space invading laterally into
the right parapharyngeal
space ﬇. Note the normal left
parapharyngeal space fat st.
5
 Parapharyngeal Space Lesion
Suprahyoid and Infrahyoid

Squamous Cell Carcinoma, Palatine Tonsil Squamous Cell Carcinoma, Palatine Tonsil
(Left) Axial CECT shows a
large palatine tonsil squamous
cell carcinoma (SCCa) invading
posterolaterally into the
parapharyngeal space ſt.
Note the fatty triangle of the
normal contralateral
parapharyngeal space ﬇.
(Right) Axial CECT in the same
patient demonstrates the
palatine tonsillar SCCa
invading the sublingual space
ſt and lateral parapharyngeal
space ﬊. Bilateral malignant
level II nodes st are also
noted.

Non-Hodgkin Lymphoma, Pharyngeal Non-Hodgkin Lymphoma, Pharyngeal

Mucosal Space Mucosal Space
(Left) Axial CECT
demonstrates a bulky,
bilateral nasopharyngeal non-
Hodgkin lymphoma bulging
into both parapharyngeal
spaces ſt. The "feathery"
appearance ﬇ on the left
suggests invasion of the
parapharyngeal space. (Right)
Axial CECT in the same patient
shows the mass nearly
obliterating the left
parapharyngeal space ſt.

Sarcoma, Masticator Space Sarcoma, Masticator Space

(Left) Axial CECT shows a
masticator space
osteosarcoma with
destruction of the mandible
and extension through the
maxillary sinus wall ſt. Note
mild mass effect on the
parapharyngeal space ﬇.
(Right) Axial bone CT in the
same patient demonstrates
"sunburst" malignant
periosteal changes ſt of
osteosarcoma.
Parapharyngeal space
compression ﬇, from lateral
to medial, is characteristic of a
masticator space tumor.

6
 Parapharyngeal Space Lesion
Rhabdomyosarcoma, Masticator Space
Benign Mixed Tumor, Parotid Space
Adenoid Cystic Carcinoma, Parotid Space
Suprahyoid and Infrahyoid
Rhabdomyosarcoma, Masticator Space
(Left) Axial T1 MR shows a
large masticator space
rhabdomyosarcoma ſt in a 7-
year-old boy. The
parapharyngeal space fat ﬇
is displaced medially and is
partly effaced. Note the
normal-appearing left
parapharyngeal space fat ﬊.
The right parotid gland is also
invaded by tumor st. (Right)
Axial T2WI MR reveals a large
rhabdomyosarcoma in the
medial masticator space,
destroying the mandible ﬇.
The mass displaces and
invades the parapharyngeal
space ſt.
Benign Mixed Tumor, Parotid Space
(Left) Axial T1WI MR shows a
large, deep parotid tumor ſt
with effacement of the
pterygoid muscles, airway
compromise, and mass effect
on the soft palate st. The
parapharyngeal space ﬇ is
markedly flattened and
displaced medially but not
invaded. (Right) Coronal T1WI
MR in the same patient
confirms a thin, hyperintense
fat stripe, supporting that the
parapharyngeal space ﬇ is
stretched over the mass but
not invaded.
Adenoid Cystic Carcinoma, Parotid Space
(Left) Axial T1 C+ FS MR shows
an enhancing, invasive,
recurrent tumor in the parotid
gland ſt with extension into
the parapharyngeal space ﬇
in a patient previously treated
for parotid adenoid cystic
carcinoma. Parapharyngeal
fat has been replaced by
tumor. (Right) Coronal T1 C+
FS MR in the same patient
demonstrates a deep lobe
tumor extending into the
parapharyngeal space ﬇.
There is also perineural tumor
ſt along the 3rd division of
the trigeminal nerve at the
foramen ovale.
7
 Parapharyngeal Space Lesion
Suprahyoid and Infrahyoid

Mucoepidermoid Carcinoma, Parotid Space Abscess, Masticator Space

(Left) Axial CECT of high-grade
mucoepidermoid carcinoma of
the parotid ſt shows focal
calcifications st at the tumor
component involving the deep
lobe. Parapharyngeal fat is
displaced medially ﬇.
Compare to normal
parapharyngeal fat on right
﬊. (Right) Abscess ﬈ of the
medial pterygoid muscle ﬉,
causing effacement & medial
displacement of
parapharyngeal space fat ſt,
is shown on axial CECT. Note
normal right parapharyngeal
fat ﬇. Inflammatory
stranding extends to the deep
lobe of the parotid ﬊.

Tonsillar Abscess, Pharyngeal Mucosal Tonsillar Abscess, Pharyngeal Mucosal

Space Space
(Left) Axial CECT in a patient
with a 2-week history of
tonsillitis shows pus in the
parapharyngeal space ﬇ with
a large, adjacent, inflamed
palatine tonsil ſt and
associated masticator space
phlegmon st. (Right) Axial
CECT in the same patient
reveals an inferior palatine
tonsil abscess ſt causing
extensive submandibular
space cellulitis ﬇ and
parapharyngeal and
masticator space abscess (not
shown).

Parotitis, Acute, Parotid Space Pterygoid Venous Plexus Asymmetry

(Left) Axial CECT
demonstrates asymmetric
enlargement and
enhancement of the right
parotid gland ſt. There is
stranding in the subcutaneous
fat and increased density in
the right parapharyngeal
space fat ﬇ from associated
edema. (Right) Axial CECT
demonstrates a prominent
asymmetric left pterygoid
venous plexus as racemose
enhancement in the deep
masticator ſt and anterior
parapharyngeal ﬇ space.

8
 Parapharyngeal Space Lesion
Venolymphatic Malformation
Benign Mixed Tumor, Parapharyngeal
Lipoma
2nd Branchial Cleft Cyst, Variant
Suprahyoid and Infrahyoid
Venolymphatic Malformation
(Left) Axial CECT in a patient
with violaceous oropharyngeal
mucosa shows a tissue density
venous malformation with
phleboliths, involving the
pharyngeal mucosal ſt and
parapharyngeal ﬇ space.
(Right) Axial T2WI FS MR
reveals a high-signal
venolymphatic malformation
that fills the parapharyngeal
space ﬇ and ipsilateral
retropharyngeal space ſt. The
transspatial nature, fluid
signal, and shape all suggest
venolymphatic malformation.
Space
(Left) Axial CECT
demonstrates a lipoma in the
parapharyngeal space ﬇. This
lipoma extended inferiorly and
involved the submandibular
space (not shown). (Right)
Axial CECT shows an ovoid
benign mixed tumor ſt
centered in the
parapharyngeal space. Note
the sharp delineation ﬇
between the deep lobe of the
parotid gland and the tumor,
indicating that the lesion
arose in the parapharyngeal
space and not in the deep lobe
of the parotid gland.
Ranula, Diving
(Left) Axial NECT reveals an
ovoid, low-density cyst in the
right parapharyngeal space
﬇, deep to the palatine tonsil
ſt. This is a rare example of a
2nd branchial cleft cyst
projecting superiorly into the
parapharyngeal space. (Right)
Axial CECT reveals a fluid-
density lesion ſt in the left
parapharyngeal space. This
superior extension of a diving
ranula is confirmed on inferior
images, defining the ranular
sublingual space origin (not
shown).
9
 Pharyngeal Mucosal Space Lesion, Nasopharynx
Suprahyoid and Infrahyoid
DIFFERENTIAL DIAGNOSIS
Common
• Adenoid Tissue, Prominent/Asymmetric
• Adenoid Inflammation
• Tornwaldt Cyst
• Retention Cyst, PMS
• Nasopharyngeal Carcinoma
• Non-Hodgkin Lymphoma, PMS
Less Common
• Postradiation Mucositis, PMS
• Benign Mixed Tumor, PMS
Rare but Important
• Minor Salivary Gland Malignancy, PMS
• Rhabdomyosarcoma
• Extraosseous Chordoma, PMS
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Imaging poor in evaluating mucosal surfaces; clinician can
visualize mucosal surface
○ Carcinoma usually has mucosal ulceration
○ Lymphoma & other malignancies are submucosal
○ Caveat: Do not read CT or MR of pharyngeal mucosal
space (PMS) without knowing what clinician sees
• Big 3 tumors of this area are nasopharyngeal carcinoma,
non-Hodgkin lymphoma, & minor salivary gland malignancy
○ Arise from normal PMS structures: Mucosal surface,
lymphatic ring, & minor salivary glands
○ Malignant lesions commonly invade skull base &
cavernous sinus due to proximity to skull base
– CT (bone window) & MR are always indicated &
complementary with skull base involvement
• Nasopharyngeal mucosal space masses invade
parapharyngeal space (PPS) from medial to lateral
• Nasopharyngeal masses often present with eustachian
tube dysfunction or middle ear symptoms
Helpful Clues for Common Diagnoses
• Adenoid Tissue, Prominent/Asymmetric
○ Key facts: Lymphoid tissue in nasopharynx referred to as
adenoids
– Most prominent in posterior superior wall & roof
– Maximal size at 3-7 years old; often involute by 40
years
– May be prominent if adult had tonsillectomy
– HIV & other immune-stimulating exposures can result
in prominent adenoidal tissue
○ Imaging
– Midline nasopharyngeal soft tissue
– No extension through deep fascia or laterally into PPS
– May identify vertical aligned striped appearance of
enlarged adenoids
• Adenoid Inflammation
○ Key facts: Presents as acute pharyngitis
○ Imaging
– Adenoidal ± lingual ± palatine tonsil enlargement
– Peritonsillar soft tissue edema
– Intratonsillar enhancing septa common
10
– Isolated adenoidal involvement uncommon
• Tornwaldt Cyst
○ Key facts
– Clinically incidental
– Midline cystic lesion present on 5% of all brain MR
– Most common nasopharyngeal mucosal space lesion
– Benign developmental cyst of notochordal remnant
○ Imaging
– Nonenhancing, midline cyst between prevertebral
muscles
– Varied signal: High T1/FLAIR if proteinaceous
• Retention Cyst, PMS
○ Key facts
– Common, incidental, & asymptomatic
– Submucosal cyst located either laterally or in midline
– Often multiple
○ Imaging
– Nonenhancing single or multiple smooth cysts
– Often pear-shaped in lateral pharyngeal recess
– Clear plane between cyst & adjacent constrictor
muscles
– Internal signal varies with protein concentration
• Nasopharyngeal Carcinoma
○ Key facts
– Squamous cell carcinoma (SCCa) with 3 distinct
subtypes & strong relationship with Epstein-Barr virus
– Very common in Chinese population, including those
who relocate to USA
– Less common association with HPV
– 90% have cervical nodal metastases at diagnosis, ±
retropharyngeal nodal chain
– May present with findings of eustachian tube
obstruction
○ Imaging
– Mass centered in lateral nasopharyngeal recess with
invasion
– Typical patterns of invasion
□ Anteriorly into nasal cavity or soft palate
□ Laterally into PPS
□ Superiorly into skull base &/or sphenoid sinus
□ Posteriorly into prevertebral muscles
• Non-Hodgkin Lymphoma, PMS
○ Key facts
– Submucosal mass on endoscopy
– Nonnodal lymphoma originates in nasopharyngeal
component of Waldeyer lymphatic ring (adenoidal
component)
– Palatine tonsil > nasopharyngeal adenoid > lingual
tonsil
– Increased incidence in patients with AIDS or several
autoimmune conditions
– ~ 50% present with additional malignant nodal
involvement
○ Imaging
– Bulky homogeneous mass with variable enhancement
& intermediate T2 signal
– Mass may be located only in mucosal space or invade
into adjacent structures
– Lacks internal enhancing septa, unlike lymphoid
hyperplasia or adenoid inflammation
 Pharyngeal Mucosal Space Lesion, Nasopharynx

Suprahyoid and Infrahyoid

Helpful Clues for Less Common Diagnoses
• Postradiation Mucositis, PMS
○ Key facts
– History critical as patient will have received radiation
therapy (XRT) for head & neck malignancy
– Enhancing mucosa usually within 1st year after XRT;
then gradual decrease in degree of enhancement
○ Imaging
– Non-mass-like symmetric enhancement of mucosal
surface included in XRT field
□ Early (1-4 months): Diffuse thickening with
enhancement (edema)
□ Late: Thin, enhancing mucosa (fibrosis)
– Severe XRT findings can obscure tumor
– Mucositis typically symmetric
• Benign Mixed Tumor, PMS
○ Key facts
– Alternative terminology: Pleomorphic adenoma
– Salivary gland rests scattered throughout mucosa of
PMS
– Benign mixed tumor develops from minor salivary
gland rests
– Presents as painless submucosal mass
– Patient may report ear "fullness" or ↓ hearing if
eustachian tube affected
– Typically submucosal with high T2 signal
○ Imaging
– Smooth enhancing submucosal mass with high T2 MR
signal
– Commonly ovoid or round without invasive margins
– Fluid in mastoids & middle ear cavity when there is
mass effect on eustachian tube in nasopharynx
Helpful Clues for Rare Diagnoses
• Minor Salivary Gland Malignancy, PMS
○ Key facts
– Develops from salivary rests in mucosa of PMS
– Mucoepidermoid carcinoma less common
□ Can present with nodal metastases
○ Imaging
– Submucosal & often invasive
– Higher in T2 signal than SCCa
• Rhabdomyosarcoma
○ Key facts
– Pediatric or young adult patients
– Nasopharynx is 2nd most common head & neck site
after orbit
○ Imaging
– Variably enhancing invasive nasopharynx mass
– Skull base & intracranial extension common
• Extraosseous Chordoma, PMS
○ Key facts
– Primary malignant tumor of notochord origin
– Chordoma typically arise from clivus, rarely
extraosseous
○ Imaging
– High T2 signal with heterogenous enhancement
– Associate with midline clivus bony tract
Other Essential Information
• Imaging mimics: Skull base osteomyelitis &/or idiopathic
inflammatory pseudotumor
○ May diffusely enlarge/involve nasopharynx
○ No mucosal lesion on endoscopy & negative for
malignancy on biopsies
○ Pseudotumor may be associated with IgG4 & can
respond to steroids
SELECTED REFERENCES
1. Rodriguez DP et al: Masses of the nose, nasal cavity, and nasopharynx in
children. Radiographics. 37(6):1704-1730, 2017
2. King AD et al: Detection of nasopharyngeal carcinoma by MR imaging:
diagnostic accuracy of MRI compared with endoscopy and endoscopic
biopsy based on long-term follow-up. AJNR Am J Neuroradiol. 36(12):2380-
5, 2015

– Adenoid cystic carcinoma most frequent subtype in

nasopharynx
□ Perineural extension results in pain & palsies

Adenoid Tissue, Prominent/Asymmetric Adenoid Inflammation

(Left) Axial NECT in a 4-year-
old child imaged for symptoms
of sinus infection
demonstrates asymmetrically
prominent normal adenoidal
tissue, larger on the left ſt.
(Right) Axial T2 MR in a 45
year old with symptoms of
pharyngitis is shown. The
nasopharyngeal tonsillar
tissue is more prominent than
expected for age but still
conforms to the pharyngeal
mucosal space (PMS) ſt.
Internal architecture and
striations are maintained.
Mildly prominent reactive
retropharyngeal lymph nodes
are also present ﬇.

11
 Pharyngeal Mucosal Space Lesion, Nasopharynx
Suprahyoid and Infrahyoid

Tornwaldt Cyst Tornwaldt Cyst

(Left) Axial T2 MR incidentally
shows a well-defined, T2-
bright cyst in the midline
nasopharynx mucosal space
ſt in a patient imaged for
intracranial abnormality. This
is the classic location of a
Tornwaldt cyst. (Right) Axial
T1 C+ FS MR demonstrates a
nonenhancing Tornwaldt cyst
ſt between the prevertebral
muscles ﬇. The cyst shows
mild intrinsic hyperintensity
compared to CSF, typical of
proteinaceous contents. Note
the normally enhancing
mucosa of the lateral
pharyngeal recess st.

Retention Cyst, PMS Retention Cyst, PMS

(Left) Axial T2 MR
demonstrates a well-defined,
T2-bright lesion along the
right paramidline
nasopharyngeal mucosal
surface ﬇. This did not
demonstrate enhancement or
deep invasion and is consistent
with a PMS retention cyst.
(Right) Axial T1 MR
demonstrates a pear-shaped
cyst ſt with high T1 signal,
consistent with proteinaceous
contents. Some complex cysts
may also show low signal on
T2 sequences. Lack of local
invasion helps determine that
this is a benign lesion.

Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma

(Left) Axial T1 C+ FS MR shows
a large mass centered at left
lateral nasopharyngeal recess
ſt with invasion into the
adjacent parapharyngeal
space (PPS) st. Bilateral
enlarged, enhancing lymph
nodes ﬇ are due to
metastatic disease, as is very
common in nasopharyngeal
carcinoma. (Right) Axial T2 MR
shows a low-signal mass ſt
arising on the left side and
extending to the right. Note
the deep lateral invasion ﬇
into surrounding spaces on the
left. Retropharyngeal
adenopathy st is common in
nasopharyngeal carcinoma.

12
 Pharyngeal Mucosal Space Lesion, Nasopharynx
Non-Hodgkin Lymphoma, PMS
Benign Mixed Tumor, PMS Minor Salivary Gland Malignancy, PMS
Rhabdomyosarcoma
Suprahyoid and Infrahyoid
Postradiation Mucositis, PMS
(Left) Axial T2 FS MR
demonstrates a nearly
homogeneous mass filling the
nasopharynx ſt with
extension into the left PPS ﬇
in a patient with non-Hodgkin
lymphoma. Notice the left
mastoid air cell opacification
st due to obstruction of the
eustachian tube. (Right) Axial
CECT shows symmetric
marked enhancement on all
mucosal surfaces, including
nasopharyngeal ſt. Note
similar enhancement of the
soft palate st. Symmetry and
direct visualization of
inflamed mucosa exclude
recurrent mucosal SCCa.
(Left) Axial T2 FS MR shows a
smooth, hyperintense benign
mixed tumor ſt obliterating
the nasopharyngeal airway.
Note the sharp border
delineation and absence of
tumor invasion into the
adjacent tissues. (Right)
Coronal T1 C+ FS MR shows a
poorly marginated enhancing
mass originating in the lateral
nasopharynx, deeply invasive
into the masticator space ſt.
Note the presence of
intracranial extension along
the floor of the middle cranial
fossa ﬇ and left cavernous
sinus st.
Extraosseous Chordoma, PMS
(Left) Sagittal T1 C+ FS
demonstrates a large,
heterogeneously enhancing,
and destructive
rhabdomyosarcoma ſt
centered in the nasopharynx
of a child. The mass invades
the sphenoid sinus ﬉, anterior
clivus ﬇, and posterior hard
palate st. (Right) Axial T1 C+
MR demonstrates a midline
peripherally enhancing mass
ſt extending from the
posterior midline mucosa of
the nasopharynx ﬇ into the
posterior nasal cavity st.
13
 Pharyngeal Mucosal Space Lesion, Oropharynx
Suprahyoid and Infrahyoid
DIFFERENTIAL DIAGNOSIS
Common
• Tonsillar Tissue, Prominent/Asymmetric
• Palatine Tonsil Abscess
• Tonsillar Inflammation
• Retention Cyst, Pharyngeal Mucosal Space, Oropharynx
• Base of Tongue Squamous Cell Carcinoma
• Palatine Tonsil Squamous Cell Carcinoma
• Postradiation Mucositis
Less Common
• Non-Hodgkin Lymphoma
• Soft Palate Squamous Cell Carcinoma
• Benign Mixed Tumor, Pharyngeal Mucosal Space
• Vallecular Cyst
• Thyroglossal Duct Cyst
Rare but Important
• Posterior Oropharyngeal Wall Squamous Cell Carcinoma
• Minor Salivary Gland Malignancy, Pharyngeal Mucosal Space
• Rhabdomyosarcoma
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Oropharyngeal mucosal space/surface location includes all
mucosa between soft palate & tip of epiglottis
○ Parapharyngeal space (PPS) effaced or displaced laterally
by pharyngeal mucosal space (PMS) lesion
• Most common malignant tumors [squamous cell carcinoma
(SCCa), non-Hodgkin lymphoma, minor salivary gland
malignancy] frequently indistinguishable on CT/MR
○ SCCa typically presents with mucosal ulceration
identified on direct examination
Helpful Clues for Common Diagnoses
• Tonsillar Tissue, Prominent/Asymmetric
○ Key facts: Benign tonsillar hyperplasia usually incidental
finding or secondary to recurrent infections
– More common in children & young adults
○ Imaging: Enlarged tonsil without discrete mass or local
invasion
• Palatine Tonsil Abscess
○ Key facts: Progression of tonsillar inflammation & edema
→ phlegmon → discrete abscess
– Abscess treated with incision & drainage
– May be complicated by peritonsillar abscess if
extension to surrounding PPS, masticator space (MS),
or submandibular space (SMS)
– Acute presentation
○ Imaging: Enlarged tonsil with central low density
surrounded by peripheral enhancement on CECT
– Peritonsillar abscess: Focal low density adjacent to
tonsil involving PPS ± MS ± SMS
– Frequent bulky reactive bilateral cervical adenopathy
• Tonsillar Inflammation
○ Key facts: Presents as acute, nonsuppurative tonsillar
inflammation
– No central low-density collection; helps differentiate
inflammation (treated with antibiotics) from abscess
(may be treated surgically)
14
– Usually affects both palatine tonsils; asymmetric or
unilateral involvement more common in tonsillar
abscess
○ Imaging: Bilateral palatine ± lingual ± adenoid tonsil
enlargement with edema of peritonsillar soft tissues
– Striated pattern ("tiger stripes") of internal
enhancement without associated focal fluid collection
• Retention Cyst, Pharyngeal Mucosal Space, Oropharynx
○ Key facts: Benign, postinflammatory, asymptomatic, &
epithelial-lined mucosal cyst in PMS
– Commonly incidentally identified on head, neck, or
cervical spine imaging
○ Imaging: Simple cyst in PMS
– CT: Low-density homogeneous cyst without
enhancement
– MR: Isointense or hyperintense on T1 (depending on
proteinaceous contents); hyperintense on T2
• Base of Tongue Squamous Cell Carcinoma
○ Key facts: Invasive or exophytic mass at base of tongue
with mucosal ulceration on physical examination
– SCCa of lingual & palatine tonsil are common
– Associated with human papilloma virus (HPV) or
smoking
□ Increasing incidence associated with HPV
□ Decreasing incidence associated with smoking
– Treated with chemoradiation; some exophytic lesions
may undergo resection
– Adenopathy in levels II & III common at presentation
○ Imaging: Small SCCa may appear as subtle mucosal
asymmetry or invasive mass
– Isointense on T1 & isointense or slightly hyperintense
to muscle on T2
– Enhancement on T1 C+ MR aids in delineation of
interface between tumor & muscle
– HPV(+) nodal metastases are often cystic
• Palatine Tonsil Squamous Cell Carcinoma
○ Key facts: Etiology & behavior similar to SCCa at base of
tongue
○ Imaging: Enhancing mass centered in palatine tonsil with
invasive deep margins
– T1 FS C+ MR best evaluates extent of primary tumor
• Postradiation Mucositis
○ Key facts: History of radiation therapy & diffuse mucosal
enhancement helps differentiate mucositis from
recurrent mucosal neoplasm
○ Imaging: Acute phase shows diffuse thickening &
mucosal edema with ill-defined adjacent soft tissue
planes
– Diffuse T2 hyperintensity can persist for several years
post therapy
– Focal nodularity or enhancement deep to mucosa
suggests recurrent tumor, especially if patient reports
pain
Helpful Clues for Less Common Diagnoses
• Non-Hodgkin Lymphoma
○ Key facts: Extranodal lymphoma involving either base of
tongue lymphoid tissue or palatine tonsils
– Associated with bulky cervical adenopathy > 50% of
cases
 Pharyngeal Mucosal Space Lesion, Oropharynx

Suprahyoid and Infrahyoid

○ Imaging: Poorly circumscribed, diffusely infiltrative mass,
more often bilateral than SCCa
– Homogeneous mass, isodense on CECT, most
commonly hyperintense on T2
– Diffuse minimal enhancement without presence of
internal enhancing tonsillar septa
• Soft Palate Squamous Cell Carcinoma
○ Key facts: Mucosal mass arising from soft palate &/or
uvula
– 5-25% of all oropharyngeal SCCa
– Associated with tobacco & alcohol abuse
○ Imaging: Ill-defined, diffuse or asymmetric thickening of
soft palate
– Best visualized on sagittal & coronal plane
– Mildly enhancing infiltrating mass on CECT & MR
• Benign Mixed Tumor, Pharyngeal Mucosal Space
○ Key facts: Submucosal tumor originating in minor salivary
glands
– Typically no mucosal ulceration or deep invasion
– Slow growth rate & usually painless
○ Imaging: Variably enhancing, well-circumscribed mass on
CECT/MR
– May contain calcifications, hemorrhage, or cystic areas
– Most commonly T2 hyperintense with T1 C+
homogeneous enhancement
• Vallecular Cyst
○ Key facts: Unilocular benign cystic mass located in
vallecula
– Often congenital & arises from lingual surface of
epiglottis
○ Imaging: Hypodense nonenhancing cyst with
preservation of soft tissue planes on CECT
– T2-hyperintense lesion with variable T1 characteristics
due to proteinaceous contents
• Thyroglossal Duct Cyst
○ Key facts: May occur anywhere between foramen cecum
at tongue base & thyroid bed
– Most common congenital neck lesion
○ Imaging: Midline nonenhancing lingual tonsil cyst at
location of foramen cecum
○ Evaluate entire course of thyroglossal duct for ectopic
thyroid tissue
Helpful Clues for Rare Diagnoses
• Posterior Oropharyngeal Wall Squamous Cell Carcinoma
○ Key Facts: Lobulated posterior wall pharyngeal mass
between levels of soft palate & hyoid
– Much less common SCCa location than base of tongue
& palatine tonsil
– Associated with tobacco & alcohol abuse
– Often asymptomatic until late stage when extending
into retropharyngeal or prevertebral space
○ Imaging: Mild to moderately enhancing mass on
posterior oropharyngeal wall
– Retropharyngeal fat plane lost with invasion
• Minor Salivary Gland Malignancy, Pharyngeal Mucosal
Space
○ Key Facts: Infiltrating mass with propensity for perineural
& perivascular spread, especially CNV2 & CNV3
○ Imaging: Enhancing, T2-hyperintense mass with
infiltration & invasion
• Rhabdomyosarcoma
○ Key Facts: Transspatial mass usually usually arising from
adjacent MS or PPS
○ Imaging: Solid soft tissue mass with variable contrast
enhancement
SELECTED REFERENCES
1. Thayil N et al: Magnetic resonance imaging of acute head and neck
infections. Magn Reson Imaging Clin N Am. 24(2):345-67, 2016
2. Landry D et al: Squamous cell carcinoma of the upper aerodigestive tract: a
review. Radiol Clin North Am. 53(1):81-97, 2015
3. Takano S et al: Site-specific analysis of B-cell non-Hodgkin's lymphomas of
the head and neck: a retrospective 10-year observation. Acta Otolaryngol. 1-
4, 2015
4. Zander DA et al: Imaging of ectopic thyroid tissue and thyroglossal duct
cysts. Radiographics. 34(1):37-50, 2014
5. Loevner LA et al: Transoral robotic surgery in head and neck cancer: what
radiologists need to know about the cutting edge. Radiographics.
33(6):1759-79, 2013
6. Ulualp SO et al: Management of intratonsillar abscess in children. Pediatr Int.
55(4):455-60, 2013

Tonsillar Tissue, Prominent/Asymmetric Palatine Tonsil Abscess

(Left) Axial CECT
demonstrates incidental
symmetric near homogeneous
bilateral prominence of the
palatine tonsils ſt with mild
narrowing of the
oropharyngeal airway. (Right)
Axial CECT in a young patient
with sore throat and a bulging
tonsil demonstrates a
peripherally enhancing,
central low-density fluid
collection involving the lateral
palatine tonsil ſt with loss of
parapharyngeal fat ﬇
compatible with a peritonsillar
abscess.

15
 Pharyngeal Mucosal Space Lesion, Oropharynx
Suprahyoid and Infrahyoid

Retention Cyst, Pharyngeal Mucosal Space,

Tonsillar Inflammation Oropharynx
(Left) Axial CECT shows large
bilateral palatine tonsils ſt.
The lack of central necrosis
and striated enhancement
pattern is typical for
inflammation without abscess.
(Right) Axial CECT reveals a
large primarily low-density
submucosal cystic lesion ſt in
the superior oropharynx with a
fluid-fluid level ﬇ indicating
previous hemorrhage. Note
lack of deep extension into the
parapharyngeal space st.

Base of Tongue Squamous Cell Carcinoma Palatine Tonsil Squamous Cell Carcinoma
(Left) Axial CECT shows an
enhancing invasive right base
of tongue mass ſt that
crosses the midline. The lesion
is apparent because of
excellent contrast technique.
Note the prior nodal neck
dissection st with loss of fat
around the carotid artery.
(Right) Axial CECT
demonstrates a large
infiltrating mass centered in
the left palatine tonsil ſt. This
mass extends into the
glossotonsillar sulcus. Gas
within the superficial anterior
and medial aspect of the mass
st is due to a recent biopsy.

Non-Hodgkin Lymphoma Soft Palate Squamous Cell Carcinoma

(Left) Axial CECT
demonstrates unilateral
enlargement of a
homogeneous right palatine
tonsil ſt in a patient with
non-Hodgkin lymphoma. This
is ipsilateral cervical nodal
involvement shown with a
round enlarged right level IIB
lymph node st. (Right)
Coronal CECT shows a diffuse,
irregularly thickened soft
palate ſt greater on the left.
This extends into the left
palatine tonsil ﬇. Biopsy of
an ulcerated lesion on the soft
palate confirmed squamous
cell carcinoma.

16
 Pharyngeal Mucosal Space Lesion, Oropharynx
Benign Mixed Tumor, Pharyngeal Mucosal
Space
Thyroglossal Duct Cyst
Minor Salivary Gland Malignancy,
Pharyngeal Mucosal Space
Suprahyoid and Infrahyoid
Vallecular Cyst
(Left) Sagittal CECT
reformation shows a
homogeneous density
submucosal lesion centered in
the soft palate ſt. This
patient reported a long history
of palpable mass consistent
with a benign mixed tumor
characteristic slow growth.
(Right) Sagittal CECT
reformation shows a
homogeneously low-density,
nonenhancing cyst in the
vallecula ſt abutting the
lingual surface of the
epiglottis as well as the base
of the tongue. The patient was
asymptomatic from this
vallecular cyst.
Posterior Oropharyngeal Wall SCCa
(Left) Sagittal CECT shows a
peripherally enhancing cystic
lesion in the base of the
tongue ſt. This abuts the
superior midline aspect of the
hyoid bone ﬇ in a
characteristic location for a
thyroglossal duct cyst. (Right)
Sagittal T1 C+ FS MR just off
the midline demonstrates a
mucosal-based exophytic
squamous cell carcinoma on
the posterior wall of the
oropharynx ſt. A distinct
plane between the mass and
the prevertebral muscles ﬇
suggests against prevertebral
invasion.
Rhabdomyosarcoma
(Left) Axial T2 FS MR reveals
adenoid cystic carcinoma in
the right base of the tongue
ſt. Bright T2 signal is more
common in minor salivary
gland malignancies as
compared to squamous cell
carcinomas, which are
typically lower in T2 signal.
(Right) Axial T1 C+ MR in a
child reveals a
rhabdomyosarcoma arising
from the lingual tonsil ſt. The
bilobed enhancing mass
results in marked airway
compromise. Note the
different enhancement
pattern between the mass and
the palatine tonsils ﬇.
17
 Masticator Space Lesion
Suprahyoid and Infrahyoid
DIFFERENTIAL DIAGNOSIS
Common
• Fracture, Mandible
• Abscess, Masticator Space
• Benign Masticator Muscle Hypertrophy
• Motor Denervation CNV
• Pterygoid Venous Plexus Asymmetry
• Metastasis, Mandible-Maxilla
• Sarcoma, Other, Masticator Space
• Osteosarcoma, Mandible-Maxilla
Less Common
• Chondrosarcoma, Masticator Space
• Perineural Tumor, CNV3, Masticator Space
• Schwannoma, CNV3, Masticator Space
• Ameloblastoma
• Osteoradionecrosis, Mandible-Maxilla
• Odontogenic Keratocyst
Rare but Important
• Synovitis, Pigmented Villonodular, Temporomandibular
Joint
• Chondromatosis, Synovial, Temporomandibular Joint
• Cyst, Dentigerous (Follicular)
• Cherubism, Mandible-Maxilla
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Masticator space (MS) has wide differential
• Most pathology related to mandible, teeth, or
temporomandibular joint (TMJ)
• Imaging strategy
○ CT 1st-line imaging tool
– Review both soft tissue & bone algorithm & windows
○ CECT important for evaluation of infectious process or
masses
– Abscesses can be subtle; look for focal areas of low
density
○ Bone CT
– Look for fracture
– If mandible lesion: Determine relationship to teeth
– If infection: Look for empty tooth socket from recent
extraction
– If MS mass: Look for bone erosion & check for skull
base involvement
○ MR with contrast complementary
– Characterization of noninfectious masses
– Perineural tumor to foramen ovale (CNV3)
– Evaluation of skull base involvement &/or intracranial
extension
Helpful Clues for Common Diagnoses
• Fracture, Mandible
○ Key facts
– Mandible simulates ring: 2 breaks common (50%)
□ Parasymphyseal fracture often associated with
contralateral angle/body or subcondylar fracture
○ Imaging
18
– CT: Lucent, noncorticated lines with variable diastasis,
angulation, & comminution
□ In condylar neck fracture, condylar head pulled
medially by lateral pterygoid muscle
□ Unilateral fracture may be associated with
contralateral TMJ dislocation → empty TMJ sign
• Abscess, Masticator Space
○ Key facts
– Most common MS mass; usually dental source of
infection
○ Imaging
– CECT: Swelling of masticator muscles
– Pus often subtle, ill-defined low density
– Bone CT: Recently extracted tooth
– MR: Infiltration of fat best seen on T2; focal collection
best seen on T1 C+ FS
• Benign Masticator Muscle Hypertrophy
○ Key facts
– Benign enlargement of muscles of mastication
(temporalis, masseter, medial, & lateral pterygoids)
□ Masseter muscle most common
– Uni- or bilateral muscle enlargement
○ Imaging
– Muscles have normal density/intensity &
enhancement
– Cortical thickening of mandible & zygomatic arch
• Motor Denervation CNV
○ Key facts
– Altered appearance of masticator muscles from loss
of CNV3 innervation
○ Imaging
– Acute/subacute: Swelling of muscles with edema,
enhancing muscles
– Late subacute: ↓ swelling & enhancement
– Chronic: Fatty atrophy, no enhancement
• Pterygoid Venous Plexus Asymmetry
○ Key facts
– Unilateral prominence usually incidental
○ Imaging
– CT/MR: Enhancing tubular structures in medial MS or
parapharyngeal space
• Metastasis, Mandible-Maxilla
○ Key facts
– Mimics dental disease
– Most often breast, thyroid, kidney, lung
□ Neuroblastoma (NBL) most common in children
○ Imaging
– Single/multiple, lytic/sclerotic lesions; aggressive
periosteal reaction typical in NBL
• Sarcoma, Other, Masticator Space
○ Key facts
– Rhabdomyosarcoma, leiomyosarcoma, liposarcoma,
Ewing sarcoma, & synovial sarcoma
○ Imaging: Aggressive, poorly defined mass
• Osteosarcoma, Mandible-Maxilla
○ Key facts
– Malignant tumor with osteoid matrix
○ Imaging
– Ill-defined expansile mandibular mass; CT: Often
tumoral calcification ± aggressive periosteal reaction
 Masticator Space Lesion

Suprahyoid and Infrahyoid

Helpful Clues for Less Common Diagnoses • Odontogenic Keratocyst
• Chondrosarcoma, Masticator Space ○ Key facts
○ Key facts – Typically posterior mandible
– Malignant cartilage origin tumor; arises in MS or TMJ ○ Imaging
○ Imaging – CT/MR: Expansile, nonenhancing mass + cortical
– CT: Focal calcifications or chondroid matrix, less so in thinning
higher grade tumor Helpful Clues for Rare Diagnoses
– MR: Typically T2 hyperintense, variable enhancement • Synovitis, Pigmented Villonodular, Temporomandibular
• Perineural Tumor, CNV3, Masticator Space Joint
○ Key facts ○ Key facts
– Spread of tumor along CNV3 (mandibular branch of – Monoarticular inflammatory arthropathy
trigeminal nerve) ○ Imaging
– Most common MS malignancy: Sarcoma, non-Hodgkin – Bone CT: Articular erosions, cysts
lymphoma
– MR: Heterogeneous mass, dark T2 signal
○ Imaging
• Chondromatosis, Synovial, Temporomandibular Joint
– CT: Widened inferior alveolar canal &/or foramen
○ Key facts
ovale
– Benign calcifying synovial metaplasia
– MR: Thickening & enhancement along CNV3 to
○ Imaging
foramen ovale
– CT: Calcified loose bodies in TMJ
• Schwannoma, CNV3, Masticator Space
– MR: T1 & T2 focal signal loss
○ Key facts
• Cyst, Dentigerous (Follicular)
– Encapsulated tumor of Schwann cell origin, which
displaces rather than infiltrates fascicles of CNV3 ○ Key facts
○ Imaging – Benign developmental jaw cyst associated with crown
of unerupted tooth
– Ovoid enhancement along CNV3 course; ± smooth
enlargement foramen ovale ○ Imaging
• Ameloblastoma – Well-defined expansile cyst surrounding crown of
impacted or unerupted tooth
○ Key facts
• Cherubism, Mandible-Maxilla
– Benign but locally aggressive neoplasm originating
from odontogenic epithelium ○ Key facts
○ Imaging – Genetically distinct from fibrous dysplasia
– Expansile multiloculated or multilobulated mixed ○ Imaging
cystic & solid posterior mandible mass – Bilateral multilocular, expansile lucent lesions in
• Osteoradionecrosis, Mandible-Maxilla mandible, displacing teeth
○ Key facts
– Loss of bone vitality after radiation
SELECTED REFERENCES
○ Imaging 1. Gamss C et al: Imaging evaluation of the suprahyoid neck. Radiol Clin North
Am. 53(1):133-44, 2015
– CT: Lytic permeative change, cortical loss 2. Meltzer DE et al: Masticator space: imaging anatomy for diagnosis.
– MR: Marrow bright on T2, dark on T1 Otolaryngol Clin North Am. 45(6):1233-51, 2012

Fracture, Mandible Fracture, Mandible

(Left) Axial bone CT in a
pedestrian struck by a motor
vehicle shows bilateral
mandible fractures, including
the right parasymphysis ſt,
extending between the cuspid
and 1st premolars, and the left
body ﬇ extending between
the 1st and 2nd molars.
(Right) Sagittal bone CT in a
trauma patient shows an
empty condylar fossa ſt
secondary to the comminuted
left mandibular condyle and
neck fractures ﬇, resulting in
medial dislocation of the left
condyle.

19
 Masticator Space Lesion
Suprahyoid and Infrahyoid

Abscess, Masticator Space Abscess, Masticator Space

(Left) Axial CECT reveals
marked left cheek swelling
with heterogeneous density of
the medial pterygoid and
masseter muscles containing
focal areas of low density st
that are indicative of pus in
the masticator space. (Right)
Axial bone CT in the same
patient reveals the source of
collections to be an infected
tooth socket after recent
extraction ﬇. This is the most
common cause of masticator
space infection and should be
carefully sought whenever
masticator space infection is
suspected.

Benign Masticator Muscle Hypertrophy Motor Denervation CNV

(Left) Axial CECT
demonstrates bilateral,
although asymmetric,
enlargement of the masticator
muscles. Note greater
enlargement of the left medial
pterygoid ſt and masseter ﬇
muscles relative to the right
but symmetric density and no
abnormal enhancement.
(Right) Axial NECT in a patient
with squamous cell carcinoma
of the face and a perineural
tumor involving the 5th
cranial nerve reveals
denervation atrophy of the
right masseter ﬇ and medial
pterygoid st muscles.

Pterygoid Venous Plexus Asymmetry Metastasis, Mandible-Maxilla

(Left) Axial CECT reveals a
mass-like appearance of the
left pterygoid venus plexus ſt
relative to the right st at the
deep aspect of the lateral
pterygoid muscle. This is most
often an incidental benign
finding and is rarely associated
with a caroticocavernous
fistula. (Right) Axial bone CT in
a patient with jaw pain reveals
a lytic destructive process
centered in the posterior body
of the left mandible with
cortical erosion ſt. This was
the only metastasis from
previously unsuspected lung
cancer.

20
 Masticator Space Lesion
Sarcoma, Other, Masticator Space
Osteosarcoma, Mandible-Maxilla
Chondrosarcoma, Masticator Space
Suprahyoid and Infrahyoid
Sarcoma, Other, Masticator Space
(Left) Axial CECT in a young
child reveals a large mass in
the right deep face ﬇,
isodense to muscle.
Destruction of the medial
mandible ſt and
posteromedial displacement
of parapharyngeal fat st
indicate that this aggressive
process arises in the
masticator space. (Right) Axial
T2WI FS MR in the same
patient shows this
rhabdomyosarcoma ﬇ to be
more heterogeneous. An area
of intrinsic T2 hyperintensity
ſt was nonenhancing and
necrotic on postgadolinium
images.
Osteosarcoma, Mandible-Maxilla
(Left) Axial CECT shows a
large, markedly dense mass
centered in the left masticator
space and involving or
displacing the masseter st
and medial pterygoid ﬇
muscles. (Right) Axial bone CT
in the same patient reveals the
hyperdensity to be bone
formation in a mass centered
at the left mandibular angle.
The lesion has features of
osteosarcoma with the classic
sunburst pattern of periosteal
reaction st. Note that the
involved mandibular marrow is
sclerotic ſt.
Chondrosarcoma, Masticator Space
(Left) Axial CECT shows a low-
density mass ſt with intrinsic
calcifications filling the left
infratemporal fossa. The mass
is surprisingly large without
cheek expansion, although it
deforms the posterior wall of
the left maxillary sinus st.
(Right) Axial T2WI FS MR in
the same patient reveals a
well-defined mass filling the
infratemporal fossa. The mass
is heterogeneous but
predominantly hyperintense,
which is typical of chondroid
tumors.
21
 Masticator Space Lesion
Suprahyoid and Infrahyoid

Perineural Tumor, CNV3, Masticator Space Perineural Tumor, CNV3, Masticator Space
(Left) Axial T1 C+ FS MR shows
a patient with facial deformity
﬇ from prior left segmental
mandibulectomy for adenoid
cystic carcinoma, with very
subtle asymmetric
enhancement of muscles of
mastication ſt. Note also the
abnormal enhancement at the
mandibular foramen st.
(Right) Coronal T1 C+ FS MR in
the same patient reveals a
thick, enhancing perineural
tumor tracking through the
masticator space to the
foramen ovale ﬇ along the
mandibular nerve st.

Schwannoma, CNV3, Masticator Space Schwannoma, CNV3, Masticator Space

(Left) Coronal T1WI FS MR
demonstrates a large, well-
defined, homogeneously
enhancing, solid mass ſt in
the right masticator space
extending through the central
skull base to the middle
cranial fossa. (Right) Coronal
T1 C+ FS MR in a young
patient with a diagnosis of
neurofibromatosis type 2
shows similar spread of a
mandibular nerve (V3)
schwannoma ſt through the
enlarged foramen ovale ﬇ to
the right Meckel cave.

Ameloblastoma Osteoradionecrosis, Mandible-Maxilla

(Left) Axial bone CT shows an
expanded body of the right
mandible associated with an
unerupted and malpositioned
3rd molar tooth st. The lesion
has a benign appearance with
expansion and marked
thinning of the buccal &
lingual cortex, with focal
cortical dehiscence ſt. (Right)
Axial bone CT demonstrates
heterogeneous "moth-eaten"
destruction of the right
hemimandible with focal areas
of intraosseous gas st.
Evolving intraosseous bone
sequestrum is also noted ſt.

22
 Masticator Space Lesion
Odontogenic Keratocyst
Synovitis, Pigmented Villonodular,
Temporomandibular Joint
Cyst, Dentigerous (Follicular)
Suprahyoid and Infrahyoid
Odontogenic Keratocyst
(Left) Coronal NECT reveals an
expansile unilocular cystic
lesion arising in the right
mandibular ramus ﬇ and
expanding cephalad into the
masticator space. Note the
marked thinning of the cortex
in some areas ſt. (Right) Axial
T1 C+ FS MR in the same
patient shows an expansile
lesion ſt without appreciable
enhancement, indicating a
truly cystic nature. The
keratocyst extends laterally
into the masseter muscle st.
Chondromatosis, Synovial,
Temporomandibular Joint
(Left) Coronal CECT
demonstrates a moderately
enhancing soft tissue mass
centered around the left
temporomandibular joint
associated with erosion of the
mandibular condyle ﬈ and
glenoid fossa ﬉. There is no
evidence of new bone
formation or calcifications.
(Right) Coronal bone CT shows
subtly sclerotic right
mandibular condyle ﬇. The
articular surface is slightly
irregular, suggesting
degenerative change, but
small calcified bodies ﬉ are
also evident in the joint.
Cherubism, Mandible-Maxilla
(Left) Axial bone CT
demonstrates smooth-walled
cystic expansion of the left
hemimandible ﬇, abutting an
impacted left 3rd mandibular
molar st. There is no
abnormal calcification,
periosteal reaction, or
associated soft tissue mass.
(Right) Axial bone CT in a child
shows symmetric expansion of
the angles of the mandible
with a multiloculated
appearance. No cortical
destruction is evident, though
the remaining cortex is
markedly thinned and focally
dehiscent in scattered places
st.
23
 Buccal Space Lesion
Suprahyoid and Infrahyoid
DIFFERENTIAL DIAGNOSIS
Common
• Accessory Parotid Gland
• Squamous Cell Carcinoma, Nodes
• Squamous Cell Carcinoma, Buccal Mucosa
• Minor Salivary Gland Malignancy, Oral
• Fungal Sinusitis, Invasive
Less Common
• Venous Malformation, Buccal Space
• Abscess, Masticator Space
• Perineural Tumor, CNV2
• Squamous Cell Carcinoma, Sinonasal
• Non-Hodgkin Lymphoma
• Lymphatic Malformation, Buccal Space
Rare but Important
• Lipoma, Buccal Space
• Juvenile Angiofibroma
• Sarcoma, Other, Masticator Space
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Buccal space (BS) is pyramidal fat-filled space of midface;
forms padding of cheeks
• No defined fascial boundaries
○ Medial border: Buccinator muscle
○ Lateral border: Muscles of facial expression
○ Posterior border: Masseter, mandible, pterygoid
muscles, parotid gland
○ Superior extent: Retromaxillary fat pad
• BS contains predominantly fat & small lymph nodes
○ Parotid duct traverses BS; pierces buccinator muscle at
level of upper 2nd molar
○ Accessory parotid gland found in ~ 20%
• Majority of BS pathology is nodal disease or extension of
pathology from adjacent structures & spaces
○ Oral cavity & specifically buccal mucosa; maxillary sinus
infection or tumor
○ Masticator space (MS)/parotid space (PS) infection or
tumor
• Imaging strategies
○ Either CT or MR useful for evaluation of BS
○ Buccal masses, especially adjacent to mandible/maxilla,
often subtle on imaging
– Look for asymmetry of fat density (CT) or signal
intensity (T1 MR)
– Caveat: Dental amalgam obscures BS disease CT/MR
Helpful Clues for Common Diagnoses
• Accessory Parotid Gland
○ Key facts
– "Extra" parotid tissue (20%)
– Subject to same inflammatory & neoplastic processes
as parotid glands
○ Imaging
– Along anterior aspect of masseter surface, separate
from remaining parotid gland tissue
– Texture, CT density/MR intensity & contrast
enhancement same as main parotid gland
24
• Squamous Cell Carcinoma, Nodes
○ Key facts
– Facial lymph node group
– Primary lesion: Buccal mucosa, maxillary sinus, or skin
○ Imaging
– Rounded mass typically lateral to facial vein & artery
– Necrosis/cystic change may be evident
• Squamous Cell Carcinoma, Buccal Mucosa
○ Key facts
– Lesion clinically evident
– Can be subtle on imaging
○ Imaging
– Look for asymmetry of thickness of buccinator &
infiltration of buccal fat
– Noncontrast CT or T1 MR shows fat infiltration well
– Coronal imaging often most helpful for extent of
lesion & buccinator involvement
• Minor Salivary Gland Malignancy, Oral
○ Key facts
– Clinically evident lesion
– Minor salivary gland (MSG) located in hard-soft palate
junction > > buccal mucosa
– Adenoid cystic carcinoma & mucoepidermoid
carcinoma most common MSG malignancies
○ Imaging
– Performed to evaluate for soft tissue extent, bone
invasion, & adenopathy
– Well-defined, smooth submucosal mass
– Look for extraosseous & marrow fat infiltration
• Fungal Sinusitis, Invasive
○ Key facts
– Aggressive, often rapidly progressive infection
– May not be clinically suspected
– Maintain high index of suspicion for
immunosuppressed patient (steroid use, diabetes,
malignancy, chemotherapy, chronic renal disease)
○ Imaging
– CT 1st-line study for sinusitis
– Infiltration of buccal fat around maxillary sinus
– Bone destruction not feature until late in process
– MR: T2 FS best to evaluate full extent
Helpful Clues for Less Common Diagnoses
• Venous Malformation, Buccal Space
○ Key facts
– Congenital low-flow vascular malformation due to
error in vein formation
– Most commonly subcutaneous &/or intramuscular
– Focal, multifocal or diffuse
○ Imaging
– Mixed enhancing lobulated mass or extensive
confluent infiltrative lesion
– Hyperdense/hypointense small, round phleboliths
essentially diagnostic
– T2 hyperintense, diffuse or patchy enhancement
• Abscess, Masticator Space
○ Key facts
– Abscess from maxillary or mandibular dental disease
spread to BS
○ Imaging
 Buccal Space Lesion

Suprahyoid and Infrahyoid

– Loss of clarity of buccal fat ± rim-enhancing low-
density fluid collection (CT)
– Bone windows key to identify infected tooth
– Facial pus often does not form well-defined collection
– MR: Infiltration of fat best seen on T2; focal collection
best seen on T1 C+ FS
• Perineural Tumor, CNV2
○ Key facts
– Malignant tumor spread along sheath of large nerves
distant from primary site
– Infraorbital nerve traverses retromaxillary fat of BS
– Primary tumors: Cheek melanoma & squamous cell
carcinoma (SCCa)
○ Imaging
– MR more sensitive than CT, especially T1 C+ FS
– CT or MR: Thickened CNV2 ± mild enhancement
– Carefully review nerve course: Infraorbital canal →
pterygopalatine fossa
• Squamous Cell Carcinoma, Sinonasal
○ Key facts
– Any maxillary sinus malignancy may invade through
anterolateral or posterolateral wall to BS
○ Imaging
– Primary mass is destructive; SCCa heterogeneous &
necrotic
– Asymmetry of buccal fat, bone destruction (CT)
– MR: Infiltration of BS, orbit
• Non-Hodgkin Lymphoma
○ Key facts
– BS secondarily involved by adjacent facial primary non-
Hodgkin lymphoma (NHL)
○ Imaging
– Mass infiltrates MS, PS & maxillary sinus
– NHL in BS facial lymph node; aggressive NHL often
heterogeneous & infiltrative
• Lymphatic Malformation, Buccal Space
○ Key facts
– Congenital low-flow vascular malformation due to
error in lymphatic vessel formation
– Any space in H&N, BS less common than others
○ Imaging
– Nonenhancing, uni- or multilocular cystic mass with
fluid-fluid levels typical
Helpful Clues for Rare Diagnoses
• Lipoma, Buccal Space
○ Key facts
– 15% of lipomas occur in H&N; may occur in any H&N
space & may be transspatial
○ Imaging
– Low-density (CT) & high-T1 (MR) signal mass
– FS sequences decrease fat signal
• Juvenile Angiofibroma
○ Key facts
– Male teenagers
– Most often present with nasal obstruction or
epistaxis; rarely extends to BS
○ Imaging
– Hypervascular benign tumor of nose that originates
near sphenopalatine foramen margin
○ Multiple directions of spread possible
– Medial: Fills nasal cavity & nasopharynx
– Superior: Anterior cranial fossa
– Posterior: Sphenoid bone & sinus
– Lateral: Through pterygomaxillary fissure to MS &
retromaxillary fat of BS
• Sarcoma, Other, Masticator Space
○ Key facts
– Fibro-, synovial & undifferentiated sarcoma
○ Imaging
– Invasive mass involves BS
SELECTED REFERENCES
1. Orlowski HLP et al: Imaging spectrum of invasive fungal and fungal-like
infections. Radiographics. 37(4):1119-1134, 2017
2. Merrow AC et al: 2014 revised classification of vascular lesions from
International Society for Study of Vascular Anomalies: Radiologic-Pathologic
Update. Radiographics. 36(5):1494-516, 2016
3. Wassef M et al: Vascular anomalies classification: recommendations from
International Society for Study of Vascular Anomalies. Pediatrics.
136(1):e203-14, 2015

Accessory Parotid Gland Squamous Cell Carcinoma, Nodes

(Left) Axial CECT reveals
bilateral soft tissue masses ſt
overlying the masseter
muscles. Their density, texture,
and enhancement
characteristics appear almost
identical to those of normal
parotid glands. (Right) Axial
CECT demonstrates a
cystic/necrotic mass ſt in the
left buccal space abutting the
anterior margin of the
masseter muscle and adjacent
to the facial vein and distal
parotid duct st.

25
 Buccal Space Lesion
Suprahyoid and Infrahyoid

Squamous Cell Carcinoma, Buccal Mucosa Minor Salivary Gland Malignancy, Oral
(Left) Axial T1WI MR reveals a
soft tissue mass st isointense
to the muscle but with an ill-
defined anterior margin
infiltrating the right buccal
fat. This asymmetry of fat may
seem obvious but can be a
blind spot on imaging. (Right)
Axial T1 C+ FS MR shows an
irregular rim-enhancing cystic
mass ſt with solid
enhancement at the buccal
mucosa st. Fine-needle
aspiration of the cheek mass
suggested salivary tissue; final
pathology showed poorly
differentiated carcinoma.

Fungal Sinusitis, Invasive Venous Malformation, Buccal Space

(Left) Axial NECT reveals
partial opacification of the left
maxillary sinus in a patient
with a history of lymphoma.
More significant, there is
marked infiltration of the
buccal space fat st. This was
proven to be aspergillus
infection. (Right) Axial STIR
MR shows a complex, mostly
T2-hyperintense cheek mass
predominantly in the buccal
space ſt but also extending
deep into the oral cavity ﬇.
Rounded areas of low signal
intensity representing
phleboliths st are a key
finding to make this diagnosis.

Abscess, Masticator Space Perineural Tumor, CNV2

(Left) Axial T1 C+ FS MR shows
extensive inflammation and
enhancement of the right
buccal space ſt and anterior
masseter muscle st. A focal,
peripherally enhancing fluid
collection ﬇ adjacent to the
mandible is also evident in this
infection of dental origin.
(Right) Axial T1WI MR shows a
patient with prior resection of
facial skin squamous cell
carcinoma ſt. Recurrence is
seen as perineural tumor
along the infraorbital nerve
st through the retromaxillary
fat ﬇ to the pterygopalatine
fossa.

26
Another random document with
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 As for Rose, she had been but a little while with the Fifields till she
began to realize the difference between that and the Blossoms.
Especially was she quick to notice the petty friction, the note of
jarring discord, that made up the atmosphere at the Fifields’. What
one wanted another was sure to object to, what one said was
immediately disputed; the sisters nagged Mr. Nathan, and he in turn
nagged his sisters. No doubt at heart they loved each other, but the
delicate consideration for each other’s wishes, and the gentle
courtesy of affection, that so brightened the Blossom home was
wholly absent here.
Another thing she could not but see was the prevailing tone of
discontent. Though the lives of Miss Fifield and Miss Eudora were
much easier than those of Miss Silence and Mrs. Patience, the one
was always complaining of the dullness of Farmdale, and the other
making bitter reflections on life in general. Had Rose come directly
from Mrs. Hagood’s all this might have escaped her notice, but her
stay in the white cottage with its sweet-spirited inmates had given
her a glimpse of a different life, an ideal that would always linger with
her.
As the two houses were not the length of the green apart Rose
was a frequent visitor at the Blossoms’. “Did your plants freeze last
night?” she asked as she came in one afternoon. “Miss Eudora lost
some of her very prettiest ones. She says it was because Mr. Nathan
didn’t fix the fire right, and he says it was because she didn’t put the
window down tight. They were quarreling over it when I came away,
and yesterday they disputed all day whether the meat bill came in
Tuesday or Wednesday.”
“There, there, Rose,” interrupted Mrs. Blossom, “you are a
member of the Fifield family now, and have no right to repeat or we
to listen to anything you may see or hear there.”
Grandmother Sweet laid down her knitting, “As thee goes through
life, Rose, thee will find many people whose lives seem not to be
ordered by the law of love; at such times always remember that
silence is not only the part of prudence but of true charity. At the
same time thee can learn to avoid the mistakes thee sees others
make.”
“Well,” Rose spoke with emphasis, “I will try to avoid the mistake
of squabbling all the time over trifles—I’m not saying that any one
does so, you know, and when I get to be an old lady I’m going to be
as gentle and lovely as Grandmother Sweet,” and she gave her a
hug and a kiss.
On her part Rose had gone to the Fifields’ with the firm resolve to
do her very best. On her first coming to the Blossoms’, while her
nerves were still keyed up in a tension of excitement, little had been
said to her in regard to the manner of her leaving Mrs. Hagood. But
after she had calmed down to her normal self Mrs. Blossom had
talked to her very seriously of the danger of yielding to passion and
impulse, and had shown her that in spite of all she had to endure
what trouble she might easily have brought on herself, and how
much worse off she might have been because of her hasty action.
So that Rose instead of thinking it a very fine, brave act to have run
away, as she was at first inclined, began to feel that it was something
to regret, and be ashamed of, and because of which she must do
exceedingly well indeed, to win and hold a high opinion.
As Rose was neat and deft, and above all anxious to please, she
soon became quite a favorite with the two middle-aged Fifield
sisters, and Miss Eudora inclined to make a confidante of her.
“So you have lived in cities most of your life?” she said one
morning as Rose was dusting her room.
“Yes, but I like the country better.”
“You do?” exclaimed Miss Eudora, pausing with a curl half
brushed, for, unlike her sister, she affected the willowy, the
languishing; she liked garments that flowed, ribbons that fluttered,
and still framed her little wrinkled face in the curls that had been the
pride of her girlhood.
“Now, I think it is perfectly delightful to live in a city. I spent a winter
in Albany, with my Aunt Morgan some years ago. What a winter that
was—” and she clasped her hands, “one round of gayety and
amusement. Aunt made a large party for me, I shall have to show
you a piece of the dress I wore. Aunt said she was proud of me that
night, and I’m sure,” with a little simper, “I had compliments enough. I
suppose,” and she gave her grey curls a toss, “it’s my own fault that
I’m not living in Albany to-day.”
“If you liked it so well why didn’t you stay?” asked Rose.
“When a young girl has the admiration I had, she doesn’t always
know what she does want. But I can tell you I made quite an
impression on Some One that evening.”
“How did you look then?” Rose was trying to imagine Miss Eudora
as a young girl.
“Oh, just as I do now,” with a complacent glance in her mirror. “I
haven’t changed as some people do. Not long ago I met a friend—
well, an old admirer, and he said he would like to know what I did to
keep myself so young; that I didn’t look any older than I did when he
first knew me. I think my hair may have something to do with that;
curls do have a youthful effect. That’s the reason, I believe, Jane is
always wanting me to put mine back.
“Jane,” and she sank her voice to a whisper, “was always plain,
and never received the admiration, or was the favorite with
gentlemen I was, and it has always made her jealous of me. But I’m
fond of my curls,” giving them a shake. “Why, I even had a poem
written on them once, and I sha’n’t put them up, at least not till I
begin to grow old.”
Rose listened in amazement. She was sure Miss Silence was
younger than Miss Eudora, her hair was not grey, nor her face
marked with such little fine lines, and neither she nor Mrs. Patience
ever talked like that. It was all very queer, and most of all that Miss
Eudora could fancy that she looked young.
“You were a long time doing the chamberwork,” Miss Fifield
remarked when Rose went downstairs. Miss Fifield was in the
kitchen baking, her scant house dress clinging to her angular figure,
and her grey hair drawn back with painful tightness.
 Rose noted the contrast between the two sisters as she answered,
“Miss Eudora was talking to me.”
“What about?” a trifle sharply.
Rose hesitated slightly. “Several things; her visit to the city for
one.”
“I’ll warrant. Perhaps you found it interesting, but when you have
heard the same story twenty-seven years, as I have, twenty-seven
years this winter, it will get to be a weariness of the flesh; that and
her lovers.” She shot a keen glance at Rose, who could not help a
giggle.
Miss Jane Fifield shook the flour from her hands with energy. “I
used to hope that Eudora would grow sensible sometime, but I’ve
about given it up. One thing I am thankful for, that there is something
inside of my head, and not all put on the outside!” and she shut the
oven door with a force that threatened danger to the lightness of the
pound cake she was baking.
 CHAPTER XVI
UNDER A CLOUD

Rose had been a few weeks at the Fifields, long enough to learn
the family ways, so that Miss Fifield felt she could leave home for a
long-planned visit. It was a stormy day, and Mrs. Patience suddenly
exclaimed, “I wonder who can be coming this way in such a hurry?
Why, I believe—yes, it is Rose, running as fast as she can. I hope
Eudora is not sick.”
Almost as she spoke the door opened and Rose rushed in, snow-
powdered and breathless; her hat blown partly off, her face wet with
tears as well as snow flakes, and her voice broken and thick with
sobs, as without giving time for any questions she burst out:
“You said it was a leading of Providence for me to go to the
Fifields’. But it wasn’t; and he says he will have me put in jail if I don’t
tell where the money is. And how can I tell when I don’t know?
Maybe God cares for some folks, but I’m sure He doesn’t for me or I
wouldn’t have so much trouble. I wish I was dead, I do!” and flinging
herself down on the well-worn lounge she buried her face in the
pillow and burst into a storm of sobs.
What did it all mean? They were equally perplexed by the mystery
and distressed by Rose’s evident grief. Mrs. Patience drew off her
things and tried to calm her with soothing words; Miss Silence
brought the camphor bottle—her remedy for all ills. But Rose only
cried the harder till Mrs. Blossom kindly, but with the authority that
comes of a calm and self-controlled nature, said, “Rose, you must
stop crying, and tell us what is the trouble.”
Then choking back her sobs Rose lifted her tear-swollen face and
exclaimed, “Oh, Mrs. Blossom, Mr. Fifield says I have taken a
hundred dollars! A hundred dollars in gold! And I don’t know one
thing more about it than you do, but he won’t believe me, and he
calls me a thief, and everybody will think I am awful, when I want to
be good, and was trying so hard to do my best. What shall I do?” and
she wrung her hands with a gesture of utter despair.
Further questioning at last brought a connected story, from which it
appeared that Nathan Fifield had a hundred dollars in gold, that from
some whim he had put for safe keeping in the parlor stove. That
morning, going around the house to tie up a loose vine, he had
glanced through the parlor window and seen Rose at the stove with
the door open. And when, his suspicion aroused, he had looked for
the money it had been to find it gone, and at once had accused Rose
of the theft.
“And he says I showed guilt when I saw him,” Rose wailed, “and I
did start, for I was frightened to see a face looking in at the window,
and with the snow on the glass I didn’t know at first who it was.”
“But what were you in the parlor, and at the stove for?” questioned
Mrs. Blossom.
“I was dusting the front hall and the parlor. Miss Fifield sweeps the
parlor once a month and I dust it every week, though I don’t see the
need, for those are all the times anybody ever goes into it. Some
feathers came out of the duster, it’s old and does shed feathers, and
I had opened the stove door to throw them in. I didn’t know there
was ever any money in a little leather bag in there; I never dreamed
of such a thing. And if I had I shouldn’t have touched it. Madam
Sharpe always trusted me with her purse, and I never took a penny
from her. I’m not a thief, if he does say that I am. But they won’t
believe me. Miss Eudora is just as certain, and I shall have to go to
jail, for I can’t tell where the money is.”
“Poor child!” and Grandmother Sweet stroked the head that had
gone down in Mrs. Patience’s lap. “It is borne on my mind,” and she
glanced around the little group, “that Rose is wholly innocent, and
that mindful of her youth and inexperience it were well for some of us
to see Neighbor Fifield if an explanation of the mystery cannot be
found.
“No,” with a wave of her hand, as both of her granddaughters
made a motion to rise, “Silence, thee is apt to be hasty and might
say more than was seemly; and Patience, thee inclines to be timid,
and might not say as much as was needful. Thy mother is the one to
go; she has both prudence and courage.”
“Oh, how good you are to me!” Rose exclaimed. “And never so
good as now! I thought you would believe me, I just felt it would kill
me if you didn’t, and now that I know you do I won’t be afraid of
anything.”
Mrs. Blossom was already wrapping herself in her cloak. “Come,
Rose, put on your things; the sooner this is sifted the better,” and
Rose, as many another had done before her, felt a new comfort and
strength in Mrs. Blossom’s strength.
They found Mr. Fifield and his sister hardly less excited than Rose.
“You cannot regret, Mrs. Blossom, any more than I do, this most
distressing occurrence,” and Mr. Nathan rubbed his flushed bald
head with his red silk handkerchief. “I would rather have given the
money twice over than have had it happen. But I must say that it is
no more than I expected when my sisters persisted, against my
judgment, in bringing into the house a girl of whose ancestors they
knew nothing, and who most likely is the child of some of the foreign
paupers who are flooding our shores. I’m sorry, though not surprised,
that it has ended as it has.”
Mr. Nathan was really troubled and sorry, as he said, but he could
not help a spark of self-satisfaction that he had been proven in the
right and his sisters in the wrong. As for Miss Eudora, keenly
mortified at the turn matters had taken, her former friendliness to
Rose only increased her present indignation.
“It’s not only the loss of the money,” she exclaimed, “but the
ingratitude of it, after all our kindness to her, and I gave her my pink
muffler; she never could have done what she has if she had not
been really hardened.”
“But what proof have you that she took the money?” asked Mrs.
Blossom. “As you say she is a stranger to us all, a friendless,
homeless orphan, whose condition is a claim to our charity as well
as our generosity.”
 “Proof,” echoed Mr. Nathan. “Pretty plain proof I should call it, and
I’ve served three terms as Justice of the Peace. Last Saturday the
money was safe in its place of concealment. This morning I
surprised her there and her confusion on discovery was almost
evidence enough of itself. When I look for the package it is gone,
and during this time not a soul outside the immediate family has
been in the house. I regret the fact, but every circumstance points to
her as the guilty one.”
“For all that,” Mrs. Blossom’s voice was calmly even, “I believe
there is some mistake. At the Refuge they told Patience they had
always found her truthful and honest, and while she was with us we
never saw anything to make us doubt that she was perfectly trusty. I
did not even know of her meddling with what she ought not to.”
“Oh, she’s a sly one,” and Mr. Nathan rubbed his head harder than
before. “She has taken us all in—and that includes myself, and
inclines me still more to the belief that this is not her first offence;
and also to the opinion that she should be promptly dealt with.”
“At the same time I hope,” urged Mrs. Blossom, “that you will do
nothing hastily. Imprisonment is a terrible thing for a young girl like
Rose, and might blast her whole life. Time makes many things clear,
and it is always better to err on the side of mercy than of justice.”
“Certainly, certainly. And I do not know,” lowering his voice so it
might not reach Rose, “that I should really send her to jail; but the
law—” and he waved his hand with his most magisterial air, “the law
must be a terror to evil-doers. If not, what is law good for? We might
as well not have any, and my social as well as my official position
demands that I enforce it.”
“And she deserves to be well punished, if ever any one did.” Miss
Eudora gave an indignant shake to her curls as she spoke. “And I
was just thinking of giving her the blue cashmere I had when I went
to Albany. Jane is always complaining of what she calls my ‘shilly-
shally’ ways, and finding fault with my lack of decision, and I feel that
at whatever cost to myself I must be firm in this. Though nobody
knows what a shock it has been to my nerves.”
 “Besides,” triumphantly added Mr. Nathan Fifield, who felt that he
was on the defensive before Mrs. Blossom, and holding up as he
spoke an old-fashioned, richly chased gold locket, “here is further
evidence. While Rose was gone Eudora made an examination of her
effects and this is what she found concealed in a pincushion. Now I
leave it to you if it looks reasonable that a child in her position would
have a valuable trinket like that; or if she had, would keep it hidden?”
When they entered the house Mrs. Blossom had told Rose to stay
in another room, but through the partly opened door she caught a
glimpse of the locket as it swung from Mr. Nathan’s fingers.
“That is mine!” she cried, darting in. “My very own, and it was my
mother’s. What right have you with it, I should like to know? And why
isn’t it stealing for you to go and take my things?”
“Hush, Rose!” Mrs. Blossom reproved. And then her faith in Rose
a little shaken in spite of herself, “If the locket is yours, as you say,
why did you never tell us about it? And why did you hide it so?”
“Why, I never once thought of it,” she answered, looking frankly up
at Mrs. Blossom. “I don’t think the locket is pretty at all, it is so queer
and old-fashioned, and I don’t even know whose picture is inside. All
the reason I care for it is because it was my mother’s. And I sewed it
up in that pincushion, which one of the teachers at the Refuge gave
me, because I was afraid if Mrs. Hagood saw the locket she might
take it away from me.”
“I wonder if this could have been her mother’s father,” for Mrs.
Blossom’s mind at once turned to the subject she had thought of so
often—that of Rose’s family.
“There was a chain to the locket once, but I broke and lost that. I
remember that mamma used sometimes to let me wear it, and it
seems to me she said it was Uncle Samuel’s picture, but I’m not
sure.”
“It certainly is a good face.” And Mrs. Blossom held out the open
locket to Miss Eudora, who as she took it let it drop from her fingers
that the unwonted excitement had made tremulous. In striking the
floor a spring was pressed to a compartment behind the picture, and
as Mr. Nathan Fifield stooped to pick it up a piece of closely folded
paper fell out.
Mrs. Blossom hastily spread this out, and found it the marriage
certificate of Kate Jarvis and James Shannon, dated at Fredonia, N.
Y., some sixteen years before. “Here is a clue to Rose’s family,” she
exclaimed, as they all clustered about the bit of time-yellowed paper,
forgetting for the moment the cloud that rested so heavily over Rose.
“It surely should be,” responded Mr. Nathan.
“I shall write to Fredonia at once,” continued Mrs. Blossom. “And
as the minister whose name is signed may in the meantime have
died or moved away, my best course would be to write first to the
postmaster for information, would it not?”
 “Here is a clue to Rose’s family.”—Page 216.

“That is what I should advise.” Squire Nathan was never so happy

as when giving advice. “It might be well to inclose a letter to the
minister, and also a copy of the marriage certificate. If Rose has any
relatives living she ought to trace them by this. Though whether she
is likely to prove any credit to her family or not is doubtful,” he added,
recalling with a frown the fact that she was a suspected criminal.
“I have faith in her that she will.” Mrs. Blossom’s tone was decided.
“And if you are willing to let matters rest for the present I will, if you
have no objections, take Rose home with me.”
“I shall be only too glad to have you, for my part.” Miss Eudora’s
tone was fervent. “After what has happened I don’t feel that I could
endure her in the house another day.”
“And of course I shall consider you responsible for her
safekeeping,” added Mr. Nathan. “She admits that she ran away
once; she may do so again.”
“No, I won’t, you need not be afraid.” Rose’s voice was trembling,
but she held it firm.
“For you understand,” with emphasis, “that I am not dropping the
matter of the missing money, but only, at your request, passing it
over for the present. I will repeat, however, that if Rose will confess
and return the money, no one but ourselves shall ever know of it. If
she does not I shall feel myself constrained, much as I may regret
the necessity, to resort to more severe measures,” and he blew his
nose with a great flourish of his red silk handkerchief by way of
emphasis.
 CHAPTER XVII
SUNSHINE AGAIN

So absorbed was Rose in her trouble that she took little or no

interest in the attempt to discover her family, or the discussions that
took place in the Blossom household as to its probable result. “I don’t
believe I have any relatives,” she said indifferently, “or they would
have looked after me when my mother and father died. And even if I
have they wouldn’t want to own any one accused of stealing.”
That was the burden of all her thoughts; she woke in the morning
to a sense of overwhelming calamity, and went to sleep at night with
its pressure heavy on her heart. When Grandmother Sweet had
mildly questioned if in the discovery of the marriage certificate she
did not see the hand of Providence, she had replied, with the
irritability of suffering, that she didn’t believe in Providence at all. “I
might,” she had added, “if that money could be found; I sha’n’t till
then.”
For to Rose the executioner’s sword had not been lifted, only
stayed for the time. Visions of arrest and imprisonment were
constantly before her, all the more terrifying that the vagueness of
her knowledge as to their realities left ample room for her
imagination. “How can I tell where the money is when I don’t know?”
was the question she repeated over and over. “And you know what
he said he would do if I didn’t tell?”
She refused to go to school for fear her schoolmates had heard of
her disgrace. She cried till she was nearly blind, and fretted herself
into a fever, till Mrs. Blossom, fearing she would make herself really
sick, talked to her seriously on the selfishness as well as the harm of
self-indulgence, even in grief, and the duty as well as the need of
self-control.
Rose had never thought of her conduct in that light before, and left
alone she lay for a long time, now thoroughly aroused from her
morbid self-absorption, and looking herself, as it were, fully in the
face. The fire crackled cheerily in the little stove, the sunshine came
in at the window of the pleasant, low chamber, on the stand by her
bed were a cup of sage tea Grandmother Sweet had made for her, a
glass of aconite Mrs. Patience had prepared, and a dainty china
bowl of lemon jelly Miss Silence had brought to tempt if possible her
appetite. Mute evidence, each and all of kindly affection, that
touched Rose and filled her with a sense of shame that she had
made such poor return for all that had been done for her.
Rising with a sudden impulse, she went to the little glass, pushed
back the tumbled hair from her tear-swollen face, and sternly took
herself to task. “I’m ashamed of you, I am indeed, that after you have
been taken into this home, and cared for, you should be so
ungrateful as to make every one in it uncomfortable now, because
you happen to be in trouble; and should have shown yourself as
disagreeable, and selfish, and thoughtless as you have. Not one of
them would have done so, you may be sure; and if you ever expect
to grow into a woman that people will respect and love as they do
Grandmother Sweet, or Mrs. Blossom, or Miss Silence, or Mrs.
Patience, you must learn to control yourself. And now, to begin, you
must brush your hair, bathe your eyes, go downstairs and do as you
ought to do. I know it will be pretty hard, but you must do it.”
It was hard. With a morbid self-consciousness that every one
could not but know of her trouble she had hidden, shrinking from the
village folk who so often came in; she was so weak that as she
crossed the room she had to put her hand against the wall to steady
her steps; and now that she was making the effort to rouse herself
she began to see the luxury it had been to be perfectly wretched. But
Rose resisted the temptation to throw herself again on the bed; she
crept steadily, if somewhat weakly, downstairs, and made a brave
attempt at smiling. With a guilty sense of all the opportunities for
making herself useful she had neglected, she took up a stitch in her
knitting Grandmother Sweet had dropped; overcast some velvet for
Mrs. Patience, who was in a hurry with a bonnet; and that done
helped Miss Silence set the table and make supper ready.
 They all saw the struggle Rose was making and helped her by
keeping her mind as much as possible off from herself. And though
that missing money still hung its dark shadow over her, and she
started at every step outside with the sinking fear that it might be
some one coming to arrest her, when she went to her room that night
Grandmother Sweet patted her cheek as she kissed her good-night
and whispered, “Thee has done bravely, Rose,” an unspoken
approval she read in the manner of the others. More than that, she
was surprised to find her heart lighter than she would have thought
possible a few hours before.
To keep steadily on in the way she had marked out for herself was
anything but easy during those days of suspense and anxiety. To
hold back the lump that was always threatening to rise in her throat,
the tears from springing to her eyes; to keep a cheerful face when
her heart would be sinking down, down; to feel an interest in the
concerns of others when her own seemed to swallow up everything
else. But it was her first step in a habit of conscious self-discipline
that she never forgot, and that helped her to meet many an after
hour of trial.
So something over a week went by, for though Mrs. Blossom had
seen Mr. Nathan Fifield several times the mystery was as much of a
mystery as the first day, and in spite of all Mrs. Blossom could urge
both he and Miss Eudora seemed to grow the more bitter toward
Rose. Nor had there come any answer to the letters of inquiry sent to
Fredonia. Every possible theory having been exhausted in both
cases, the subjects had come to be avoided by a tacit consent.
While as to the matter of the marriage certificate, that had made so
little impression on Rose’s mind that she was less disappointed than
the others in regard to it. Mrs. Blossom did not fail to pray daily at
family devotions that the truth they were seeking might be revealed,
and innocence established, and she moved around with the serene
manner of one who has given over all care to a higher power. But
though Rose was unconsciously sustained by a reliance on that
strong faith she did not pray for herself. A hopeless apathy chilled
her. There might be a God, it didn’t matter much to her, for if there
was she was an alien to His love, and she knew she was that for all
the rest might say.
But one afternoon Rose saw a little procession—Mr. Nathan Fifield
and his two sisters, in single file, crossing the now snow-covered
common in the direction of Mrs. Blossom’s. All her fears revived at
the sight. She sprang up, her eyes dilated, her face flushing and
paling. “There they come!” she cried. “I knew they would. They are
going to put me in prison, I know they are! Oh, don’t let them take
me away! Don’t let them!” and she threw herself down beside Miss
Silence and hid her face in her lap as if for safety.
Silence put her strong arms about the trembling form. “Sit up,
Rose,” she said in a matter-of-fact tone, “and wait till you see what
there is to be afraid of.”
By the time Rose had struggled back to outward calmness the
visitors had entered; Mr. Nathan, his face almost as red as the red
silk handkerchief he waved in his hand; Miss Eudora dissolved in
tears; and Miss Fifield with an expression of mingled vexation and
crestfallen humility.
There was a moment’s awkward silence, broken by Mr. Nathan in
an abrupt and aggravated tone. “I’ve come to explain a mistake I
have been led into by women’s meddling and—”
“You needn’t include me,” interrupted Miss Eudora. “You know I
wouldn’t have said what I did if you hadn’t made me feel that we
were in danger of being murdered in our beds, and I hadn’t thought
Jane would be always blaming me if I didn’t use decision. Nobody
can tell how painful it has been for me to do what I have. I don’t
know when my nerves will recover from the strain, and I’ve lost flesh
till my dresses are so loose they will hardly hang on me. I’m sure I
never dreamed that Jane—”
“Oh, yes, lay all the blame you can on Jane,” rejoined that lady
grimly. “It isn’t often you get the chance, so both of you make the
best of it. I’m sure when I went away I never dreamed that you were
going to get in a panic and act like a pair of lunatics, particularly a
strong-minded man like Nathan. I never was so astonished as when
I reached home on the stage to-day and found out what had
happened. Eudora says she wrote me about it, but if she did she
must have forgotten to put the State on; she always does, and the
letter may be making the round of the Romes of the whole country;
or else Nathan is carrying it in his pocket yet—he never does
remember to mail a letter.”
“If I were you I wouldn’t say anything about remembering, now or
for some time to come,” snapped her brother.
“Friends,” Grandmother Sweet’s voice was serenely calm, “if thee
will refrain from thy bickering and explain what thee means, it will be
clear to our minds what doubtless thee wishes us to know.”
While Rose, unable longer to restrain her impatience, exclaimed,
“Oh, tell us, have you found who stole the money?”
“That is just what I want to do if I can have a chance,” and Mr.
Fifield glared at Jane and Eudora. Then to Rose, “No, we haven’t
found who stole the money,” and as her face paled he hastened to
add, “because, in fact, the money was not stolen at all.”
“Where—what—” cried his eager listeners, while Rose drew a long
breath of infinite relief and sank back in her chair trembling, almost
faint with the joyful relaxation after the long strain of anxiety.
“Jane,” Mr. Nathan continued, rubbing his head till every hair stood
up, “simply saw fit to remove the money from the place where she
knew I was in the habit of keeping it, without even letting me know
what she had done.”
“You see,” explained Miss Fifield, feeling herself placed on the
defensive and determined to maintain it boldly, “I had just read of a
man who kept his money in a stove, and one day some one built a
fire and burned it all up, so I felt a stove was not a very safe hiding-
place.”
“Well,” snorted Mr. Nathan, “as there hasn’t to my certain
knowledge been a fire in that parlor stove for the last four years, I
don’t think there was much danger, to say nothing of the fact that
gold will not burn.”
 “But it will melt,” triumphantly. “Besides, I have been told that when
burglars go into a house under carpets and in stoves are among the
first places they look. For these reasons I changed it to a trunk under
a pile of papers in the store-room. I intended to have told Nathan
what I had done, but in the hurry of getting away I did forget. But I
should have thought that before accusing any one they would have
waited to see what I knew about the matter.”
“You say so much about my being forgetful that I didn’t suppose
you ever did such a thing as to forget,” growled Mr. Nathan. And
Eudora added, “And her mind’s always on what she is doing. She
has so little patience with mistakes I never thought of her being the
one to blame.”
“At any rate,” retorted Miss Fifield, “I don’t lose my glasses a
dozen times a day. And I don’t put things in the oven to bake and get
to mooning and let them burn up. I admit I was in fault about this,
and I am as sorry as I can be for the trouble it has made, and most
of all for the unjust suspicion it has brought on Rose; but, fortunately,
no one but ourselves is aware of this, and I don’t know as it will
make matters any better to harp on it forever.”
In fact, it needed no words to tell that the Fifields were not only
heartily sorry for what had happened, but decidedly ashamed. For
every one had been touched in the way to be felt most keenly;
Squire Fifield in that he had been proven unjust and mistaken in his
opinion, Miss Eudora that she had been hard-hearted, and Miss
Fifield that she had failed in memory and laid herself open to blame.
This blow at the especial pride of each, made them, while really glad
that Rose had been proved innocent, for the moment almost wish
that she or some one could at least have been guilty enough to have
saved them the present irritation of chagrin and humiliation.
Perhaps unconsciously something of this showed itself in Mr.
Nathan’s manner as he said: “Yes, Rose, we deeply regret that we
have wrongfully accused you—though I must still say that under the
circumstances we seemed justified in doing so, and I hope you will
accept this as a compensation for the trouble it has made you,” and
he dropped a couple of gold eagles in her lap.
 Rose’s cheeks crimsoned. “I don’t want any such money,” she
cried hotly, flinging the gold coins to the floor. “Because I was poor
and hadn’t any home or friends you thought I must be a liar and a
thief. If you had said as though you’d meant it that you were sorry for
the way you had treated me it would have been all I asked. I don’t
ask to be paid for being honest. It’s an insult for you to offer to, and
I’d beg before I’d touch it, I would!”
“Rose, Rose!” reproved Mrs. Blossom, who had been unable to
check the indignant torrent. “I trust you will overlook the way Rose
has spoken,” she hastened to say. “This last week has been a great
strain on her, and her nerves are in a condition that she is hardly
responsible.” As she spoke she gave a warning glance at Silence,
from the expression of whose face she knew that she approved of
Rose’s action, and was fearful would endorse it in words; at the
same time Mrs. Patience looked at Rose in amazement that she
should dare thus to provoke Nathan Fifield’s well-known irascible
temper, and all present waited for the explosion they expected would
follow.
But contrary to their expectation after a moment’s amazement he
began to laugh. “She’ll do,” he said to Mrs. Blossom with a nod of
approval. “Grit like that will pull through every time, and she’s got it
about right, too. Upon my word,” rubbing his hands as if at a sudden
idea, “if no one else puts in a claim I will be tempted to adopt her
myself. I believe an education wouldn’t be wasted, and with her
spunk I’d like to see what she would make.”
One good thing about Rose’s temper was that though fiery its
flame was quickly spent, and penitence was almost sure to swiftly
follow wrath. It was so in this case; hardly had he ceased speaking
when a meek little voice was heard, “I didn’t do right at all, Mr. Fifield,
to talk to you as I did, and I hope you’ll forgive me?”
“Well, my dear,” was the answer, “I didn’t do right either in being so
ready to think evil of you, in being on the lookout for something
wrong, as I was, and I hope you’ll forgive me?”
“And me, too,” sobbed Miss Eudora. “I never was hard on anybody
before in my life, and I’m sure I never will be again.”
 “And now,” observed Miss Fifield drily, “I suppose I ought to ask to
be forgiven for being the guilty one.”
“Oh, Miss Fifield,” and Rose caught her hand, “we all forget things;
I know I tried you lots of times by forgetting. It wasn’t—I suppose—
strange they should have thought as they did, but it’s all right now.
And please promise me, Mr. Fifield and Miss Eudora, that you will let
it all go, and never say anything unpleasant to Miss Fifield about it.”
“Why, child!” cried Mr. Nathan, as if astonished at the idea, “I
wouldn’t say anything unpleasant to my sisters, I never do. Of course
I have to hold them level now and then, but I don’t know as I ever
spoke a really unpleasant word to them in my life.”
“Yes,” Miss Fifield’s tone was complacent, “that is one of the things
I have always been thankful for, that we were a perfectly harmonious
family. I don’t deny that I am tried sometimes with Nathan and
Eudora, but I never let them know it.”
“I have my trials, too,” added Miss Eudora with a pensive shake of
her little grey curls, “but I bear them in silence. Family squabbles are
so disgraceful that I don’t see how a person of refinement could ever
take part in one.”
Rose stared round-eyed from one to another speaker, and Silence
Blossom turned her face away for a moment; but Grandmother
Sweet smiled gently, for she had long ago learned how seldom it is
that people know their own faults, or see themselves as others see
them.
As they were leaving Miss Fifield turned to Rose. “Of course we
shall want you to come back to us. When will that be?”
“Not just at present,” Mrs. Blossom hastened to answer. “First of
all she must have time to rest and get back to her usual self.” Rose
lifted grateful eyes, for at that moment it didn’t seem to her that she
could enter the Fifield house again.
At the door Miss Eudora paused. “And you haven’t heard anything
yet about her people? Finding the marriage certificate in the locket
was just like a story. And if she should prove to be an heiress how