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
Another random document with
no related content on Scribd:
Telkens wordt hij wakker geschud door elleboogstooten van de juffrouw
naast hem, die zachtjes zegt:

„Toe nou Janes!” waarop hij dan knorrig: „la’-me met rust,” bromt.

In Ambro’s vindingrijk brein rijpt alweer een mooi plan. [238]

Hij klimt weer van de bank en constateert met genoegen, dat de poffertjes
inmiddels gekomen zijn.

Ofschoon ze erg heet zijn, vallen de jongens er direct op aan en smullen

naar hartelust.

Ambro, die eerst stevig doorgegeten heeft, houdt nu met eten op en laat
een stuk of vier poffertjes op zijn bord liggen.

„Lust je niet meer?” vraagt Chris verwonderd.

„Zal je gewaar worden, man! Nog wel vijf dozijn. Maar die blijven bewaard
voor m’n vrind hiernaast.”

„Je vrind?” en Chris stapt ook op de bank en kijkt over het schut.

„Hij heeft ’m om,” lacht hij tegen ’t gezelschap, wijzend naar het hoekje
waar de man nog steeds zit te dommelen.

„Toe, ga nou gauw deur, aap!” zegt verontwaardigt de juffrouw, die de

partij opneemt van haar echtgenoot.

De andere jongens zijn nu ook komen kijken en vier ondeugende

gezichten loeren over het schut naar het gezelschap naast ze.

„Toe, gane jullie sitte! D’r is hier niks besonders te sien, hoor!” wordt hun
toegeroepen.

„Vooruit, jongens, we gaan weg,” zei Ambro, zóó hard, dat de buren het
goed konden verstaan.

„Ja, gane jullie maar, leelijke deugnieten,” riep de beleedigde juffrouw.

De jongens doken naar omlaag.

„Maar we gaan niet heusch,” fluisterde Ambro. „Eerst nog een bak met
den dronken oome hebben. Nou net doen of we weggaan, knullen.” [239]

Ze schuifelden met hun voeten en liepen heen en weer, zoodat de buren

werkelijk dachten, dat ze weg waren.

Toen haalde Ambro een touw uit zijn zak, en maakte aan het einde
daarvan een groote lus.

De jongens volgden vol belangstelling zijn bewegingen.

„Zoo, dat is klaar,” zei Ambro. „Nou moet jij me helpen, Chris. Als ik onder
de bank kruip om oome Janes z’n voet in die las te krijgen, moet jij die
overgebleven poffertjes op je vork doen en als je dan de vork in de hoogte
houdt en er een mep tegen geeft met je andere hand, dan vliegen de
poffers die menschen hiernaast om hun ooren. En dan heb ik m’n handen
vrij en zal je oome Janes een buiging zien maken. Maar dan weghollen,
hoor! Want ze zullen ons even achterna rennen!”

Chris was onmiddellijk bereid en zachtjes ging hij op de bank staan om op

het eerste sein van Ambro den aanval te beginnen.

Intusschen was Ambro onder de bank gekropen.

Tusschen de twee kamertjes was aan den onderkant een groote spleet
open en daardoor waren de beenen van de buren zichtbaar.

Heel voorzichtig sloeg nu Ambro de lus om den schoen van „Oome

Janes”, die met de beenen over elkaar rustig zat te dommelen.

„Chris,” fluisterde hij. „Gooien!”

Hup! vier welgemikte, dikke poffers vlogen naar alle kanten in de

gezichten van de verbaasde buren. [240]
En temidden van dit tumult rolde eensklaps „Oome Janes” door een
vreeselijken ruk voorover, en sloeg met z’n armen op tafel, midden
tusschen de bordjes met poffertjes.

De woede en de verbazing van de omstanders is niet te beschrijven. En

tusschen al die woedende menschen zat Oome Janes met een onnoozel
gezicht te kijken, terwijl hij mompelde:

„Hè, hè … is da … slape!”

De jongens vlogen als een pijl uit den boog weg, achterna gezeten door
een der mannen van het gezelschap. Ze waren hem echter te vlug af en
de man gaf den wedloop dan ook spoedig op.

En zoo eindigde de eerste kermisavond der vier bengels.

Dat er de verdere dagen nog een aantal streken uitgehaald werden dient
geen betoog.

Toen ze op den laatsten dag echter hun kermispot nakeken, bleek het, dat
ze al hun geld nog niet verteerd hadden.

„We zijn zuinige pantalonika’s geweest,” zei Chris.

„Nou alle centen van avond stuk slaan?” vroeg Piet.

„Neen,” zei Ambro. „Ik weet wat leuks. Laten we de helft van de spiejen nu
bewaren om Karel, Paul en Wim te fuiven als ze terug zijn. We vieren dan
meteen ons afscheid van de lagere school. Want al blijft de bende
bestaan, we waaien toch verschillende kanten uit.”

Ze waren er alle drie voor te vinden en er [241]werd dien avond een gulden
negen en vijftig en een halve cent apart gelegd voor de afscheids-fuif.

En zoo vinden we de heele club dan terug op het stukske grond, dat al
zoo menig keer getuige was van hun jongensstreken, n.l. het weiland.

„We zullen eerst vreugdevuren ontsteken,” zegt Ambro.

Hij pakte al wat hij aan papieren en vodden vindt bijeen en gooit het op
een hoop.

Nu worden er houtjes gezocht en met behulp van de noodige lucifers, die

Ambro voor dit doel had meegebracht, wordt het vuurtje aangestookt.

Als het eindelijk lustig brandt, dansen de jongens er in woesten krijgsdans

om heen.

„Vooruit jongens, nu gaan we al het lekkers opeten,” zegt Chris plotseling.

„Lekkers?” vraagt Karel verwonderd.

„Wachten,” gebiedt Ambro. En dan gaat hij op hoogdravenden toon voort:

„Laat mij, roovers van het Hol van Kaan, wier hoofdman ik ben, nog
éénmaal als medescholier het woord tot jullie voeren.

„Wij zijn hier bijeen gekomen, om het afscheid te vieren van onze geliefde
en hooggewaardeerde lagere school. Over een week zitten we allen te
zweeten op een H … h … h … oogere School. Dàn zullen we aan den lijve
voelen wat werken heet. Totnogtoe hebben we pret gehad en óók wel es
gewerkt, maar dáár, geloof me, zullen ze ons mores leeren.

„Laten we, terwijl we al de lekkernijen opbikken, [242]die wij van onze

kermiscenten ter eere van jullie terugkomst gekocht hebben, de heerlijke
dagen herdenken die we doorgebracht hebben vanaf de Bewaarschool tot
nu.

„En roovers, laten we elkaar beloven steeds ons clubje in eere te houden
en geen vreemde snoeshanen naar binnen te smokkelen.

„De roovers van het Hol van Kaan, zij leven hoog!”

Een oorverdoovend applaus beloonde deze schitterende feestrede.

Toen vond Chris, dat hij nu niet minder kon, dan Ambro voor zijn speech
te bedanken.
Heel waardig stond hij op uit het gras, waarin hij languit lag en sprak
Ambro toe met de volgende woorden:

„Ambro, Hoofdman der roovers van het Hol van Kaan.

„Uit naam van de heele bende dank ik je voor je emmese toespraak.

„Je weet, ik kan niet zoo goed kletsen als jij, maar ik wil je alleen zeggen,
dat zoo’n kameraad als jij nog gevonden moet worden. Hè, jongens?”

„Nou en of! Zeg dat wel!” gilden de overige roover-leden dooreen.

„En,” ging Chris verder. „We hopen dan ook, dat je onze Hoofdman zult
blijven, we gaan door dik en dun met je mee. Hiep hôj voor Ambro!”

„Hiep hôj!” schreeuwden ze allen eenige malen.

„En nou de boel opschransen,” zei Chris, die vond, dat ie na zulk een
schoone rede recht op zijn aandeel had. [243]

Het was een waar feestmaal, de onvolprezen zuurballen, okkie’s, noga-

blokken, al wat het magazijn van Hazelip herbergde was aanwezig.

Toen alles op was, haalde Ambro een fijn bonbon-zakje te voorschijn,

waarin zeven rhumboonen zaten.

„Deze godendrank heb ik tot het laatste bewaard, we zullen den drank
opslurpen en met de chocolade-huls klinken op onze trouwe vriendschap.”

Plechtig reikte hij ieder een rhumboon over.

En even plechtig ging het zoete slokje naar binnen.

Toen gingen ze vlak bij elkaar staan en ze stootten aan met de eenigszins
weeke overblijfselen van de boonen.

„Lang leve de bende van Kaan, lang leve Ambro, hiep hôj!”

Toen was het feest geëindigd en gingen ze allen voldaan naar huis. [244]
[Inhoud]
 BESLUIT.

En nu ben ik aan het einde van mijn verhaal gekomen. De vacantie is

om en de jongens gaan naar de H.B.S. of Gymnasium.

Er komt nu een heel andere tijd voor ze, Ambro heeft dit zeer goed
gevoeld. Er moet stevig gewerkt worden en er kunnen geen heele
middagen meer besteed worden aan schelmenstreken.

Ik zou jullie nog heel veel van ze kunnen vertellen, misschien laat ik
ze nog wel eens als H.B.S.-sers voor jullie verschijnen.

Op dit tijdstip, dat is dus vijftien jaar na den tijd waarop ze hun
jongensstreken uithaalden, zijn ’t allen deftige mijnheertjes geworden.

Maar wacht, ik zal de film even laten draaien, net als bij het begin van
mijn boek, dan zien jullie mijn helden weer levensgroot op het doek
verschijnen.

Rrrrrrrr … zegt de motor, wacht even, hij weigert … rrrrr …

Kijk, zien jullie dien heer, deftig in het zwart met hoogen hoed op en
een portefeuille onder [245]den arm, die daar juist het Gerechtshof
verlaat.

Dat is Puckie!

Een coupeetje op luchtbanden rolt aan.

Er uit stapt een slanke jongeman.

Het is Paul, nu een zeer bekende kinder-arts met drukke praktijk.

Rrrrrrrr.…. de Rotterdamsche Beurs.

Tusschen een troepje druk pratende heeren, loopt Karel, hij is een
gezeten graanhandelaar geworden.

Nu gaan we ver weg.…. de film voert ons naar Indië.

Zie je dien heer, die daar in een langen rieten stoel in de voorgalerij
van zijn huis een fijne manilla rookt?

Dat is Wim, hij is ingenieur.

VIJFTIEN JAAR LATER

[246]

We gaan terug naar Holland. Een groot kantoor in Amsterdam.

Er zitten eenige heeren aan groote bureaux te schrijven.

Een van die heeren staat voor het raam, hij kauwt peinzend op zijn
penhouder en tuurt naar buiten.
Het is Chris, hij is candidaat-notaris.

Nu zijn we aan boord van een groot schip. Over de verschansing leunt
de eerste stuurman.

Hoe kranig staat hem zijn uniform, en hoe pienter kijken de levendige
oogen onder de stuurmans-pet uit.

Het is Piet.—Nu kan hij z’n lust tot avonturen bot vieren.

Florence.—Het is midden-zomer.

Voor een van de groote café’s op de Piazza del Duomo zit een jonge
man.

Hij heeft een schetsboek in de hand en maakt kleine krabbels van de

voorbijgangers.

Nu kijkt hij op.

Waar hebben we dit vroolijk, open gelaat meer gezien.

Halo! ’t Is Ambro. Hij is om studies te kunnen maken naar Italië

vertrokken.

Hij is onveranderd, de hoofdman van het Hol van Kaan.

Z’n oogen staan nog even overmoedig en brutaal als vroeger. Hij zal
zijn weg wel vinden door ’t leven.

Zoo—nu hebben jullie mijn helden een voor [247]een teruggezien, allen
als welgestelde burgers.

Er is niet één mislukt van het aardige jongenstroepje. En ik denk, dat

ze allen nog wel eens met weemoed terugdenken aan de heerlijke
onbezorgde dagen van
HET HOL VAN KAAN.
 Inhoudsopgave

INHOUD
I. DE BENDE UIT HET HOL VAN KAAN 1
II. „VAN M’N EIGEN VERDIENDE CENTEN.” 6
III. „TUSSCHEN HEMEL EN AARDE.” 11
IV. ’N KWARTJE ’N RAT! 18
V. EEN DROEVE DAG. 26
VI. HET „MONSTER”. 32
VII. DE GEHEIMZINNIGE MACHT. 38
VIII. NETTE MANIEREN... EN ONNETTE JONGENS. 46
IX. WIE EEN KUIL GRAAFT VOOR EEN ANDER... 58
X. EEN „DIKKE” VRIEND. 69
XI. DE KUNSTVEILING. 89
XII. DE MISLUKTE NACHT-WANDELING. 96
XIII. HET GEHEIMZINNIGE APPARAAT. 109
XIV. VAN EEN VLIEGER EN EEN MEISKE. 117
XV. KAREL’S EERSTE OPTREDEN. 127
XVI. RATTEN, KOGELFLESCHJES EN LADDERS! 141
XVII. AMBRO EN PAUL OP REIS. 160
XVIII. AMBRO REDT EEN SECTIE SOLDATEN. 170
XIX. VERRADERLIJKE ROOK! 182
XX. VAN EEN DIEFSTAL OP SCHOOL EN EEN
VUILNISBLIK ALS KOEKEPAN. 196
XXI. DE KERMIS. 213
XXII. DE KERMIS. 220
XXIII. BESLUIT. 244
 Colofon
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Metadata

Het hol van

Titel:
Kaan
Emilie
Info
Auteur: Belinfante
https://viaf.org/viaf/282449992/
(1875–1944)
Willem
Frederik Info
Illustrator:
Heskes (1891– https://viaf.org/viaf/286489399/
1973)
Aanmaakdatum 2023-11-12
bestand: 10:55:32 UTC
Nederlands
(Spelling De
Taal:
Vries-Te
Winkel)
Oorspronkelijke
1919
uitgiftedatum:

Codering
Dit boek is weergegeven in oorspronkelijke schrijfwijze. Afgebroken
woorden aan het einde van de regel zijn stilzwijgend hersteld.
Kennelijke zetfouten in het origineel zijn verbeterd. Deze
verbeteringen zijn aangegeven in de colofon aan het einde van dit
boek.

Documentgeschiedenis

2023-11-11 Begonnen.

Verbeteringen

De volgende verbeteringen zijn aangebracht in de tekst:

Bladzijde Bron Verbetering Bewerkingsafstand

1 heldinnen -heldinnen 1
5, 5, 149,
150, 150,
150, 152, societeit sociëteit 1/0
155, 159,
190
Zaterdag-
11 Zaterdagmiddag 1
middag
23, 172 „ [Verwijderd] 1
[Niet in
Passim. „ 1
bron]
42 ., „ 2
64, 68,
, . 1
203
mond-
72 mondharmonika’s 1
harmonika’s
72 direkt direct 1
76 bangert bangerd 1
77 goeïge goeiige 2/1
toeloo-
78 toeloopend 4
loopend
89 Boeker’s Boekers’ 2
 90 vernield vernielt 1
97 Bangert Bangerd 1
97 snert-krullen snert-knullen 1
kracht-
110 krachtpatser 1
patser
kwasie- kwasi-
127 1
onverschillig onverschillig
131 ” [Verwijderd] 1
138 eenigzins eenigszins 1
139 Diena Dina 1
goud-
165 goudreinetten 1
reinetten
202 onmiddelijk onmiddellijk 1
206 onmiddelijke onmiddellijke 1
222 Einkelijk Eindelijk 1
223 raakt raadt 1
239 volgde volgden 1

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Overzicht van gebruikte afkortingen.

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n.l. namelijk
O.-I. Oost-Indisch
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