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1 Imaging inHead andNeck Surgery
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Fig. 1.5 Cystic neck lesions. (a) Second branchial cleft
cyst with a smooth, non-enhancing rim and internal low
density positioned deep to the SCM, lateral to the carotid
sheath and posterior to the submandibular gland. (b) SCC
1.4.7 Carotid Body Tumour
nodal metastasis (arrow), which is predominantly cystic
but has a thickened enhancing margin. The primary lesion
was a small tumour in the right base of the tongue (short
arrow)
tense, with a “salt and pepper” appearance on
both T1 and T2 whereby punctate regions of
A carotid body tumour, also known as chemodectoma, is a highly vascular glomus tumour that
arises from paraganglion cells of the carotid
body. They are the most common type of paraganglioma in the head and neck (60–70%) and
are bilateral in 10% of cases. A small number are
familial (up to 10%) with an autosomal dominant
inheritance and associated with multiple endocrine neoplasia (MEN IIa and IIb), phakomatoses
(neurobromatosis type 1, tuberous sclerosis
complex and von Hippel–Lindau disease) and
Carney triad [20].
Carotid body tumours are located at the
carotid bifurcation, with characteristic splaying
of the ICA and ECA (the “lyre” sign), see
Fig.1.6. On CT, they demonstrate vivid contrast
enhancement. On MRI, carotid body tumours
appear T1 iso- to hypointense, and T2 hyperin-
haemorrhage (salt) are intermingled with small
ow voids (pepper). Lesions enhance intensely
following gadolinium administration.
The splaying of the carotid vessels or the
“lyre” sign is nicely demonstrated on digital subtraction angiography, with an intense tumour
blush and early venous drainage due to arteriovenous shunting. The ascending pharyngeal artery
generally constitutes the main arterial supply to
the tumour. As with other paragangliomas,
carotid body tumours will show uptake with
68Ga-DOTATATE PET/CT as well as metaiodobenzylguanidine (MIBG), which is useful in
assessing multicentric tumours. MIBG is comparatively more costly and has decreased spatial
resolution compared to 68Ga-DOTATATE PET/
CT but may be useful in some tumours that are
negative on PET/CT.
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Fig. 1.6 Carotid body
tumour. (a) Axial
contrast-enhanced CT
(CECT) demonstrates an
avidly enhancing lesion
within the right carotid
space, splaying the
internal and external
carotid arteries. (b) The
sagittal image from
time-resolved MRA
shows the “lyre sign”
G. Aw and J. Gillespie
1.5 Skin Cancer
slice, high-resolution bone windows. If there is a
concern for invasion through the calvarium, then
Most non-melanoma skin cancers can be managed without any imaging prior to treatment.
However, tumours that are large or in difcult
anatomical sites, such as the eyelid, lip or ear,
may require imaging to assess for deeper invasion. The histology of the primary tumour may
also alter the need for staging.
In patients with squamous cell carcinoma
(SCC), high-risk features, such as recurrent
tumours, >2cm in diameter, poorly differentiated
histology, perineural invasion and lymphovascular invasion, may prompt further staging with CT
given the increased risk of nodal and distant
metastases. Merkel cell carcinoma (MCC) is a
neuroendocrine tumour of the skin. Although
these tumours are rare, they are highly aggressive
with a high incidence of nodal and distant metastases. It is now generally accepted to include
FDG-PET in the staging of patients with MCC
[21, 22].
CT should be the initial imaging modality for
large tumours that are xed to underlying structures. Bony invasion is well demonstrated on thin
MRI may be required. MRI is also useful in
lesions where there is suspicion of orbital invasion, especially tumours around the medial
canthus.
The other feature that should prompt imaging
with MRI is if there are clinical features suggestive of perineural tumour spread (PNS). This
occurs when tumour spreads along the perineurium of peripheral sensory and motor nerves and
is associated with dysaesthesia or motor dysfunction depending on the nerve involved, most commonly the trigeminal and facial nerves. It can
occur years after prior treatment of a skin cancer.
Therefore, any new symptoms of cranial neuropathy should prompt a dedicated, high-resolution
skull base MRI (MR neurogram) to assess for
PNS.Imaging features (Fig.1.7) include thicken-
ing and abnormal enhancement of the nerve, with
loss of the normal fat pads around the skull base
foramina and expansion or erosion of the foramina [23]. There may also be secondary signs of
nerve involvement with denervation changes in
the muscles of facial expression or mastication.
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Fig. 1.7 Perineural tumour spread. (a) Axial T1-weighted
MRI demonstrates loss of the normal fat within the left
pterygopalatine fossa (arrow). (b) Coronal T2 FS
sequences show high signal intensity and volume loss
within the muscles of mastication (arrow) consistent with
subacute denervation change. T1 post contrast FS
sequences in axial (c) and coronal (d) planes show abnormal enhancement and thickening of the maxillary and
mandibular divisions of the left trigeminal nerve (arrows)
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G. Aw and J. Gillespie
In patients with Stage III or IV melanoma,
PET-CT is the imaging method of choice to
assess for nodal or visceral metastases. Highresolution CT performed alongside the PET can
detect small pulmonary nodules (<8 mm) that
may not demonstrate FDG uptake due to their
small size. Contrast-enhanced MRI of the brain is
the most sensitive modality for the detection of
intracranial metastases and should be considered
in patients with Stage IV disease if there are no
contraindications to MRI [24]. Due to the presence of melanin, which causes T1 shortening,
cerebral metastases may demonstrate high signal
intensity on T1-weighted sequences. They may
also be low signal intensity on T2-weighted
sequences due to the presence of haemorrhage.
1.6 Upper Aerodigestive Tract
Neoplasia
Neoplasms of the upper aerodigestive tract may
come to the attention of the general surgeon due
to the detection of an enlarged lymph node in the
neck. The vast majority of these will be SCC,
although other malignancies, such as adenoid
cystic carcinoma or adenocarcinoma, can rarely
arise from the mucosa of the upper aerodigestive
tract.
Size is one of the key features that may
arouse suspicion for a pathological node. The
standard measurement to determine if a node is
enlarged or not is the short-axis diameter, measured in the axial plane, with 10mm generally
accepted as the cut off for most neck nodes, or
up to 12 mm in the jugulodigastric (level 2)
nodes. However, it is important to remember
that there are multiple imaging features to consider when evaluating pathological lymph
nodes. These include the morphology of the
node (with loss of the normal fatty hilum), presence of necrosis or cystic change, increased
enhancement and calcication [25]. These features are demonstrated in Fig.1.8.
Extranodal extension (ENE) is a nding on
clinical examination in which the nodes are xed
to adjacent muscles, there is invasion of the skin
or features of invasion into other structures (brachial plexus or sympathetic trunk) [24]. This
may be supported by radiological evidence of
ENE with nodes demonstrating poorly dened
or spiculated margins with encasement of vessels and direct invasion into the adjacent
musculature.
In a patient with a pathological node (palpable or detected on imaging), one of the rst
imaging steps is to perform an ultrasound-guided
ne needle aspirate or core biopsy, including
testing for p16 staining (to assess for HPV status). CT is used to detect a primary lesion and
also stage the nodal disease in the neck [26]. At
the same time, the patient should undergo a comprehensive clinical assessment including nasendoscopy to assess for a primary lesion. MRI is
typically reserved for specic tumours such as a
small oropharyngeal primary tumour being considered for trans- oral robotic surgery (TORS) as
seen in Fig.1.9. FDG/PET is particularly helpful
in HPV positive tumours and can help to localise
the primary site and is also important in assessing for treatment response following radiotherapy (± chemotherapy).
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Fig. 1.8 Neck nodes. (a) Normal node on ultrasound
with a fat-containing echogenic hilum and thin cortex
with reniform shape. (b) SCC nodal metastasis on ultrasound demonstrating loss of the normal fatty hilum, lobulated margins and loss of the normal reniform shape. (c) A
small focus of necrosis (arrow) in a right level Ib node on
CT was conrmed to be a metastasis from an SCC of the
ventral tongue. (d) T1 post contrast FS MRI of a large
nodal mass demonstrating evidence of ENE with spiculated margins (arrow) and inltration into the adjacent
sternocleidomastoid muscle
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G. Aw and J. Gillespie
a
b
Fig. 1.9 Oropharyngeal SCC. (a) Ultrasound-guided
FNA of a left level II lymph node. The arrow demonstrates the needle within the node. (b) CECT of the left
level II node with internal necrosis. Subtle thickening and
enhancement of the left base of the tongue represents the
1.7 Conclusion
primary oropharyngeal tumour (arrow), better demonstrated on the contrast-enhanced T1 FS axial MRI (c) and
PET (d). Note the central photopaenia within the node on
FDG-PET due to necrosis of the node
complementary roles to assist the physician and
surgeon in making diagnostic and therapeutic
Imaging plays an essential role in the evaluation
decisions.
of both benign and malignant head and neck conditions, with a combination of CT, MRI, ultrasound, nuclear medicine and angiography playing
Acknowledgements The authors thank Dr. Patrina
Campbell for her review of this chapter.
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Roentgenol. 2007;188(6):1706–15.
17. Evangelista L, Sorgato N, Torresan F, Boschin IM,
Pennelli G, Saladini G, etal. FDG-PET/CT and parathyroid carcinoma: review of literature and illustrative
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JG. Congenital cystic masses of the neck:
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EY, et al. Extraadrenal paragangliomas of the
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Thyroid
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StevenCraig
2.1 Introduction
Thyroid surgery is commonly encountered in
modern general surgery training and practice, but
it was not always so. In the early 1900s, thyroid
surgery was banned in France and parts of the
United States because of high mortality rates
associated with bleeding, unrecognised bilateral
nerve injuries and unrecognised severe hypocalcaemia. At that time, thyroid surgery could not be
conducted safely because of a lack of detailed
understanding of the anatomy and physiology of
the thyroid gland.
Although modern thyroid surgery is now safe
and low risk, with a near zero mortality rate, it
should not be entered into lightly. Easy access to
medical imaging in Australia has increased the
detection of thyroid pathology, particularly
asymptomatic thyroid nodules and low-risk papillary thyroid cancer. To prevent unwarranted surgical risk to patients, it is imperative to understand
the nuanced indications for thyroid surgery, and
the extent of surgery required.
2.2 The Basics: Essential
Anatomy, Embryology
andPhysiology
2.2.1 Embryology andAnatomy
2.2.1.1 Origin
The follicular cells of the thyroid develop from
the foramen caecum, an embryological midline
diverticulum in the oor of the mouth that originates between the rst and second pharyngeal
pouches.
The parafollicular C-cells develop from neural
crest cells that derive from the ultimobranchial
body and migrate into the superolateral margins
of the gland. The embryological remnant of this
migration is the Tubercle of Zuckerkandl.
Failure of descent of all or part of the thyroid
from the foramen caecum results in ectopic thyroid tissue. In adults, the brous remnant of the
foramen caecum is located between the anterior
2/3 and posterior 1/3 of the tongue. This is the
most common location for the ectopic thyroid tissue (lingual thyroid), and when present, it represents the sole thyroid tissue in 75% of cases.
S. Craig (*)
Illawarra Shoalhaven Local Health District,
Wollongong, NSW, Australia
Graduate School of Medicine,
University of Wollongong, Wollongong, Australia
e-mail: steven@drstevencraig.com.au
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
B. Ashford (ed.), Head and Neck Surgery for General Surgeons,
https://doi.org/10.1007/978-981-19-7900-2_2
2.2.1.2 Thyroglossal Duct
Differential growth of the embryo causes elongation of the embryological thyroid diverticulum
and its subsequent descent into the lower neck,
forming the thyroglossal duct. The duct descends
in the midline, closely associated with the hyoid
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S. Craig
bone. The thyroid gland comes to rest in the
lower neck and begins to mature by week 7.
The thyroglossal duct is usually obliterated
between weeks 7 and 10. Failure of obliteration
can result in a persisting thyroglossal duct or
cyst. Thyroglossal cysts can enlarge, become
infected and carry a 1% lifetime risk of malignancy. Cysts are generally located between the
hyoid bone and thyroid isthmus but can lie anywhere between the base of the tongue and the
thyroid.
When present, the pyramidal lobe is located at
the apex of the thyroid isthmus. It is a remnant of
the thyroglossal duct.
2.2.1.3 Thyroid Anatomy
The thyroid is a buttery-shaped organ located
immediately anterior to the trachea. In adults, a
normal gland extends from the cricoid cartilage
down to the level of the sixth tracheal ring. The
gland comprises two lobes (each lobe measures
roughly 4cm×2cm×1cm), a mid-section (the
isthmus), a lateral projection of varying size
(Tubercle of Zukerkandl) and a pyramidal lobe.
The normal thyroid weighs between 20 g and
25 g. It is enveloped by the pre-tracheal fascia
and is attached to the trachea by strong brous
tissue, the ligament of Berry.
Blood Supply
Superior Thyroid Artery (STA) andExternal
Branch ofSuperior Laryngeal Nerve
The superior thyroid artery (STA) is the rst
branch of the external carotid artery (ECA). It
branches from the ECA beneath the anterior border of the sternocleidomastoid muscle (SCM) at
the level of the hyoid cartilage. At the superior
pole of the thyroid, the STA has a close relationship to the external branch of the superior laryngeal nerve (EBSLN).
The superior laryngeal nerve (SLN) of the
vagus divides into an internal branch (purely sensory to the supra-glottic larynx) and an external
branch. The EBSLN is the sole motor supply to
the cricothyroid muscles. These muscles tense
the vocal cords to produce pitch.
Inferior Thyroid Artery (ITA)
The ITA originates from the thyrocervical trunk
(majority) or directly from the subclavian artery.
It passes superomedially, anterior to the vertebral artery and deep to the carotid sheath before
entering the thyroid. The ITA is a close relation
to the recurrent laryngeal nerve (RLN) at the
mid-pole of the thyroid. The ITA provides the
sole blood supply to the superior and inferior
parathyroid glands, via secondary and tertiary
branches.
Thyroidea IMA
The thyroidea IMA is an infrequent vascular
variant that arises commonly from the brachiocephalic trunk and extends to the lower border of
the thyroid in the midline. It can also arise from
the common carotid artery or the right subclavian
artery.
Venous Drainage
The thyroid is drained by a venous network that
ultimately forms the paired superior, middle and
inferior thyroid veins. The superior and middle
veins drain directly into the internal jugular vein.
The inferior vein drains into the brachiocephalic
vein.
The middle thyroid vein is an important operative landmark. The middle thyroid vein is the
only important structure that crosses the anterior
surface of the common carotid, and it must be
ligated safely during the lateral exposure of the
thyroid gland. An important point to note is that
while the superior and inferior thyroid are paired
veins and arteries, there is no middle thyroid
artery.
2.2.1.4 Recurrent Laryngeal Nerve
(RLN)
Anatomy andFunction
The RLN branches off the vagus nerve in the
superior mediastinum. The left RLN passes posteromedially beneath the aortic arch, whereas the
right RLN passes posteromedially around the
subclavian artery. Both nerves then ascend in the
tracheo-oesophageal groove.
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The RLN on each side divides into a lateral
(sensory) and a medial (motor) branch within the
larynx, although branching is sometimes seen
proximal to the larynx where the branches appear
more as posterior (sensory) and anterior (motor).
The RLN is related closely to the posterior surface of the thyroid gland, branches of the ITA and
Berry’s ligament.
The RLN provides the sole motor supply to
the intrinsic muscles of the larynx, with the
exception of the cricothyroid muscles. As such,
the RLN is the sole nerve for voice control, and
identication and protection of these nerves are
of utmost importance during thyroid surgery.
Embryology
The RLN is a derivative of the sixth pharyngeal
arch, and in contrast, the SLN is a derivative of
the more cranial fourth pharyngeal arch. The vascular derivatives of the fourth pharyngeal arch
include the aorta (left) and subclavian artery
(right). Linear growth of the embryo displaces
these vessels into the mediastinum, dragging
both RLN inferiorly.
Arteria Lusoria andtheNon-recurrent
Laryngeal Nerve
In 1/200 patients, the right subclavian artery fails
to develop in its normal position. Instead, the
right subclavian artery branches off the aorta
(usually the fourth branch) to pass to the right
behind the oesphagus to supply the upper limb.
As a result, the right RLN is then non-recurrent
and branches immediately from the right vagus
nerve around the level of the cricoid cartilage to
supply the larynx. It is particularly at risk of
injury during thyroidectomy. The nding of a
retro-oesophageal right subclavian artery on
cross-sectional imaging is a clue to a nonrecurrent right-sided RLN.
2.2.2 Physiology
2.2.2.1 Thyroid Hormone Synthesis
Ingested iodine is taken up into the follicular cell
by the basolateral sodium/ iodine (Na+/ I−) symporter. Iodine diffuses into the follicular colloid
via pendrin.
Thyroglobulin (Tg) is produced in the endoplasmic reticulum and exocytosed into the follicular colloid. Thyroid peroxidase (TPO)
catalyses the oxidation of iodine and its binding
to thyroglobulin tyrosine residues (a process
called organication).
Organied thyroglobulin is cleaved into thyroxine (T4) and small amounts of triiodothyronine (T3). The majority of circulating T3 is
derived from the peripheral conversion of T4 to
T3.
2.3 Thyroid Nodules andBasic
Thyroid Work-up
Thyroid nodules are discrete lesions within the
thyroid gland that appear radiologically different
from the surrounding thyroid parenchyma. They
are very common in the general population and
become more prevalent with age. The common
term ‘goitre’ describes an enlarged thyroid gland
of any cause. Hence, a multi-nodular goitre is an
enlarged thyroid caused by the presence of more
than one nodule. Thyroid nodule assessment and
work-up are perhaps the most common initial
thyroid presentation encountered by general
surgeons.
There are numerous differential diagnoses for
thyroid nodules. Three key questions that should
always be kept in mind during the assessment of
thyroid nodules to guide work-up, diagnosis and
management decisions are as follows:
• Is the nodule hyperfunctional? This is the
rst question asked, as ne needle aspira-
tion biopsy (FNAB) should not be per-
formed on hyperfunctioning nodules, as less
than 1–2% of hyperfunctional nodules are
malignant.
• Is the nodule malignant? This is the second
question asked, as the treatment of malig-
nancy would occur regardless of
symptoms.
• Is the nodule causing symptoms? This is the
third question asked. This is often the hardest
to determine, as many of the common thyroid
nodule symptoms can also be caused by other
pathologies.
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