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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4385_Библиотеки_им_академика_М_И_Перельмана
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ImagIng of the neck
Figure 53.7 US of the larynx (a) showing a sizeable laryngeal tumour (green arrow) extending
through a defect in the thyroid cartilage (black arrow) with the corresponding axial CT (b) conrming extra-laryngeal spread of tumour (white arrow).
Figure 53.8 US showing a midline infrahyoid homogenous anechoic cystic mass with posterior
wall enhancement (white arrow) in keeping with a thyroglossal duct cyst.
268 Head and Neck
IMAGING OF THE NECK
Figure 53.9 Axial contrast CT showing a septated thick-walled right level 2 mass (white arrow)
displacing the submandibular gland anteriorly and deep to sternomastoid in keeping with an
infected second branchial cleft cyst.
Second Branchial Cleft Cyst
Classically present as a level II neck mass, supercial to the carotid sheath, posterior to
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the submandibular gland (SMG) and along the anteromedial border of sternomastoid
(Figure 53.9).
If a beak is identied pointing medially on US, then cross-sectional is warranted to
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exclude a sinus/stula.
Metastatic SCC should be considered until proven otherwise in patients over 40 years.
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Ranula
is is a retention cyst. May be conned to the oor of mouth or extends into subman-
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dibular space through a defect in the mylohyoid muscle (plunging ranula).
US shows unilocular, well-dened cystic submental mass related to the sublingual
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gland.
CT shows solitary, low-attenuation, non-enhancing thin-walled mass.
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MRI shows mass of low T1 and high T2 signal.
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Lipoma
US shows a characteristically striped or feathery mass.
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CT shows similar low attenuation as surrounding fat.
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MRI shows high T1/T2 signal, low on fat suppression sequences.
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Vascular Malformations
is is common in the head and neck. ey are venous and lymphatic malformations,
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or a combination.
Venous malformations are commonly found in the masticator space especially within
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the masseter.
Head and Neck 269
IMAGING OF THE NECK
Figure 53.10 Axial T2-weighted MRI showing a high signal right carotid space mass (white arrow)
containing several signal voids (small black arrows) consistent with a paraganglioma.
US shows heterogenous echo pattern with multiple sinusoidal spaces.
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MRI shows striking high signal on T2-weighted sequences.
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Most common lymphatic malformation is a cystic hygroma, usually posterior triangle.
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Imaging shows multiloculated mass, invaginates between vessels/other structures to
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occupy multiple contiguous spaces.
Paraganglioma
ey occur anywhere along the carotid sheath. Most common is a carotid body
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tumour (CBT).
CBTs occur at the bifurcation of the common carotid artery with characteristic splay-
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ing of the internal and external carotid arteries.
MRI shows characteristic ‘salt and pepper’ appearance (Figure 53.10) with the ‘pepper’
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or low-signal representing ow voids of feeding vessels.
The Hot Neck
Patients with pyrexia, pain, neck swelling, trismus, restricted neck movements or ody-
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nophagia should be considered to have neck sepsis.
e most common sources are tonsillar or odontogenic infection.
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Imaging to assess whether surgical intervention is required (Table 53.1).
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Odontogenic infections require an orthopantomogram (OPG) to assess dentition.
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US is the rst-line investigation in children and any supercial infection.
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Contrast CT of the neck and mediastinum are done to assess deep neck spaces, extent
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of infection and any complications such as vascular thrombosis, neural dysfunction
and mediastinitis.
Table 53.1 Imaging in the hot neck: What the surgeon needs to know
Is there an abscess or just inammatory change?
If an abscess is present, in which space/spaces?
How large is the abscess?
Extent of abscess
Is the mediastinum involved?
Is the airway compromised?
Is there jugular vein thrombosis?
270 Head and Neck
IMAGING OF THE NECK
Figure 53.11 Sialolithiasis (a) OPG demonstrates a right-sided SMG calculus. (b) US demonstrates
an echogenic calculus with acoustic shadow. (c) CT demonstrates a distal left submandibular
ductal calculus.
SALIVARY GLAND OBSTRUCTION AND SIALADENITIS
Sialolithiasis
SMG is more commonly aected than the parotid.
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15% of calculi are radiolucent.
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US/CT are most sensitive (Fig ure 53.11).
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Sialography is useful to plan therapeutic stone retrieval, lithotripsy or balloon sialo-
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plasty. Up to 15% failure rate, can cause ductal trauma or provoke acute sialadenitis.
MR sialography using non-interventional, T2 weighted technique relies on inherent
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salivary ow and high sensitivity/specicity (Figure 53.12).
Figure 53.12 MR sialography. (a) T2-weighted axial image to illustrate ductal uid. (b) Highlighted
ductal pattern.
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IMAGING OF THE NECK
Figure 53.13 (a) US demonstrates an obstructed left submandibular duct. (b) US reveals a sublin-
gual space mass lesion, which was subsequently conrmed histologically as an adenocarcinoma in
the sublingual gland. (c) Coronal MRI shows a bulky enhancing mass in the left sublingual space.
(d) PET-CT illustrates avid salivary gland lesion.
Salivary Strictures
Preferentially aect parotid ducts.
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Two-thirds focal stricture, one-third multiple/diuse strictures.
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US/sialography/MR sialography are able to depict stricture. CT us less useful.
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Type of obstruction important to guide onward treatment decisions.
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Sialadenitis
is aects oen elderly, immunosuppressed, malnourished patients with poor oral
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hygiene.
US used in acute setting to exclude abscess, obstructive stone/stricture or underlying
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neoplasm (Figure 53.13).
Chronic sialadenitis causes gland atrophy. US/sialography/scintigraphy used to deter-
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mine useful gland function.
Dry Mouth and Glandular Hypofunction
e presentation of a non-obstructive, non-suppurative multisite glandular swelling or even
a unilateral asymmetric, atypical nding may be secondary to a diuse inammatory or
systemic condition.
272 Head and Neck
IMAGING OF THE NECK
Sjögren’s Syndrome
OPG may show accelerated dental decay.
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Diagnosis, labial mucosal biopsy, antibody screening, abnormal US/sialography/
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scintigraphy.
US may show atrophic hypoechoic pseudocystic regions and eventual fatty
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replacement.
Sarcoidosis
Multisystem disorder.
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Bilateral parotid gland enlargement.
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US shows fatty inltration, facilitates FNA cytology (FNAC)/core biopsy.
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IGG4-Related Systemic Disease
is is a relatively newly recognised multisystem disorder; raised serum IgG4
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concentrations.
US shows geographic textural abnormality and hypervascularity, facilitates FNAC/
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core biopsy.
CT/MRI shows enhancement of salivary tissue.
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Radiotherapy
Can induce debilitating xerostomia; usually subjective patient reporting.
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US/CT/MRI shows reduced gland volume and ductal ectasia/brosis.
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Salivary ow studies/sialography/scintigraphy identify impaired glandular function/
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stricture formation.
New intensity-modulated radiation therapy (IMRT) techniques use reduced dose
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delivery to salivary glands.
Salivary Masses and Suspected Neoplasms
Benign Neoplasms
Pleomorphic Adenomas
90% occur in the supercial lobe of the parotid.
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On US is lobulated, clearly dened, echo-poor, homogenous.
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MRI if malignancy is suspected to evaluate deep lobe lesions and facial nerve weak-
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ness; surveillance if managed non-operatively. Low signal T1, T2 bright appearance.
(Figu re 53.14).
Warthin’s Tumour
On US is well-dened, heterogenous, hypoechoic septated/cystic lesion and oen
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bilateral.
MRI, T1 bright appearance (Figure 53.15).
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Oncocytomas
ese are rare, commonly present as solitary parotid lesions and 10% bilateral.
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Dicult to distinguish from benign/low-grade tumours on imaging.
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MRI shows cystic degeneration, T1 hypointense/isointense and T2 fat-saturated.
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Head and Neck 273
IMAGING OF THE NECK
Figure 53.14 Deep lobe Pleomorphic Adenoma (PA) (a and b) on contrast-enhanced CT. (c and d)
Post-gadolinium, fat-saturated MR images.
Malignant Neoplasms
Approximately 20% of all parotid, 50% of submandibular and 90% of sublingual gland
tumours are malignant. Imaging may appear deceptively benign. US suggestive of malignancy may show inhomogeneity, posterior acoustic shadow, raised inherent vascular ow
and ill-dened/inltrative margins.
Mucoepidermoid Tumours
Most common parot id malignancy; they make up 12–29% of all sa livary malignancies.
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MRI shows cystic change, abundant hypointense brous tissue.
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274 Head and Neck
MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
Figure 53.15 (a) US of well-circumscribed, heterogenous Warthin’s lesion. (b) Axial T2W MR of left
parotid Warthin’s. (c and d) DWI of a Warthin’s. (e) Matched ADC (apparent diffusion coefcient)
image demonstrating hypercellularity.
Adenoid Cystic Carcinomas
Second most common salivary gland lesion. ey are the most common malignant
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tumousr within SMGs.
MRI shows T2 hypointense signal, T1 bright intralesional bleeds. May identify local
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perineural spread.
54. MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
Introduction
e laryngotracheal region provides the important functions of airway maintenance, airway
protection, phonation and swallow. Injury to structures in this region are diverse and rare
but can result in severe morbidity and mortality.
Anatomy
e lar yngotracheal complex is relatively well prote cted and can dee ct signica nt tr aumatic force
before being injured. e larynx is divided into three subsites: supraglottis, glottis and subglottis.
e subglottis is continuous with the trachea inferiorly and contains a complete cartilaginous
ring structure (cricoid) which is the most sensitive and vulnerable region to even trivial trauma.
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MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
Epidemiology and Aetiology of Laryngotracheal Injury
e majority of traumatic laryngotracheal injuries occur in males, with an incidence of up
to 1 in 5000 emergency presentations and up to 2000 deaths annually reported in the United
Kingdom. e mechanism of injury to the larynx can be classied as either external trauma
(blunt or penetrating) or internal injury (inhalation or iatrogenic). Central to all laryngotracheal injuries, irrespective of mechanism, is the potential for a compromised airway.
Blunt Injuries
Blunt injuries can be further subclassied into the following:
Crush injury: is is sustained especially in motor vehicle accidents where a hyperex-
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tended neck is thrust forward exposing the larynx to anterior crushing forces.
Clothesline injury: is is a high-velocity impact of the larynx with a stationary object.
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is can lead to instant exsanguination from cricotracheal separation or a crushed larynx.
Strangulation injury (e.g. hanging) injury: is may initially be minor but may lead to
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subsequent laryngeal oedema and compromised airway.
Penetrating Injuries
Penetrating laryngotracheal injuries can cause varying degrees of damage depending on the
location and the nature of the weapon used. Injury to neurovascular and so-tissue structures can result in oedema, inammation, haemorrhage, scarring and anatomica l disruption.
Gunshot wounds tend to cause a broad spectrum of damage, whereas stab wounds follow a
more predictable course of injury.
Inhalational Injuries
Inhalational injuries to the larynx and trachea occur following inhalation of toxic gases,
exposure to res or ingestion of toxic substances. is may involve the transfer of high levels of thermal energy, causing signicant airway oedema. Early securement of the airway is
essential as delayed oedema can occur.
Iatrogenic Injuries
Iatrogenic injuries to the laryngotracheal complex can occur following instrumentation of
the airway (e.g. endotracheal intubation or elective laryngeal surgery such as microlaryngoscopy). Factors such as high cu pressure, prolonged duration of intubation, use of large
diametre endotracheal tubes and patient-specic factors such as diabetes have all been identied as contributing to post-intubation injury.
Pathophysiology of Laryngeal Trauma
e complexities and complications associated with chronic laryngeal injury are variable,
unpredictable and oen not discernible at the outset. e potential problems include
Scarring, subluxation and ankylosis of the arytenoids and cricoarytenoid joints
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Fibrosis of the laryngeal muscles disrupting the mucosal wave
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Anterior and posterior glottic webbing, and supraglottic and subglottic scarring
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Neural injury can lead to muscle palsy
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Unstable cartilage fractures, malunion or non-union
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Functionally these may lead to progressive shortness of breath, airway obstruction, glottic
incompetence, dysphonia, aspiration and dysphagia.
Classication of Laryngeal Trauma
Classication systems help to provide a unied approach to the assessment and management of laryngeal injuries. Several classication systems for traumatic laryngeal injury exist.
Fuhrman et al. classify laryngotracheal injuries into ve groups (Box 54.1). Classication of
posterior glottic stenoses, described by Bogdasarian and Olson, is based on the structures
involved (Figure 54.1).
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MANAGEMENT OF LARYNGOTRACHEAL TRAUMA
BOX 54.1 LARYNGOTRACHEAL INJURY CLASSIFICATION
(by Trone et al.; Group 5 added by Fuhrman et al.)
Group 1: Minor endolaryngeal haematoma without detectable fracture
Group 2: Oedema, haematoma, minor mucosal disruption without exposed cartilage,
non-displaced fractures noted on computed tomography (CT) scan
Group 3: Massive oedema, mucosal tears, exposed cartilage, fold immobility
Group 4: As group 3, but with more than two fracture lines or massive trauma to
laryngeal mucosa
Group 5: Complete laryngotracheal separation
Evaluation of Laryngotracheal Trauma
Assessment and management of laryngotracheal injury following the principles of advanced
trauma and life support (ATLS) and a multidisciplinary team approach is essential
(Figure 54.2). Like any other traumatic event, the primary goal is to assess and where neces-
sary to protect the airway. Urgent review of patients is vital as those initially exhibiting only
subtle symptoms can progress to complete airway obstruction from progressive oedema.
e most common presenting symptoms include dysphonia, dyspnoea, dysphagia, neck pain
and haemoptysis. Patients with penetrating neck injuries may present with haemodymic
Figure 54.1 Classication of posterior glottic stenosis. (a) Type I, isolated inter-arytenoid band.
(b) Type II, posterior glottic mucosal tunnel, but no arytenoid cartilage ankylosis. (c) Type III, ankylosis
and immobility of one arytenoid joint. (d) Type IV, ankylosis and immobility of both arytenoid joints.
Head and Neck 277
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