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7 Sonography oftheOropharynx, Hypopharynx, Larynx, andCervical Esophagus
157
Major impedance differences between a tumor and
healthy laryngeal tissue allow the detection of intralaryngeal
processes [5]. This is possible above all for intralaryngeal
cysts (Figs.7.34 and 7.35). We often can see only parts of
these cysts by endoscopy, but ultrasound allows the complete
detection of the cyst, so we can optimize the planning of
therapy (Video 7.5).
Fig. 7.32 External
laryngocele (LC) with
retrohyoidal extension. HY
hyoid, TC thyroid cartilage
Additionally, with the ultrasound devices used today in routine sonography, intralaryngeal cancer growth can be seen with
ultrasound. Similar to cysts, the tumor itself is hypoechoic, with
or without acoustic enhancement, which depends on the tumor
structure (Fig.7.36). Sometimes it is possible to detect specic
features of the tumor growth, such as inltration of the cartilages
(Fig.7.37, Video 7.6) or even tumor breakthrough (Fig.7.38).
Fig. 7.33 Supraglottic cancer
(TU). TO tongue base, HY
hyoid
158
Fig. 7.34 Inner laryngocele
(CY) of the right Morgagni’s
sinus. The cyst appears
homogenous and hypoechoic,
with a relative acoustic
enhancement and regular
margins. TC thyroid cartilage.
Inset shows intraoperative
situs
P. J e ck er
Fig. 7.35 Small cyst (CY) of
the left vestibular fold. TC
thyroid cartilage. Inset shows
intraoperative situs
7 Sonography oftheOropharynx, Hypopharynx, Larynx, andCervical Esophagus
Fig. 7.36 Larynx cancer
(TU) with contact to the
thyroid cartilage (TC). Inset
shows intraoperative situs
159
Fig. 7.37 Cancer (TU) of the
left ventricular fold. The
tumor seems to inltrate the
thyroid cartilage (TC)
160
Fig. 7.38 Adenoid cystic
carcinoma (TU) of the
anterior subglottic mucosa.
The examination in a sagittal
plane (right) indicates
destruction (arrows) of the
cricoid cartilage (CC). TC
thyroid cartilage, TR trachea
P. J e ck er
Destruction of the cartilage and tumor growth outside of the
larynx into the surrounding tissue can be seen without problems
(Fig.7.39). With major destruction of the cartilage, the view of
intralaryngeal parts of the tumor becomes better (Fig.7.39b).
7.4 Tumors oftheHypopharynx
andtheCervical Esophagus
Inltration of the hypopharynx by laryngeal cancer or primary hypopharynx cancer also can be seen by ultrasound. In
our experience, this is possible for T2 tumors or larger but is
difcult for T1 tumors. Typically, the tumors are detectable
medial to the thyroid gland (Fig.7.40), which often is moved
laterally by the tumor. The tumor itself is hypoechoic and
inhomogeneous, sometimes inltrating the thyroid gland.
The same can be seen in cases of cancer of the proximal
esophagus (Fig.7.41). The tumor can clearly be identied,
since the typical stratied pattern of the esophagus no longer
exists [6]. Instead of this typical pattern of the healthy organ,
the tumor is characterized as a hypoechoic mass, sometimes
inltrating the thyroid gland. Usually the whole extension of
the tumor cannot be seen because major parts may be covered by the acoustic shadow of the clavicle.
Similarly, a Zenker diverticulum can sometimes be seen
in the left hypopharynx, next to the thyroid gland (Fig.7.42).
7 Sonography oftheOropharynx, Hypopharynx, Larynx, andCervical Esophagus
a
161
b
Fig. 7.39 Detection of special situations with ultrasound. (a, b) Tumor
(RF) breaks through thyroid cartilage (sk) (arrows). (b, c) Tumor
growth outside of the larynx (arrows). (d, e) Inltration of the sterno-
cleidomastoid muscle (SCM) (arrows) and the thyroid gland (THY).
CCA common carotid artery. Inset shows corresponding CT
162
P. J e ck er
c
d
Fig. 7.39 (continued)
7 Sonography oftheOropharynx, Hypopharynx, Larynx, andCervical Esophagus
e
Fig. 7.39 (continued)
163
Fig. 7.40 Hypopharynx
cancer. The tumor (TU)
typically moves the thyroid
gland (THY) to the side. CCA
common carotid artery, SCM
sternocleidomastoid muscle
164
P. J e ck er
Fig. 7.41 Esophageal cancer
(TU), inltrating the thyroid
gland (THY), seen in frontal
plane (a) and sagittal plane
(b). CCA common carotid
artery, CL clavicle, ES cranial
esophagus. Inset shows
endoscopic nding
a
b
7 Sonography oftheOropharynx, Hypopharynx, Larynx, andCervical Esophagus
Fig. 7.42 Zenker
diverticulum (ZD). CCA
common carotid artery, IJV
internal jugular vein, THY
thyroid
165
References
1. Welkoborsky HJ, Jecker P, Maurer J, Mann WJ.Ultraschalldiagnostik
Kopf-Hals. Stuttgart: Thieme; 2013.
2. Orloff LA. Head and neck ultrasonography. 2nd ed. San Diego:
Plural Publishing; 2017.
3. Coquia SF, Hamper UM, Holman ME, DeJong MR, Subramaniam
RM, Aygun N, Fakhry C.Visualization of the oropharynx with tran-
scervical ultrasound. AJR Am J Roentgenol. 2015;205:1288–94.
4. Bozzato A, Zenk J, Gottwald F, Koch M, Iro H.Inuence of thyroid
cartilage ossication in laryngeal ultrasound. Laryngorhinootologie.
2007;86:276–81. German.
5. Gomaa MA, Hammad MS, Mamdoh H, Osman N, Eissawy
MG. Value of high resolution ultrasonography in assessment of
laryngeal lesions. Otolaryngol Pol. 2013;67:252–6.
6. Jecker P, Seidel J, Mann WJ. Staging of esophageal cancer using
ultrasound. Radiologe. 2007;47:115–8. German.
Sonography ofParapharyngeal Masses
CourtneyM.Tomblinson andMichaelL.Hinni
8
8.1 Introduction
Lesions of the parapharyngeal space (PPS) can be primary or
secondary. Primary lesions are limited in number, owing to
the paucity of tissues contained within the region. PPS
tumors account for only 0.5% of head and neck neoplasms
[1]. Of these, 80% are benign and almost half arise from the
salivary gland, namely, pleomorphic adenoma [2, 3]. The
second most frequently encountered PPS tumors are neurogenic tumors, followed by paraganglioma [4, 5].
8.2 Anatomic Boundaries
oftheParapharyngeal Space
The PPS is a potential space that forms an inverted pyramid,
extending from the skull base along the inferior surface of
the petrous temporal bone superiorly to the greater cornu of
the hyoid bone inferiorly [6]. Some authors consider the
parapharyngeal space caudal to the mandibular angle to be
obliterated and thus regard the styloglossus muscle as a landmark for the inferior boundary [5]. The medial boundary is
formed by the superior constrictor muscle and pharyngobasilar fascia. From anterior to posterior, the lateral boundary is
formed by the medial pterygoid muscle, mandibular ramus,
deep lobe of the parotid gland, and posterior belly of the
digastric muscle. The prevertebral fascia forms the posteromedial boundary.
The PPS includes both pre-styloid and post-styloid components, separated by the tensor-vascular-styloid fascia,
which extends from the styloid process to the tensor veli
palatini [6–8]. Two other fascial layers have been described,
the stylopharyngeal aponeurosis or aileron and the cloison
sagittale, but controversy exists about their course and how
they divide the compartments of the PPS [5]. Given the
debate in the literature, these structures are likely to be
inconsistent and vary among patients.
The carotid sheath comprises all three layers of the deep
cervical fascia and represents a limited barrier between the PPS
(laterally) and the retropharyngeal space (medially) [9–11].
This intimate relationship allows for processes traversing one
of these spaces to easily enter the other [1].
Anteriorly, the PPS is contiguous with both the masticator
and sublingual spaces, with implications for the spread of
infection.
8.2.1 Pre-styloid Compartment
The pre-styloid compartment consists predominantly of fat
through which traverse the inferior alveolar nerve, lingual
nerve, auriculotemporal nerve, and ascending pharyngeal
artery. The deep lobe of the parotid gland is directly lateral to
the pre-styloid compartment. Salivary gland tumors, the
most common parapharyngeal mass, arise in the pre-styloid
compartment, displacing the great vessels posteriorly [12],
as shown in Fig.8.1.
C. M. Tomblinson
Department of Radiology and Radiological Sciences, Vanderbilt
University Medical Center, Nashville, TN, USA
M. L. Hinni (
Department of Otolaryngology–Head and Neck Surgery,
Mayo Clinic, Phoenix, AZ, USA
e-mail: hinni.michael@mayo.edu
© Springer Nature Switzerland AG 2019
H. J. Welkoborsky, P. Jecker (eds.), Ultrasonography of the Head and Neck, https://doi.org/10.1007/978-3-030-12641-4_8
*)
8.2.2 Post-styloid Compartment
The post-styloid compartment, consisting largely of
structures in the carotid sheath, contains the carotid artery,
internal jugular vein, cranial nerves IX–XII, sympathetic
chain, and deep lymph nodes.
167