Head and Neck Masses Part 1
Question and answer review of head and neck masses for radiology board review. Prepare to succeed!
Show Notes/Study Guide:
Esthesioneuroblastomas originate from what type of cells?
Esthesioneuroblastomas arise from olfactory cells.
Esthesioneuroblastomas classically have a dumbbell-shaped appearance. Where is each part of the dumbbell typically located?
An esthesioneuroblastoma typically starts at the cribriform plate (olfactory cell in origin) and that is where the waist of the dumbbell typically would be. One end of the dumbbell would extend upwards through the skull base/inferior intracranial vault and the other end of the dumbbell may extend down into the sinuses. Classic imaging appearance is solid enhancing mass at cribriform plate extending upwards into brain with a large cystic component and a solid inferior component extending inferior into sinuses)
An esthesioneuroblastoma typically presents at which age?
Bimodal distribution is common for an esthesioneuroblastoma with onset around age 20 and around age 60.
Which nuclear medicine studies classically show uptake with an esthesioneuroblastoma?
These are often somatostatin positive lesions so you would expect uptake on an Octreotide scan and a GA68 Dotatate scan. Note that FDG PET has a lot of intracranial uptake so there is early data suggesting that Ga68 Dotatate could be useful as Ga68 Dotatate does not have high brain uptake as with FDG PET. Esthesioneuroblastoma may show uptake like that of brain on FDG PET/CT.
What are the top 2 most common locations for a chordoma?
A chordoma originates from the notochord so these can present anywhere from the skull base to the sacrum. The #1 most common location is within the sacrum. The #2 most common location is within the clivus. Chordomas are T2 bright. The thumb sign is when a chordoma projects from the clivus posteriorly and indents the pons.
The top differential consideration for a chordoma of the clivus is what?
Chondrosarcoma. However, compared to a chordoma that is often at midline, a chondrosarcoma is often lateral to midline.
What entity should you think of first if you are given a clinical history of a male teenager with frequent and severe nose bleeds and you are shown an image of a very vascular mass centered in the sphenopalatine foramen that expands the pterygopalatine fossa?
Juvenile nasal angiofibroma.
What is the primary vascular supply of a juvenile nasal angiofibroma?
The ascending pharyngeal artery or the internal maxillary artery. These are very vascular so you would expect a prominent blush on angiography.
Bonus question: What is the main arterial supply on an angiogram to evaluate a posterior nosebleed?
The sphenopalatine artery. Note that if you are going to treat with embolization you need to make sure there is no variant anastomosis with the ophthalmic artery as you really DO NOT want to embolize the eye.
What is a leading cause of posterior nosebleed that does not present with a mass but rather with multiple arteriovenous malformations (AVMs)?
Osler-Weber-Rendu syndrome / hereditary hemorrhagic telangiectasia (HHT). This is a high-yield entity for the ABR Core Exam. Classic on board exams would be a provided clinical history of recurrent nosebleeds and a picture showing telangiectasias of the face and hands. Most common sites of AVMs are nose, skin, and liver but AVMs may also be elsewhere like the lungs or GI tract. This is autosomal dominant so expect a family history.
What should you think of first if you are shown a maxillary sinus mass in a 30–40-year-old patient that enlarges the maxillary sinus ostium and extends into the nasopharynx without bony destruction?
Antrochoanal polyp. A buzzword for this entity is a mass causing non-destructive widening of the maxillary ostium.
What is the classic location of an inverting papilloma?
The lateral wall of the nasal cavity. Note that inverting papillomas often cause focal hyperostosis that is subsequently is trapped within the mass.
What is the classic MRI appearance of an inverting papilloma?
Buzzword is a “cerebriform pattern” that appears like brain on both T1- and T2-weighted images.
Approximately what percent of inverting papillomas harbor a squamous cell carcinoma?
About 10% of inverting papillomas will have an associated squamous cell carcinoma. This is a risk you should be aware of for test purposes.
What is a SNUC and where is the most common location of a SNUC?
SNUC is a sinonasal undifferentiated carcinoma. The most common location of a SNUC is in the maxillary antrum. SNUC is more aggressive and has a worse prognosis compared to a garden variety sinonasal squamous cell carcinoma. A SNUC often presents as a large, mildly enhancing, fungating mass with ill-defined margins.
Sinonasal lymphoma is most common in what age group?
In general, sinonasal lymphoma is most common in the >60-year-old age range. Sinonasal lymphoma tends to be more common in the nasal cavity compared to the sinuses.
If you are shown a cystic structure at the floor of the mouth that looks like “a sack of marbles” with fat lobules in fluid what is this classic for?
Floor of mouth dermoid/epidermoid cyst. Note that location at floor of mouth and presence of internal fat makes dermoid most likely but these often can’t be differentiated on imaging.
What do you call a large mucous retention cyst that arises from the sublingual space and extends inferiorly under the mylohyoid muscle?
A plunging ranula.
In a young adult with a new mass in the left cervical level II region what malignancy do you need to exclude first?
HPV-related squamous cell carcinoma. This presents with large necrotic nodes in the neck. Note that this can look like a brachial cleft cyst, but squamous cell carcinoma must be excluded.
