Head and neck reports must combine accurate descriptions with foresight

Well-delineated parapharyngeal ectopic pleomorphic adenoma, obliterating parapharyngeal fat pad, shifting styloid process backward and the pharyngeal air column to contralateral side. A. Axial CT (Top). B. Coronal T1-weighted MRI with contrast (Bottom). (Provided by S. Robinson)

In treating an underlying problem in the head and neck, potential complications must be identified and graded in the radiologist's report for correct follow-up. Radiologists may be able to solve a clinical problem directly with a single approach such as ultrasound. But other modalities must be used when ultrasound fails due to the depth of a lesion or air within the lumen, making evaluation of the head and neck complex, according to researchers from Italy, Austria, and Switzerland.

Ultrasound is performed first in the case of suspected abscess or inflammatory lesion in the infrahyoid neck or involving the salivary or thyroid glands. CT is used if the lesion extends beyond ultrasound's field-of-view. Experts suggest that, in general, CT or MRI should be used first only when the lesion originates in the suprahyoid neck or upper aerodigestive tract.

"We have to know what techniques to use to resolve the clinical problems and subsequent questions," said Prof. Roberto Maroldi, a professor of radiology at the University Hospital of Brescia, Italy.

Maroldi addressed inflammatory lesions and infectious inflammatory lesions that can spread into deep spaces of the neck, orbit, and cranial cavity.The accuracy of MR or CT in depicting location and disease extent allows drainage or removal of some retropharyngeal abscesses in deep spaces with a transnasal endoscopic technique.

Since 2006, diffusion-weighted MRI has been able to discriminate between cellulitis and abscess at an earlier stage than was possible with standard CT, he said.

Dr. Soraya Robinson, a consultant radiologist at Urania Diagnostic Centre in Vienna, spoke about diagnosing and reporting tumoral lesions. For traumatic lesions to the head and neck, the radiologist needs to identify cases requiring immediate attention, such as those involving the optic nerve or a vascular lesion. The most complete imaging examination for maximum diagnosis must be performed as soon as possible.

Contrast-enhanced T1-weighted axial MR examination shows diffusely infiltrating neurofibroma in carotid sheath, pushing the vessel anteriorly and the parotid gland laterally. (Provided by S. Robinson)

One imaging protocol should answer all the relevant questions for immediate and later management of emergency polytrauma patients, said Dr. Minerva Becker, chief of head and neck radiology at the University Hospital of Geneva.

If the polytrauma patient has sustained a specific soft-tissue injury, such as to the nerves of the brachial plexus, new MR techniques to visualize hematoma or fractures leading to nerve root compression would be used immediately, along with 3D acquisitions and 3D contrast-enhanced MR to follow nerve roots. Fiber tracking to see nerve fibers in the brachial plexus is a novel technique that is starting to be used to plan surgery and minimize functional impairment by surgery.

As the relationship between the radiologist and clinician evolves, imaging advances and improvements in surgical procedures seem to act as catalysts. Each spurs the other forward to more precise diagnosis and minimally invasive techniques, such as minisurgery for fractures and more endoscopic surgery to treat face and neck lesions.

Coronal CT shows unilateral atrophy of mastication muscles, an indirect sign of lesion in unilateral mandibular nerve (cranial nerve V3). (Provided by S. Robinson)

Surgeons taking into account aesthetics, as well as function, routinely use 3D reconstructions of displaced face fractures to plan surgery to minimize scars.

"Many young people are involved in car and sports accidents and have to live with the result of facial surgery for decades. There are new ways to repair fractures without external scars, but this is only possible with precise descriptions - and 3D imaging - of the trauma," Becker said.