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Computed tomography of the nasopharynx and neck
THE JOURNAL OF COMPUTED TOMOGRAPHY
COMPUTED TOMOGRAPHY AND NECK SHARDUL D. VIBHAKAR, AND ERROL M. BELLON,
M.D., M.D.
CHRISTINE
Computed tomography (CT) is unparalleled for evaluation of the nasopharynx and the neck in comparison with other radiologic modalities. Its abiIity to demonstrate soft tissue and bone abnormalities has established its role as a primary method of radiologic diagnosis, frequently obviating the need for further radiologic elaboration. Furtherdistinction more, in many cases, CT provides among inflammatory, neoplastic, and traumatic conditions.
KEY WORDS:
7:2594X5,
1983
OF THE NASOPHARYNX
ECKHAUSER,
MATERIALS
M.D.,
AND METHODS
All cases were studied on a General Electric CT/T 8800 scanner with a scan time of 9.6 seconds for 576 views at a pulse width of 3.3 msec. Sequential sections were obtained at 5 mm section widths for bony detail in the cervical spine, apd at 10 mm section widths for the soft tissues of the neck and nasopharynx. Intravenous contrast used in studying the soft tissues consisted of an injection of a 50-ml bolus of diatrizoate meglumine and diatrizoate sodium (Renografin-60), followed by rapid drip infusion of diatrizoate meglumine (Rena-M DIP) during the period of scanning.
Nasopharynx; Neck; Computed Tomography CASE REPORTS Prior to the advent of computed tomography (CT) diagnostic evaluation of the neck consisted of an array of studies including multiple plain radiographs utilizing different projections and exposures, tomography, barium swallow, and laryngography. This paper illustrates seven cases wherein abnormalities of the nasopharynx and neck (pharyngeal abscess with parapharyngeal spread, parathyroid cyst, two cases of nasopharyngeal carcinoma, venous thrombophlebitis, laryngeal carcinoma, and cervical spine fracture] are demonstrated more clearly by CT than by other radiologic methods.
From the Department of Radiology, Cuyahoga County Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio. Address reprint requests to: Shardul D. Vibhakar, MD, Department of Radiology, Cuyahoga County Hospital, 3395 Scranton Road, Cleveland, Ohio 44109. Received February 25, 1983. Accepted March 28, 1983. ‘0 1963 by Elsevier Science Publishing Co., Inc. 52 Vanderbilt
Ave., New York, NY
11149.936X/63/$3.00
10017
Case 1 A 66-year-old white alcoholic woman with a past history of bleeding esophageal varices, mesocaval shunt, posthepatic encephalopathy, multiple electrolyte abnormalities, congestive heart failure, and thyroid surgery for carcinoma diagnosed many years previously, presented at this admission with a sore throat, fever, and chills. She had difficulty swallowing, and redness and swelling over the left eye, face, and neck. A CT scan of the neck (Figures 1A and 1B) showed changes suggestive of an inflammatory focus in the left oropharynx, with spread of the to involve the left eye inflammatory process and lower neck without extension into the mediastinum. On physical examination, necrotic ulceration of an inflamed left tonsil was seen. Sputum and blood cultures were positive for Neisseria meningitidis group C. Therefore, a pharyngeal abscess with parapharyngeal extension was diagnosed. The patient was successfully treated with antibiotics.
260
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ET AL.
THE JOURNAL OF COMPUTED
TOMOGRAPHY
VOL. 7 NO. 3
FIGURE 1. (B) Note the FIGURE
1. (A) Soft tissue
prominence of the nasopharynx on the left (large arrow) with poorly defined stringy densities extending laterally to the region of the parotid gland and anteriorly and posteriorly in the subcutaneous and intermuscular planes (small arrows). Note the asymmetry of the air space caused by the nasopharyngeal phlegmonous mass.
stringy densities with poorly defined hazy areas of increased attenuation [arrows) within the subcutaneous fat, which normally has uniform low attenuation. These numerous infiltrating soft tissue densities represent the parapharangeal spread of the phlegmonous process.
Case 2 A 42-year-old white man presented with a sixmonth history of a slowly enlarging painful mass in the left lower neck, which became more prominent in the recumbent position. A CT scan (Figure 2A) showed an encapsulated low-density mass in the region of the lower pole of the left lobe of the thyroid, which extended into the mediastinum (Figure 2B), and was suggestive of a cyst. This was confirmed by ultrasound examination, and at surgery, a large parathyroid cyst measuring 8 X 10 cm was resected. A component about 4 cm in diameter extended into the left supraclavicular region. Case 3 A 4%year-old Vietnamese woman, who arrived in the United States three months prior to admission, presented with a lump in the right side of the neck and pain during extension of the neck. On visual examination of the oropharynx, lymphoid hyperplasia was noted, most prominent on the right. Biopsy of the nasopharynx was negative, and biopsy
FIGURE 2. (A) A well defined rounded low attenuation parathyroid cyst in the lower neck on the left (Pj. The left thyroid (curved arrow) is seen displaced laterally, and the right thyroid (straight arrow) appears normal. of
the lump in the right neck was reported as chronic hyperplastic lymphadenitis. A CT scan of the nasopharynx demonstrated a prevertebral soft tissue mass (Figure 3A), and, in addition, showed erosion of the clivus (Figure 3B), which was further substantiated with a radionuelide bone scan. Because the patient was oriental, lymphoepithelial carcinoma was considered likely, and a repeat biopsy of the nasopharynx was ad-
AUGUST
1983
FIGURE 2. (B) A CT scan at an upper thoracic level shows the intrathoracic extent of the parathyroid cyst [PI. The trachea is compressed and deviated to the right by the cyst.
FIGURE 3. (B) CT scan at the level of the foramen magnum and clivus clearly demonstrates the bony erosion of the clivus on the left and replacement by tumor tissue (arrow).
CT OF NASOPHARYNX
& NECK
261
FIGURE 3. (A) The nasopharyngeal mass has a variegated appearance showing soft tissue and low density attenuation characteristics. A component of tumor, which is rounded, well defined, and of decreased attenuation, is on the right. The component on the left has a variegated appearance, predominantly that of soft tissue attenuation characteristics. Note the anterior extent of the tumor mass to the nasal airway.
262
VIBHAKAR
ET AL.
vised. This biopsy established the diagnosis of lymphoepithelioma. The patient subsequently developed left-sided sixth nerve palsy and ptosis, consistent with left parasellar involvement, and was treated with radiotherapy.
Case
4
A 76-year-old black man with history of diabetes, hypertension, gout, bilateral sensory neuronal hearing loss, and recent bilateral iridectomies for narrow-angle glaucoma, presented with a two-week history of acute, sharp, stabbing pain in the right eye, with periorbital distribution of pain. On clinical examination he was found to have a right supranuclear seventh nerve palsy. The clinical picture was thought to be representative of Gradenigo’s syndrome or Raeder’s paratrigeminal syndrome. A CT scan of the orbits and nasopharynx showed
FIGURE 4. (A) A CT scan at the level of the nasopharynx shows the soft tissue tumor mass [arrow) in the right nasopharynx causing marked asymmetry of the nasopharyngeal air space.
THE JOURNAL OF’ COMPUTED
TOMOGRAPHY
VOL. 7 NO. 3
a nasopharyngeal mass on the right (Figure 4A) with parasellar extension. The superior ophthalmic vein on the right was abnormally tortuous (Figure 4B), indicating impedance of flow into the cavernous sinus. The clinical findings of acute right orbital pain and the cranial nerve palsies could be readily explained by parasellar extension of the nasopharyngeal mass, which on biopsy showed squamous cell carcinoma. The patient was treated by radiation therapy.
Case
5
A 27-year-old black man, an intravenous drug abuser since age 14, was admitted for pain and swelling on the right side of the neck. A CT scan of the neck [Figure 5) showed a low-density filling defect in the
FIGURE 4. (B) A scan at a higher level shows the tortuous superior ophthalmic vein (arrow) secondary to the right parasellar extension of the nasopharyngeal tumor and impedance of venous flow to the cavernous sinus. The right parasellar region appears hazy and indistinct when compared with the opposite side.
AUGUST
CT OF NASOPHARYNX& NECK
1983
263
FIGURE 6. A CT scan of the midcervibal region showing
the laryngeal tumor [arrow] protrudinq into the laryngeal air space with resultant asymmetrical8 appearance of the air space.
DISCUSSION FIGURE 5. A CT scan of the upper neck shows a hypo-
dense thrombus within the right internal jugular vein (arroow).The peripheral rim of increased attenuation is probably enhancement of vasa vasorum.
right internal jugular vein, consistent with thrombus. The patient was treated with heparin and antibiotic, improved, and was discharged.
Case
6
A 7%year-old white man, who presented with difficulty swallowing and a recent change in voice, had squamous cell carcinoma involving the left arytenoid and postcricoid regions. The extent of the tumor could not be established by laryngoscopy. A subsequent CT scan showed the tumor confined to the larynx (Figure 6). Biopsy showed poorly differentiated squamous cell carcinoma. The patient underwent total laryngectomy followed by radiation treatment.
Case
7
An 18-year-old white male adolescent sustained a flexion injury to the cervical spine while playing football, and became quadriplegic as a result. Plain radiographs showed a fracture/dislocation at C5-6 level. A CT scan of the cervical spine (Figures 7A and 7B) done six months later illustrates the clarity afforded by CT in traumatic injuries to the spine, although it was not contributory to the management of this specific case.
Computed tomography is a noninvasive examination with minimal patient discomfort and an information yield that in most cases obviates the need for further radiologic evaluation of nasopharyngeal and neck lesions. Elimination of the need to move the patient’s neck into different positions is advantageous in patients with painful and traumatic conditions (cases 1, 3, and 7). In some cases, direct laryngoscopy is limited or impostiible due to the patient’s inability to open the mouth adequately, and in these situations, a CT scan can aid or, in some cases, substitute for the direct visual examination (cases 1, 3, and 6). The roye of CT in evaluating the nasopharynx and neck has been alluded to in the literature (l-4). The array of cases with neoplastic, inflammatory, and trauma/tic etiologies presented here illustrates the clarity of detail and major contribution by CT to diagnosis and management. In inflammatory conditions, the extent and type of involvement is demonstrated by CT (Figure 1A and 1B). This is helpful in clinical management of the patient, as absence of demonstrable low-density abscess collection indicates that surgical drainage is not needed. The diagnosis of jugular thrombophlebitis (Figure 5) can be made specifically, and the extent determined noninvasively by CT (511.Use of CT rather than ultrasound is preferred in ~this situation because the mechanical pressure of the ultrasound transducer may cause pain over a inflamed, tender area, and might possibly fragmen : and dislodge the thrombus. In neoplastic conditions (cases’2, 3, 4, and 6), the site and extent of involvement is clearly demon-
264
VIBHAKAR ET AL.
FIGURE 7. [A) A CT scan at midcervical level viewed with wide window setting showing the vertical fracture extending in the anteroposterior direction (arrow), with vertical separation of the posterior vertebral body.
THE JOURNAL OF COMPUTED TOMOGRAPHY
VOL. 7 NO. 3
strated by CT. In case 3, the striking abnormalities involving both soft tissues and bone demonstrated the need for repeat biopsy and histologic review. A large number of cases of lymphoepithelial carcinoma has been reported in oriental populations (6,7), and the tumor is comparatively rare in the American population. It is of uncertain etiology (6), but its histologic variations have been well studied (7), and it is known to respond to radiation therapy (8,9). Bone reformation has been observed following radiotherapy (9). We believe that CT is the optimum modality to observe the soft tissue and bony response to treatment. Furthermore, in case 3 the demonstration of clivus erosion indicated tumor involvement and served as an accurate predictor of the sixth and third cranial nerve involvement that subsequently developed. In case 4, CT resolved the complex neurologic problem of the patient through demonstration of a nasopharyngeal tumor with parasellar extension. In case 7, CT very clearly demonstrated a lamina fracture (Figure 7B), which was not well visualized on plain radiographs. Vertical fractures of the vertebral body are frequently associated with lamina fractures (IO), as is demonstrated in our case. SUMMARY
FIGURE 7. (B) A CT scan 5 mm caudal to Figure 7A shows the right lamina fracture (arrow) with minimal displacement at the fracture.
We advocate CT as the initial radiologic modality in suspected abnormalities of the nasopharynx and neck. We have found that in many cases, the need for further radiologic elaboration is obviated because of CT’s high diagnostic yield. REFERENCES 1. Mancuso AA, Bohman L, Hanafee W, Maxwell D. Computed tomography of the nasopharynx: Normal and variants of normal. Radiology 1980. 137:113-21. 2. Thawley SE, Gado M, Fuller TR. Computerized tomography in the evaluation of head and neck. Laryngoscope 1978; 88:451-g. 3. Miller EM, Norman D: The role of computed tomography in the evaluation of neck masses. Radiology 1979; 133:145-g. 4. Mancuso AA, Hanafee WN, Juillard GJF, et al. The role of computed tomography in the management of cancer of the larynx. Radiology 1977; 124:243-4. 5. Pate1 S, Brennan J. Diagnosis of internal jugular vein thrombosis by computed tomography. J Comput Assist Tomogr 1981; 5:197-200. 6. Lee C, Kim KS, Rogers LF. Triangular cervical vertebral body fractures: Diagnostic significance. Am J Roentgen01 1982; 138:1123-32. 7. Yeh S. A histological classification of carcinomas of the nasopharynx with a critical review as to the existence of lymphoepitheliomas. Cancer 1962; 15:895-920.
CT OF NASOPHARYNX
AUGUST 1983
8. Wang CC, Little JB, Schulz MD. Cancer of the nasopharynx. Its clinical and radiotherapeutic considerations. Cancer 1962; 15:921-6. 9. Unger JD, Chiang LC, Unger GF. Apparent reformation of the base of the skull following radiotherapy for nasopharyngeal carcinoma. Radiology 1978; 126:779-82. 10. Lee C, Kim KS, Rogers LF. Triangular cervical vertebral body fractures : Diagnostic significance. Am J Roentgen01 1982; 138:1123-32.
CONTINUING 1.
MEDICAL
EDUCATION
The optimal imaging modality sopharynx and neck are: a. Barium swallow. b. Laryngogram. c. Computed tomography. d. Plain laminography.
QUESTIONS
for evaluating
2. Lymphoepithelial carcinoma is: a. Never seen in the United States, b. Common in the United States. c. Common among orientals. d. Common among Europeans.
the na-
& NECK
‘265
3. Computed tomography evaluation of nasopharynx and neck is suitable for: a. Soft tissue tumors only. b. Soft tissue inflammatory and neoplastc disease only. c. Neoplastic, inflammatory, and traumatic soft tissue and skeletal abnormalities. True or False 4. Computed a. Is of no patient. b. Cannot C. Has no radiation d. In most nations.
tomography of the nasopharynx and neck: value in the management of the traumatized diagnose thromophlebitis of neck veins. place in the follow-up of patients receiving treatment. cases obviates all other radiologic exami-
COMPUTED TOMOGRAPHY AND NECK SHARDUL D. VIBHAKAR, AND ERROL M. BELLON,
M.D., M.D.
CHRISTINE
Computed tomography (CT) is unparalleled for evaluation of the nasopharynx and the neck in comparison with other radiologic modalities. Its abiIity to demonstrate soft tissue and bone abnormalities has established its role as a primary method of radiologic diagnosis, frequently obviating the need for further radiologic elaboration. Furtherdistinction more, in many cases, CT provides among inflammatory, neoplastic, and traumatic conditions.
KEY WORDS:
7:2594X5,
1983
OF THE NASOPHARYNX
ECKHAUSER,
MATERIALS
M.D.,
AND METHODS
All cases were studied on a General Electric CT/T 8800 scanner with a scan time of 9.6 seconds for 576 views at a pulse width of 3.3 msec. Sequential sections were obtained at 5 mm section widths for bony detail in the cervical spine, apd at 10 mm section widths for the soft tissues of the neck and nasopharynx. Intravenous contrast used in studying the soft tissues consisted of an injection of a 50-ml bolus of diatrizoate meglumine and diatrizoate sodium (Renografin-60), followed by rapid drip infusion of diatrizoate meglumine (Rena-M DIP) during the period of scanning.
Nasopharynx; Neck; Computed Tomography CASE REPORTS Prior to the advent of computed tomography (CT) diagnostic evaluation of the neck consisted of an array of studies including multiple plain radiographs utilizing different projections and exposures, tomography, barium swallow, and laryngography. This paper illustrates seven cases wherein abnormalities of the nasopharynx and neck (pharyngeal abscess with parapharyngeal spread, parathyroid cyst, two cases of nasopharyngeal carcinoma, venous thrombophlebitis, laryngeal carcinoma, and cervical spine fracture] are demonstrated more clearly by CT than by other radiologic methods.
From the Department of Radiology, Cuyahoga County Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio. Address reprint requests to: Shardul D. Vibhakar, MD, Department of Radiology, Cuyahoga County Hospital, 3395 Scranton Road, Cleveland, Ohio 44109. Received February 25, 1983. Accepted March 28, 1983. ‘0 1963 by Elsevier Science Publishing Co., Inc. 52 Vanderbilt
Ave., New York, NY
11149.936X/63/$3.00
10017
Case 1 A 66-year-old white alcoholic woman with a past history of bleeding esophageal varices, mesocaval shunt, posthepatic encephalopathy, multiple electrolyte abnormalities, congestive heart failure, and thyroid surgery for carcinoma diagnosed many years previously, presented at this admission with a sore throat, fever, and chills. She had difficulty swallowing, and redness and swelling over the left eye, face, and neck. A CT scan of the neck (Figures 1A and 1B) showed changes suggestive of an inflammatory focus in the left oropharynx, with spread of the to involve the left eye inflammatory process and lower neck without extension into the mediastinum. On physical examination, necrotic ulceration of an inflamed left tonsil was seen. Sputum and blood cultures were positive for Neisseria meningitidis group C. Therefore, a pharyngeal abscess with parapharyngeal extension was diagnosed. The patient was successfully treated with antibiotics.
260
VIBHAKAR
ET AL.
THE JOURNAL OF COMPUTED
TOMOGRAPHY
VOL. 7 NO. 3
FIGURE 1. (B) Note the FIGURE
1. (A) Soft tissue
prominence of the nasopharynx on the left (large arrow) with poorly defined stringy densities extending laterally to the region of the parotid gland and anteriorly and posteriorly in the subcutaneous and intermuscular planes (small arrows). Note the asymmetry of the air space caused by the nasopharyngeal phlegmonous mass.
stringy densities with poorly defined hazy areas of increased attenuation [arrows) within the subcutaneous fat, which normally has uniform low attenuation. These numerous infiltrating soft tissue densities represent the parapharangeal spread of the phlegmonous process.
Case 2 A 42-year-old white man presented with a sixmonth history of a slowly enlarging painful mass in the left lower neck, which became more prominent in the recumbent position. A CT scan (Figure 2A) showed an encapsulated low-density mass in the region of the lower pole of the left lobe of the thyroid, which extended into the mediastinum (Figure 2B), and was suggestive of a cyst. This was confirmed by ultrasound examination, and at surgery, a large parathyroid cyst measuring 8 X 10 cm was resected. A component about 4 cm in diameter extended into the left supraclavicular region. Case 3 A 4%year-old Vietnamese woman, who arrived in the United States three months prior to admission, presented with a lump in the right side of the neck and pain during extension of the neck. On visual examination of the oropharynx, lymphoid hyperplasia was noted, most prominent on the right. Biopsy of the nasopharynx was negative, and biopsy
FIGURE 2. (A) A well defined rounded low attenuation parathyroid cyst in the lower neck on the left (Pj. The left thyroid (curved arrow) is seen displaced laterally, and the right thyroid (straight arrow) appears normal. of
the lump in the right neck was reported as chronic hyperplastic lymphadenitis. A CT scan of the nasopharynx demonstrated a prevertebral soft tissue mass (Figure 3A), and, in addition, showed erosion of the clivus (Figure 3B), which was further substantiated with a radionuelide bone scan. Because the patient was oriental, lymphoepithelial carcinoma was considered likely, and a repeat biopsy of the nasopharynx was ad-
AUGUST
1983
FIGURE 2. (B) A CT scan at an upper thoracic level shows the intrathoracic extent of the parathyroid cyst [PI. The trachea is compressed and deviated to the right by the cyst.
FIGURE 3. (B) CT scan at the level of the foramen magnum and clivus clearly demonstrates the bony erosion of the clivus on the left and replacement by tumor tissue (arrow).
CT OF NASOPHARYNX
& NECK
261
FIGURE 3. (A) The nasopharyngeal mass has a variegated appearance showing soft tissue and low density attenuation characteristics. A component of tumor, which is rounded, well defined, and of decreased attenuation, is on the right. The component on the left has a variegated appearance, predominantly that of soft tissue attenuation characteristics. Note the anterior extent of the tumor mass to the nasal airway.
262
VIBHAKAR
ET AL.
vised. This biopsy established the diagnosis of lymphoepithelioma. The patient subsequently developed left-sided sixth nerve palsy and ptosis, consistent with left parasellar involvement, and was treated with radiotherapy.
Case
4
A 76-year-old black man with history of diabetes, hypertension, gout, bilateral sensory neuronal hearing loss, and recent bilateral iridectomies for narrow-angle glaucoma, presented with a two-week history of acute, sharp, stabbing pain in the right eye, with periorbital distribution of pain. On clinical examination he was found to have a right supranuclear seventh nerve palsy. The clinical picture was thought to be representative of Gradenigo’s syndrome or Raeder’s paratrigeminal syndrome. A CT scan of the orbits and nasopharynx showed
FIGURE 4. (A) A CT scan at the level of the nasopharynx shows the soft tissue tumor mass [arrow) in the right nasopharynx causing marked asymmetry of the nasopharyngeal air space.
THE JOURNAL OF’ COMPUTED
TOMOGRAPHY
VOL. 7 NO. 3
a nasopharyngeal mass on the right (Figure 4A) with parasellar extension. The superior ophthalmic vein on the right was abnormally tortuous (Figure 4B), indicating impedance of flow into the cavernous sinus. The clinical findings of acute right orbital pain and the cranial nerve palsies could be readily explained by parasellar extension of the nasopharyngeal mass, which on biopsy showed squamous cell carcinoma. The patient was treated by radiation therapy.
Case
5
A 27-year-old black man, an intravenous drug abuser since age 14, was admitted for pain and swelling on the right side of the neck. A CT scan of the neck [Figure 5) showed a low-density filling defect in the
FIGURE 4. (B) A scan at a higher level shows the tortuous superior ophthalmic vein (arrow) secondary to the right parasellar extension of the nasopharyngeal tumor and impedance of venous flow to the cavernous sinus. The right parasellar region appears hazy and indistinct when compared with the opposite side.
AUGUST
CT OF NASOPHARYNX& NECK
1983
263
FIGURE 6. A CT scan of the midcervibal region showing
the laryngeal tumor [arrow] protrudinq into the laryngeal air space with resultant asymmetrical8 appearance of the air space.
DISCUSSION FIGURE 5. A CT scan of the upper neck shows a hypo-
dense thrombus within the right internal jugular vein (arroow).The peripheral rim of increased attenuation is probably enhancement of vasa vasorum.
right internal jugular vein, consistent with thrombus. The patient was treated with heparin and antibiotic, improved, and was discharged.
Case
6
A 7%year-old white man, who presented with difficulty swallowing and a recent change in voice, had squamous cell carcinoma involving the left arytenoid and postcricoid regions. The extent of the tumor could not be established by laryngoscopy. A subsequent CT scan showed the tumor confined to the larynx (Figure 6). Biopsy showed poorly differentiated squamous cell carcinoma. The patient underwent total laryngectomy followed by radiation treatment.
Case
7
An 18-year-old white male adolescent sustained a flexion injury to the cervical spine while playing football, and became quadriplegic as a result. Plain radiographs showed a fracture/dislocation at C5-6 level. A CT scan of the cervical spine (Figures 7A and 7B) done six months later illustrates the clarity afforded by CT in traumatic injuries to the spine, although it was not contributory to the management of this specific case.
Computed tomography is a noninvasive examination with minimal patient discomfort and an information yield that in most cases obviates the need for further radiologic evaluation of nasopharyngeal and neck lesions. Elimination of the need to move the patient’s neck into different positions is advantageous in patients with painful and traumatic conditions (cases 1, 3, and 7). In some cases, direct laryngoscopy is limited or impostiible due to the patient’s inability to open the mouth adequately, and in these situations, a CT scan can aid or, in some cases, substitute for the direct visual examination (cases 1, 3, and 6). The roye of CT in evaluating the nasopharynx and neck has been alluded to in the literature (l-4). The array of cases with neoplastic, inflammatory, and trauma/tic etiologies presented here illustrates the clarity of detail and major contribution by CT to diagnosis and management. In inflammatory conditions, the extent and type of involvement is demonstrated by CT (Figure 1A and 1B). This is helpful in clinical management of the patient, as absence of demonstrable low-density abscess collection indicates that surgical drainage is not needed. The diagnosis of jugular thrombophlebitis (Figure 5) can be made specifically, and the extent determined noninvasively by CT (511.Use of CT rather than ultrasound is preferred in ~this situation because the mechanical pressure of the ultrasound transducer may cause pain over a inflamed, tender area, and might possibly fragmen : and dislodge the thrombus. In neoplastic conditions (cases’2, 3, 4, and 6), the site and extent of involvement is clearly demon-
264
VIBHAKAR ET AL.
FIGURE 7. [A) A CT scan at midcervical level viewed with wide window setting showing the vertical fracture extending in the anteroposterior direction (arrow), with vertical separation of the posterior vertebral body.
THE JOURNAL OF COMPUTED TOMOGRAPHY
VOL. 7 NO. 3
strated by CT. In case 3, the striking abnormalities involving both soft tissues and bone demonstrated the need for repeat biopsy and histologic review. A large number of cases of lymphoepithelial carcinoma has been reported in oriental populations (6,7), and the tumor is comparatively rare in the American population. It is of uncertain etiology (6), but its histologic variations have been well studied (7), and it is known to respond to radiation therapy (8,9). Bone reformation has been observed following radiotherapy (9). We believe that CT is the optimum modality to observe the soft tissue and bony response to treatment. Furthermore, in case 3 the demonstration of clivus erosion indicated tumor involvement and served as an accurate predictor of the sixth and third cranial nerve involvement that subsequently developed. In case 4, CT resolved the complex neurologic problem of the patient through demonstration of a nasopharyngeal tumor with parasellar extension. In case 7, CT very clearly demonstrated a lamina fracture (Figure 7B), which was not well visualized on plain radiographs. Vertical fractures of the vertebral body are frequently associated with lamina fractures (IO), as is demonstrated in our case. SUMMARY
FIGURE 7. (B) A CT scan 5 mm caudal to Figure 7A shows the right lamina fracture (arrow) with minimal displacement at the fracture.
We advocate CT as the initial radiologic modality in suspected abnormalities of the nasopharynx and neck. We have found that in many cases, the need for further radiologic elaboration is obviated because of CT’s high diagnostic yield. REFERENCES 1. Mancuso AA, Bohman L, Hanafee W, Maxwell D. Computed tomography of the nasopharynx: Normal and variants of normal. Radiology 1980. 137:113-21. 2. Thawley SE, Gado M, Fuller TR. Computerized tomography in the evaluation of head and neck. Laryngoscope 1978; 88:451-g. 3. Miller EM, Norman D: The role of computed tomography in the evaluation of neck masses. Radiology 1979; 133:145-g. 4. Mancuso AA, Hanafee WN, Juillard GJF, et al. The role of computed tomography in the management of cancer of the larynx. Radiology 1977; 124:243-4. 5. Pate1 S, Brennan J. Diagnosis of internal jugular vein thrombosis by computed tomography. J Comput Assist Tomogr 1981; 5:197-200. 6. Lee C, Kim KS, Rogers LF. Triangular cervical vertebral body fractures: Diagnostic significance. Am J Roentgen01 1982; 138:1123-32. 7. Yeh S. A histological classification of carcinomas of the nasopharynx with a critical review as to the existence of lymphoepitheliomas. Cancer 1962; 15:895-920.
CT OF NASOPHARYNX
AUGUST 1983
8. Wang CC, Little JB, Schulz MD. Cancer of the nasopharynx. Its clinical and radiotherapeutic considerations. Cancer 1962; 15:921-6. 9. Unger JD, Chiang LC, Unger GF. Apparent reformation of the base of the skull following radiotherapy for nasopharyngeal carcinoma. Radiology 1978; 126:779-82. 10. Lee C, Kim KS, Rogers LF. Triangular cervical vertebral body fractures : Diagnostic significance. Am J Roentgen01 1982; 138:1123-32.
CONTINUING 1.
MEDICAL
EDUCATION
The optimal imaging modality sopharynx and neck are: a. Barium swallow. b. Laryngogram. c. Computed tomography. d. Plain laminography.
QUESTIONS
for evaluating
2. Lymphoepithelial carcinoma is: a. Never seen in the United States, b. Common in the United States. c. Common among orientals. d. Common among Europeans.
the na-
& NECK
‘265
3. Computed tomography evaluation of nasopharynx and neck is suitable for: a. Soft tissue tumors only. b. Soft tissue inflammatory and neoplastc disease only. c. Neoplastic, inflammatory, and traumatic soft tissue and skeletal abnormalities. True or False 4. Computed a. Is of no patient. b. Cannot C. Has no radiation d. In most nations.
tomography of the nasopharynx and neck: value in the management of the traumatized diagnose thromophlebitis of neck veins. place in the follow-up of patients receiving treatment. cases obviates all other radiologic exami-