2 Head and Soft Tissues of Face and Neck

SKULL AND BRAIN (Fig. 2-5). The normal anatomy of the brain on CT and
MR images is shown in Figures 2-6 and 2-7. You should
The appropriate initial imaging studies for various clinical be able to identify some anatomy on these images. There
problems are shown in Table 2-1. are many very complex imaging sequences used during
MRI depending upon the clinical question or suspected
pathology. You are not expected to be familiar with all of
The Normal Skull and Variants these, but you should realize that success in making a
diagnosis depends upon your indicating the clinical
Normal anatomy of the skull is shown in Figure 2-1. The problem accurately so the radiologist can prescribe the
most common differential problem on plain skull x-rays correct imaging sequences.
is distinguishing cranial sutures from vascular grooves
and fractures. The main sutures are coronal, sagittal, and
lambdoid. A suture also runs in a rainbow shape over the Intracranial Calcifications
ear. In the adult, sutures are symmetric and very wiggly
and have sclerotic (very white) edges. Vascular grooves are Intracranial calcifications can be seen occasionally on a
usually seen on the lateral view and extend posteriorly and skull x-ray, but they are seen much more often on CT.
superiorly from just in front of the ear. They do not have Intracranial calcifications may be due to many causes.
sclerotic edges and are not perfectly straight. Normal pineal as well as ependymal calcifications
A few common variants are seen on skull x-rays. Hyper- may occur. Scattered calcifications can occur from
ostosis frontalis interna is a benign condition of females toxoplasmosis, cysticercosis, tuberous sclerosis (Fig. 2-8),
in which sclerosis, or increased density, is seen in the and granulomatous disease. Unilateral calcifications are
frontal region and spares the midline (Fig. 2-2). Large, very worrisome, because they can occur in arteriovenous
asymmetric, or amorphous focal intracranial calcifications malformations, gliomas, and meningiomas.
should always raise the suspicion of a benign or malignant
neoplasm. Occasionally areas of lucency (dark areas) are
found where the bone is thinned. The most common Headache
normal variants that cause this are vascular lakes or
biparietal foramen. Asymmetrically round or ill-defined Headaches are among the most common of human
“holes” should raise the suspicion of metastatic disease ailments. They can be due to a myriad of causes and should
(Fig. 2-3). be characterized by location, duration, type of pain,
Paget’s disease can affect the bone of the skull. In the provoking factors, and age and sex of the patient. In the
early stages, very large lytic, or destroyed, areas may be primary care population, only fewer than 0.5% of acute
seen. In later stages, increased density (sclerosis) and headaches are the result of serious intracranial pathology.
marked overgrowth of the bone, causing a “cotton-wool” Simple headaches, tension headaches, migraine headaches,
appearance of the skull, may be seen (Fig. 2-4). Always be and cluster headaches do not warrant imaging studies. A
aware that both prostate and breast cancer can cause mul- good physical examination is essential, including evaluation
tiple dense metastases in the skull and that both diseases of blood pressure, urine, eyes (for papilledema), temporal
are more common than Paget’s disease. arteries, sinuses, ears, neurologic system, and neck. In
a patient with a febrile illness, headache, and stiff neck,
a lumbar puncture should be performed. In only a few
BRAIN circumstances is imaging indicated (Table 2-3).
In general, imaging is indicated when a headache is
Normal Anatomy accompanied by neurologic findings, syncope, confusion,
seizure, and mental status changes, or after major trauma.
Table 2-2 gives a methodology to follow or checklist of Sudden onset of the “worst headache of one’s life” (thun-
items for use when examining a computed tomography derclap headache) should raise the question of subarach-
(CT) scan. Both CT and magnetic resonance imaging noid hemorrhage. Sudden onset of a unilateral headache
(MRI) are capable of displaying anatomic “slices” in a with a suspected carotid or vertebral dissection or ipsilat-
number of different planes. The identical anatomy of the eral Horner’s syndrome should prompt a CT or MR
brain can appear quite differently on CT and MR images angiogram.
10
 Chapter 2  |  Head and Soft Tissues of Face and Neck    11

TABLE 2-1  Imaging Modalities for Cranial Problems

SUSPECTED CRANIAL PROBLEM INITIAL IMAGING STUDY
Skull fracture CT scan including bone windows
Major head trauma CT (neurologically unstable); MRI (neurologically stable)
Mild head trauma Observe; CT (if persistent headache)
Acute hemorrhage Noncontrasted CT
Intracerebral aneurysm or arteriovenous malformations MRI
Aneurysm (chronic history) MR angiogram or CT angiogram
Hydrocephalus Noncontrasted CT
Transient ischemic attack Noncontrasted CT, MRI if vertebrobasilar findings; consider
carotid ultrasonography if bruit present
Acute transient or persistent CNS symptoms or findings See Table 2-3
Acute stroke
  Suspected hemorrhagic Noncontrasted CT
  Suspected nonhemorrhagic MRI
Ataxia (acute or chronic unexplained) MRI with and without contrast
Cranial neuropathy MRI with and without contrast
Multiple sclerosis MRI of the brain
Tumor or metastases MRI
Carotid/vertebral dissection (ipsilateral Horner’s syndrome or unilateral CT angiogram of head and neck
headache)
Abscess Contrasted CT or MRI
Preoperative for cranial surgery Contrast angiography
Meningitis Lumbar tap; CT only to exclude complications
Seizure
  New onset or poor therapeutic response MRI
  New onset posttraumatic CT or MRI
  Febrile or alcohol withdrawal without neurologic deficit Imaging not indicated
Focal neurologic deficit MRI or CT without contrast
Vertigo
  If suspect acoustic neuroma or posterior fossa tumor MRI of internal auditory canal with and without contrast
  Episodic or with hearing loss MRI with and without contrast
Hearing loss
  Sensorineural MRI head and internal auditory canals
  Conductive CT petrous ridges
Vision loss
  Adult sudden or proptosis MRI with and without contrast
  Head injury CT
  Child acute or progressive or proptosis MRI
Ophthalmoplegia MRI with and without contrast
Headache See Table 2-3
Dementia Nothing or MRI (see text)
Alzheimer’s disease MRI or nuclear medicine FDG PET/CT scan
Unexplained confusion or altered level of consciousness MRI or CT without contrast
Neuroendocrine (e.g., hyperthyroidism [high TSH], Cushing’s [high ACTH], MRI with and without contrast
hyperprolactinemia, acromegaly, precocious puberty, etc.)
Sinusitis See Table 2-6
ACTH, Adrenocorticotropic hormone; CNS, central nervous system; CT, computed tomography; FDG, fluorodeoxyglucose; MRI, magnetic resonance imaging; PET, positron
emission tomography; TSH, thyroid-stimulating hormone.
12    Chapter 2  |  Head and Soft Tissues of Face and Neck

Parietal
Coronal bone
suture
Temporal
Vascular bone
groove
Lambdoid
suture
Frontal
sinus Occipital
bone
Sphenoid
sinus
Sella
Maxillary turcica
sinus

Frontal Superior
sinus orbital
rim

Ethmoid
Lesser sinus
wing of
sphenoid
Petrous
bone
Greater
wing of Maxilla
sphenoid
Mandible

Maxillary
sinus

B
FIGURE 2-1  Normal skull. Lateral (A), anteroposterior (AP) (B),
 Chapter 2  |  Head and Soft Tissues of Face and Neck    13

Lambdoid
suture

Mastoid
air cells Petrous
bone
Foramen
magnum
Mandibular
condyle
Ethmoid
sinus

Orbit

Nasal
septum

Inferior
orbital Zygoma
rim frontal
process
Maxillary
Zygomatic
sinus
arch

Coronoid
process of
Mastoid mandible
air cells
Angle of
mandible
Odontoid
process
of C2
D
FIGURE 2-1, cont’d AP Towne projection (C), and AP Waters view (D).
14    Chapter 2  |  Head and Soft Tissues of Face and Neck

TABLE 2-2  Items to Look for on a Computed Tomography

Brain Scan
Look for
focally decreased density (darker than normal) due to stroke,
edema, tumor, surgery, or radiation
increased focal density (whiter than normal) on a noncontrasted
scan
in ventricles (hemorrhage)
in parenchyma (hemorrhage, calcium, or metal)
in dural, subdural, or subarachnoid spaces (hemorrhage)
increased focal density on contrasted scan
all items above
tumor
stroke
abscess or cerebritis
aneurysm or arteriovenous malformation
asymmetric gyral pattern
mass or edema (causing effacement of sulci)
atrophy (seen as very prominent sulci)
midline shift
ventricular size and position (look at all ventricles)
sella for masses or erosion
sinuses for fluid or masses
soft tissue swelling over skull
bone windows for possible fracture
FIGURE 2-2  Hyperostosis frontalis interna. A normal variant, most
common in female patients, in which increased density of the skull occurs
in the frontal regions. Notice that sparing of the midline is present.

FIGURE 2-4  Paget’s disease. The fluffy cotton-wool densities overlying

the skull are caused by bone expansion. Note also that the calvaria is very
FIGURE 2-3  Multiple myeloma. Multiple asymmetric holes in the skull thick (arrow). The base of the skull has become softened; the cervical spine
are seen only with metastatic disease. Metastatic lung or breast carcinoma and foramen magnum look as though they are pushed up, but in reality
can look exactly the same as this case of multiple myeloma. the skull is sagging around them.

A B C
FIGURE 2-5  Axial images of the brain on computed tomography (CT) and magnetic resonance imaging (MRI). A, On a noncontrasted CT scan the
skull is easily seen, the brain is varying shades of gray, and cerebrospinal fluid (CSF) is dark. B, On a T1 MRI scan the skull is difficult to see, the brain is gray,
and the CSF is dark. C, On a T2 image CSF is white.
 Chapter 2  |  Head and Soft Tissues of Face and Neck    15

Frontal Frontal lobe

lobe

Falx Anterior horn

cerebri of lateral
ventricle

Parietal Superior
lobe cerebellar
cistern
Lateral
ventricles
Sagittal
A1 sinus
B1

Frontal lobe

Genu corpus
Frontal callosum
lobe
Caudate
nucleus
Falx
Anterior horn
cerebri
of lateral
ventricle
Putamen
Parietal
lobe Thalamus

Lateral Third ventricle

ventricles Splenium
corpus
A2 callosum
B2 Occipital lobe

Anterior horn
of lateral
Frontal
ventricle
lobe
Caudate
nucleus
Putamen
Lateral
ventricles Thalamus
Internal
Parietal cerebral veins
lobe
Atrium of
lateral
ventricle

Occipital lobe
A3 B3
FIGURE 2-6  Normal axial images of the brain at three different levels. Noncontrasted computed tomography (A1, B1, C1), T1 magnetic resonance
images (MRI) (A2, B2, C2), and T2 MRI images (A3, B3, C3).
Continued
16    Chapter 2  |  Head and Soft Tissues of Face and Neck

Temporal
lobe
Pons

Mastoid
air cells

Fourth
ventricle
Cerebellum
Skull
C1
Optic globe

Sphenoid
sinus
Temporal
lobe
Internal
carotid
Mastoid
air cells
Pons
Fourth
ventricle
C2 Cerebellum

Optic globe

Sphenoid
sinus
Temporal
lobe
Internal
carotid
Mastoid
air cells

Pons

Fourth
ventricle
Cerebellum
C3
FIGURE 2-6, cont’d
 Chapter 2  |  Head and Soft Tissues of Face and Neck    17

Parietal lobe
Cingulate gyrus
Thalamus
Frontal lobe

Corpus callosum Occipital lobe

Pons
Cerebellum
Pituitary gland
Medulla
Clivus

Nose
Spinal cord
Tongue
A C2
FIGURE 2-7  Normal T1 magnetic resonance
imaging anatomy of the brain in sagittal (A) and
coronal (B) projection.
Falx cerebri
Skull with
marrow Septum
pellucidum

Lateral ventricle Thalamus

Sylvian fissure
Third ventricle
Temporal lobe
Cerebral
peduncle Hippocampus

External Pons
auditory
meatus

ANT
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TABLE 2-3  Imaging Indications for Headaches

MRI is indicated for the following:
Sudden onset of the “worst headache of one’s life” (thunderclap
headache). CT without contrast also indicated
A headache that
worsens with exertion
is associated with a decrease in alertness
is positionally related
awakens one from sleep
changes in pattern over time
A new headache
in an HIV-positive individual
associated with papilledema
associated with focal neurologic deficit
associated with mental status changes
in a patient >60 years of age with sedimentation rate >55 mm/hr
and temporal tenderness
in a pregnant patient
Suspected meningitis or encephalitis

HIV, Human immunodeficiency virus.

For most of the above indications, computed tomography (CT) is acceptable if
magnetic resonance imaging (MRI) is not feasible or available. MRI is usually not
indicated for sinus headaches or chronic headaches with no new features. See
Table 2-6 for CT indications in sinus disease.

FIGURE 2-8  Tuberous sclerosis. Scattered calcifications are seen about

the ventricles in the posterior parietal regions. Other diseases that could
show this appearance include intrauterine TORCH infections (toxoplasmo-
sis, other agents, rubella, cytomegalovirus, herpes simplex).
18    Chapter 2  |  Head and Soft Tissues of Face and Neck

Sinus headaches can usually be differentiated from other

causes because they worsen when the patient is leaning
forward or with application of pressure over the affected
sinus. Indications for CT use in sinus headaches are pre-
sented later in Table 2-6.

Hearing Loss

Hearing loss is characterized as conductive, sensorineural,

or mixed. Conductive loss results from pathology of
the external or middle ear that prevents sound from
reaching the inner ear. Sensorineural loss results from
abnormalities of the inner ear, including the cochlea or
auditory nerve. CT is the best technique for evaluating
conductive loss and the bony structures of the middle
ear. Not all patients with conductive loss need a CT
scan. Indications include complications of otomastoiditis,
preoperative and postoperative evaluation of prosthetic A
devices, cholesteatoma, and posttraumatic hearing loss.
Sensorineural hearing loss may be sudden, fluctuating, or
progressive and may also be associated with vertigo. It can
be due to viral infections, eardrum rupture, acoustic
neuroma, and vascular occlusive diseases. Evaluation is
best done by MRI with and without intravenous contrast.

Head Trauma

On skull x-rays, fractures are dark lines that have very

sharp edges and tend to be very straight (Fig. 2-9). If a
fracture is present over the middle meningeal area, an
associated epidural hematoma may be found. If a depressed
fracture is present, the lucent fracture lines can be stellate
or semicircular (Fig. 2-10). In either of these cases,
substantial brain injury may be present, and a CT scan,
including bone windows, is indicated.
Skull x-rays are ordered much too frequently. A skull B
fracture without loss of consciousness is very rare. Signifi-
cant brain injury may be found without a skull fracture. FIGURE 2-9  Linear skull fracture. Skull fractures (arrows) are usually dark
lines that are very sharply defined and do not have white margins. On the
The patient should be examined clinically and a decision anteroposterior view (A), it cannot be determined whether the fracture is
made as to whether physical findings and the history indi- in the front or the back of the skull. With a Towne view, however, in which
cate moderate to severe head injury or mild head injury. the neck is flexed and the occiput is raised (B), this fracture can clearly be
CT, MRI, or skull radiography is not needed for low-risk localized to the occipital bone.
patients. Low risk is defined as those who are asymptom-
atic or have only dizziness, mild headache, scalp laceration,
or hematomas; are older than 2 years; and have no moder- alcohol, or other central nervous system [CNS] depres-
ate- or high-risk findings. sants). If a moderate or severe injury is present and the
Patients at moderate risk are those who have any of the patient is neurologically unstable, a CT scan should be
following conditions: history of change in the level of con- done to exclude a hematoma. If the patient is neurologi-
sciousness at any time after the injury, progressive or severe cally stable, an MR scan is preferable to look for paren-
headache, posttraumatic seizure, persistent vomiting, mul- chymal shearing injuries. In mild head injury (with no loss
tiple trauma, serious facial injury, signs of basilar skull of consciousness or neurologic deficit), the patient may be
fracture (hemotympanum, “raccoon eyes,” cerebrospinal observed. If a persistent headache occurs after trauma, CT
fluid [CSF] rhinorrhea or otorrhea), suspected child abuse, scanning should be performed.
bleeding disorder, or age younger than 2 years (unless the
injury is trivial).
High-risk patients are those with any of the following Suspected Intracranial Hemorrhage
conditions: focal neurologic findings, a Glasgow Coma
Scale score of 8 or less, definite skull penetration, meta- If the presence of acute intracranial hemorrhage is
bolic derangement, postictal state, or decreased or suspected, the study of choice is a CT scan done without
depressed level of consciousness (unrelated to drugs, intravenous contrast. The scan is done without contrast
 Chapter 2  |  Head and Soft Tissues of Face and Neck    19

ANT
R L

Vascular Air
grooves

Sutures

A
Blood

FIGURE 2-11  Gunshot wound of the head. A noncontrasted computed

tomography scan shows bilateral soft tissue swelling and a hemorrhagic
track across the brain. Blood appears white, and it also is seen within the
lateral ventricles. Several small air bubbles are seen in the lateral ventricles
along the track and along the anterior surface of the brain.

ANT

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B
FIGURE 2-10  Depressed skull fracture. This patient was hit in the head
with a hammer. The lateral view (A) shows the central portion of the frac-
ture, which is stellate (large arrows), and the surrounding concentric frac-
ture line (small arrows). Note the very wiggly posterior suture lines and the
normally radiating vascular grooves. The anteroposterior view (B) shows
the amount of depression of the fracture, although this is usually much
better seen on a computed tomography scan.

CSF

because acute hemorrhage appears to be white on a CT Blood

scan (Fig. 2-11), and so does intravenously administered
contrast. Hemorrhage into the ventricles is usually seen in
the posterior horns of the lateral ventricles. Blood is denser
than CSF and therefore settles dependently. This settling
process is not seen with subarachnoid or intraparenchymal
blood. The presence of hemorrhage is a contraindication
to anticoagulation.
Intraparenchymal bleeding can result from a ruptured
aneurysm, stroke, trauma, or tumor, which are common FIGURE 2-12  Intracerebral hemorrhage. In this hypertensive patient
complications of hypertension. Grave prognostic factors with an acute severe headache, the noncontrasted computed tomography
are large size or brainstem location. Most (80%) hyperten- scan shows a large area of fresh blood in the region of the right thalamus.
sive bleeds occur in the basal ganglia. Ten percent occur Blood also is seen in the anterior and posterior horns of the lateral ven-
tricles. Because blood is denser than cerebrospinal fluid (CSF), it is layered
in the pons, and 10% in the cerebellum. An associated dependently.
mass effect may be present with compression of the ven-
tricles or midline shift. The findings of acute hemorrhage
on a noncontrasted CT scan indicate increased density in Subdural hematomas are seen as crescent-shaped abnor-
the parenchyma (Fig. 2-12). Differentiation from calcifica- malities between the brain and the skull. They can cross
tion usually is easily made by clinical history and, if neces- suture lines, but they do not cross the tentorium or falx.
sary, by having the area of interest measured on the scan In some cases, subdural hematomas can be quite difficult
in terms of density (Hounsfield units). to see, because new blood appears denser or whiter than
20    Chapter 2  |  Head and Soft Tissues of Face and Neck

brain tissue (Fig. 2-13, A). As the blood ages (over a period differential point from an imaging viewpoint is that they
of several weeks), it becomes less dense than brain (Fig. are lenticular rather than crescentic (Fig. 2-14) and tend
2-13, B). Obviously it follows that a subacute phase occurs not to cross suture lines of the skull. Epidural hematomas
during which the blood is the same density as the brain are associated with temporal bone fractures that have
(isodense). In this stage sometimes the only clue that a resulted in a tear of the middle meningeal artery.
subdural hematoma is present is effacement of the gyral Subarachnoid hemorrhage is usually the result of trauma
pattern on the affected side, a midline shift away from the or a ruptured aneurysm. It is most often accompanied by
affected side, or ventricular compression on the affected a very severe sudden-onset headache. Subarachnoid hem-
side. orrhage can really be visualized only in the acute stage,
Epidural hematomas follow the same changing pattern when the blood is radiographically denser (whiter) than the
of density as do subdural hematomas. The major CSF. The most common appearance is increased density
in the region around the brainstem in a pattern sometimes
referred to as a “Texaco star” (Fig. 2-15). Increased density
due to the presence of blood also can be seen as a white
line in the sylvian fissures, in the anterior interhemispheric
ANT fissure, or in the region of the tentorium. In the absence
R L of trauma, a ruptured aneurysm should be suspected. As is
discussed in Chapter 9, in infants, both intraventricular
and intraparenchymal hemorrhage can be visualized and
monitored by using ultrasound. This can be done only if
the fontanelles have not closed.

Pneumocephalus

Air within the cranial vault is almost always the result of

trauma. Even tiny amounts of air are easily seen on CT as
decreased density (blackness) (see Fig. 2-11). It is preferable
H to do a CT scan instead of an MRI examination because
of the superior ability of CT to localize skull fractures and
fresh hemorrhage. It also is easier to manage an unstable
patient in a CT scanner than in an MRI machine.
A
ANT
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ANT

R L

B
FIGURE 2-13  Subdural hematomas. A noncontrasted computed
tomography scan of an acute subdural hematoma (A) shows a crescentic
area of increased density (arrows) in the right posterior parietal region
between the brain and the skull. An area of intraparenchymal hemorrhage
(H) also is seen; in addition, mass effect causes a midline shift to the left FIGURE 2-14  Epidural hematoma. In this patient, who was in a motor
(open arrows). A chronic subdural hematoma is seen in a different patient vehicle accident, a lenticular area of increased density is seen on a noncon-
(B). An area of decreased density appears in the left frontoparietal region trasted axial computed tomography scan in the right parietal region. These
effacing the sulci, compressing the anterior horn of the left lateral ventricle, typically occur over the groove of the middle meningeal artery. Areas of
and shifting the midline somewhat to the right. hemorrhage also are seen in the left frontal lobe.
 Chapter 2  |  Head and Soft Tissues of Face and Neck    21

ANT TABLE 2-4  Imaging Indications With a New

Neurologic Deficit
R L
Acute onset or persistence of the following neurologic deficits is
an indication for computed tomography or magnetic resonance
imaging:
New vision loss
Cranial neuropathy
Aphasia
Mental status change (memory loss, confusion, impaired level of
consciousness)
Sensory abnormalities (hemianesthesia/hypesthesia including single
limb)
Motor paralysis (hemiparesis or single limb)
Vertigo with headache, diplopia, motor or sensory deficit, ataxia,
dysarthria, or dysmetria

A setting the initial test of choice is a CT scan to differentiate

an ischemic event from a hemorrhagic one. A second CT
ANT scan can be obtained in 24 to 72 hours if the diagnosis is
R L
in doubt, but an MRI is more sensitive in identifying early
ischemic damage and may establish the cause of the TIA.
If initial vertebrobasilar findings are seen, an MRI provides
better evaluation of the posterior fossa than does a CT
scan. Regardless of whether a carotid bruit is present in
this setting, a duplex Doppler ultrasound examination of
the carotid arteries is indicated if the patient would be a
surgical candidate for endarterectomy. Magnetic resonance
angiography can be used to visualize carotid stenosis.

Stroke

A stroke may be ischemic or associated with hemorrhage.

An acute hemorrhagic stroke is most easily visualized on a
noncontrasted CT scan, because fresh blood is quite dense
B (white). A diagnosis of stroke cannot be excluded even with
normal results on a CT scan taken within 12 hours of a
FIGURE 2-15  Acute subarachnoid hemorrhage. A noncontrasted axial
computed tomography scan shows the blood as areas of increased density. suspected stroke. A purely ischemic acute stroke is difficult
A transverse view (A) near the base of the brain shows blood in the “Texaco to visualize on a CT scan unless mass effect is present. This
star” pattern, formed by blood radiating from the suprasellar cistern into is noted as compression of the lateral ventricle, possible
the sylvian fissures and the anterior interhemispheric fissure. A higher cut midline shift, and effacement of the sulci on the affected
(B) shows blood as an area of increased density in the anterior and poste-
rior interhemispheric fissures, as well as in the sulci on the right.
side. One key to identification of most strokes is that they
are usually confined to one vascular territory (such as the
middle cerebral artery). An acute ischemic stroke is very
easy to see on an MRI study, because the edema (increased
Hydrocephalus water) can be identified as a bright area on T2 images. In
spite of this, an MRI scan is not needed in a patient with
Dilatation of the ventricles can be either obstructive or an acute stroke. Because anticoagulant therapy is often
nonobstructive. The ventricles are easily seen on a being contemplated, a noncontrasted CT scan can be
noncontrasted CT or MRI study. If the cause is obstructive, obtained to exclude hemorrhage (which would be a
both modalities have a good chance of finding the site of contraindication to such therapy).
obstruction. After about 24 hours, the edema associated with a stroke
can be seen on a CT scan as an area of low density (darker
than normal brain). If a contrasted CT scan is done 1 day
Transient Ischemic Attack to several days after a stroke, enhancement (increased
density or whiteness) may be seen at the edges of the area
A transient ischemic attack (TIA) is defined as a neurologic (so-called luxury perfusion). During the months after a
deficit that has an abrupt onset and from which rapid stroke, atrophy of the brain occurs, which can be seen as
recovery occurs, often within minutes, but always within widened sulci and a focally dilated lateral ventricle on the
24 hours. The imaging indications for patients with a new affected side (Fig. 2-16). Specific different MRI imaging
neurologic deficit are shown in Table 2-4. A TIA indicates sequences are performed when an acute ischemic, hemor-
that the patient may be at high risk for stroke. In the acute rhagic, or chronic stroke is suspected (Fig. 2-17).
22    Chapter 2  |  Head and Soft Tissues of Face and Neck

ANT ANT

R L
R L

A B
FIGURE 2-16  Acute and chronic stroke on computed tomography (CT). An axial CT scan performed on a patient with an acute stroke (A) has little, if
any, definable abnormality within the first several hours. Later, some low density and mass effect may appear as a result of edema. Another scan, approxi-
mately 2 years later (B), shows an area of atrophy and scarring as low density in the region of the distribution of the left middle cerebral artery.

A B C
FIGURE 2-17  Ischemic stroke on magnetic resonance imaging (MRI) scan. Many lesions appear differently on MRI depending upon the specific imaging
sequences used during the procedure. Here a series of specific sequences was done for a suspected acute ischemic infarct. A, A T2 fluid attenuated inver-
sion recovery (FLAIR) image shows a bright area with mass effect in the right cerebral hemisphere (white arrow). There is also a small old infarct in the left
hemisphere with gliosis and gyral atrophy (black arrow). B, A diffusion-weighted image shows bright signal of decreased water diffusion. C, An apparent
diffusion coefficient image shows the area to be dark. This is characteristic of acute ischemic stroke.

Intracranial Aneurysm surrounding thin ring of calcium. On the contrasted study

a large nonthrombosed aneurysm will fill with contrast,
Intracranial aneurysms occur in approximately 2% to 4% although only partial filling may be seen because of a
of the population and are a cause of intracranial hemorrhage. thrombus. With MRI the aneurysm may be seen as an area
Most aneurysms occur in the anterior communicating signal void (black) on the T1 images. If gadolinium contrast
artery or near the base of the brain. The best initial way is used, the aneurysm may fill and have an increased signal
to visualize intracranial aneurysms is with CT or MRI. In (white) (Fig. 2-19).
a setting of acute headache and suspected acute intracranial In the acute setting, CT or MR angiogram is usually
bleeding, a noncontrasted CT study should be done. If the performed. Patients who have an acute bleeding episode
noncontrasted CT is negative, it is followed by a contrasted as the result of a ruptured aneurysm may have associated
CT. The noncontrasted study will show extravascular spasm (occurring after a day or so and lasting up to a week).
acute hemorrhage as denser (whiter) than normal brain. If This can make the aneurysm hard or impossible to see on
this is seen, an angiogram is done, and the contrasted CT an angiogram. For this reason, if subarachnoid hemor-
scan is skipped (Fig. 2-18). A completely thrombosed rhage is present and an aneurysm is not seen, the angio-
aneurysm is frequently seen as a hypodense region with a gram is often repeated a week or so later. For patients who
 Chapter 2  |  Head and Soft Tissues of Face and Neck    23

R L

ACA
R
L

MCA

ICA
FIGURE 2-19  Magnetic resonance image of intracranial aneurysm. A
gadolinium contrast–enhanced scan in the coronal projection shows a
FIGURE 2-18  Intracerebral aneurysm. An anteroposterior projection
large area of enhancement (arrow) representing an aneurysm.
from a digital angiogram shows the right internal carotid artery (ICA), the
anterior cerebral artery (ACA), and the middle cerebral artery (MCA). A
large rounded density seen in the region of the circle of Willis is an aneu-
rysm (large arrow).

ANT
R L R L

FIGURE 2-20  Meningioma. A noncontrasted computed

tomography scan (A) shows a very dense, peripherally based
lesion in the left cerebellar area. A bone-window image (B)
obtained at the same level shows that the density is due to
calcification within this lesion.

A B

have a long history of headache, or a familial history of (dark) on a noncontrasted CT scan and have minimal
aneurysms, a noninvasive MR angiogram is probably the surrounding low-density edema. The more edema and the
procedure of choice. more enhancement after administration of intravenous
contrast, the more malignant the lesion is likely to be. On
MR scans, these tumors are usually low signal (dark) in T1
Primary Brain Tumors and Metastases images and high signal (bright) on T2 images. They also
can show enhancement when intravenously administered
Many types of brain tumors are found. Meningiomas occur gadolinium is used as a contrast agent (Fig. 2-21).
along the surface of the brain. They grow quite slowly and Other intracranial tumors, such as pinealomas, papillo-
often contain calcium. The study of choice is a CT scan mas, lipomas, epidermoids, and others, have variable
with and without intravenous contrast. The noncontrasted appearances and are not considered here. A reasonable
scan may show the calcification, whereas the contrasted differential diagnosis can be made from the appearance
scan will show the extent of this typically vascular tumor and location of the lesions on either CT or MR scans.
(Fig. 2-20). Astrocytomas can be high or low grade and The wide variety of pituitary tumors range from benign
typically occur within the brain substance. Low-grade microadenomas to malignant craniopharyngiomas. The
tumors may contain some calcium, but they are low density examination with the best resolution for the pituitary
24    Chapter 2  |  Head and Soft Tissues of Face and Neck

R ANT R
L L

A B
ANT
R L R L R ANT L

C D E
FIGURE 2-21  Astrocytoma. These contrasted and noncontrasted computed tomography (CT) and magnetic resonance (MR) images were obtained of
the same patient and demonstrate a left astrocytoma with a large amount of surrounding edema. The noncontrasted CT scan (A) shows only a large area
of low density that represents the tumor and edema (arrows). A contrasted CT scan (B) shows enhancement of the tumor (arrows) surrounded by the dark
or low-density area of edema. A noncontrasted T1 MR image (C) clearly shows a mass effect due to impression of the tumor on the left lateral ventricle
and some midline shift. A gadolinium-enhanced T1 MR image (D) clearly outlines the tumor, but the edema is difficult to see. A T2 MR image (E) shows
the tumor rather poorly, but the surrounding edema is easily seen as an area of increased signal (white).

region is MRI, although relatively large lesions can be

imaged with thin-cut (1- to 1.5-mm) CT scans of the sellar Ant Post
region. In either case the studies are usually done with and
without intravenous contrast, because differential enhance-
ment of the tumor and the pituitary allows the margins to T
be delineated (Fig. 2-22).
Metastatic disease is best identified using MRI with SS Pons
intravenous gadolinium (Fig. 2-23). A contrasted CT scan
can be used, but it is not as sensitive as MRI. Most metas-
tases enhance with contrast agents. The reason for order-
ing any study should be carefully considered to determine
that the findings would affect the treatment. Usually little
reason is found to do a cranial MR or CT scan on a patient
who has known metastases elsewhere. Almost all metasta-
ses to the brain are quite resistant to all forms of therapy.
FIGURE 2-22  Pituitary adenoma. A sagittal view of the base of the brain
on a T1 magnetic resonance imaging scan shows the pituitary tumor (T)
Vertigo and Dizziness and its extension down into the sphenoid sinus (SS).

Sometimes vertigo and dizziness are confused. Symptoms

of vertigo are quite specific and occur in only a small subset
 Chapter 2  |  Head and Soft Tissues of Face and Neck    25

of patients who complain of dizziness. Nystagmus almost with sensorineural hearing loss or suspected acoustic
always accompanies true vertigo but is usually absent neuroma or posterior fossa tumor, an MRI is indicated.
between episodes. The workup of most patients with If conductive hearing loss and vertigo are present,
vertigo rarely involves the use of imaging procedures. If a noncontrasted CT scan of the petrous bone may be
the patient does not respond to conservative measures, indicated. Other types of dizziness may have a wide range
imaging studies should be considered in consultation with of causes ranging from postural hypotension to TIAs. Few,
an ear, nose, and throat specialist. If the patient has vertigo if any, imaging tests are indicated for dizziness until the
underlying cause becomes clear.

Suspected Intracranial Infection

Most, if not all, suspected intracranial infections are best

imaged by MRI. Probably the only exception to this is
when a sinus infection is suspected, and then a CT scan
should be ordered. It should be remembered that the
primary method for diagnosis of meningitis is lumbar
puncture. In patients who have acquired immunodeficiency
syndrome or are human immunodeficiency virus (HIV)
positive, CNS complications such as toxoplasmosis,
cryptococcal infection, and lymphoma may develop. These
complications are being seen less because of better
treatment; however, patients who have neurologic findings
or a headache often have a contrasted MRI scan for
evaluation. A CT scan also may be used but it is not as
sensitive.

Multiple Sclerosis
FIGURE 2-23  Metastatic disease to the brain. A gadolinium-enhanced
magnetic resonance image shows multiple metastases from lung cancer
Multiple sclerosis is effectively imaged only by MRI. Often
as areas of increased signal and a few metastases with central dark areas small high-signal (bright) lesions are seen on either T1 or
of necrosis (arrows). T2 images (Fig. 2-24). These plaques can have contrast

ANT ANT

R L R L

A B
FIGURE 2-24  Multiple sclerosis. The noncontrasted T1 magnetic resonance imaging scan (A) is generally unremarkable, with the exception of one lesion
in the right frontal lobe (arrow). A gadolinium-enhanced scan (B) is much better and shows many enhancing lesions, only some of which are indicated by
the arrows.
26    Chapter 2  |  Head and Soft Tissues of Face and Neck

enhancement to varying degrees in the same patient. diagnoses, imaging may be in order. In such circumstances
Whether the enhancement is related to activity of disease an MRI is the initial study of choice.
remains a matter of debate. Some authors have suggested that neuroimaging
studies are unnecessary if the mental status examination,
neurologic examination, and EEG findings are normal.
Dementia and Slow-Onset Mental Changes If the patient is younger than 40 years, has no history
of head injury, and has normal mental status and neuro-
Imaging of the brain in most patients with dementia is logic examinations but abnormal EEG, the imaging
usually an unrewarding exercise. Most of the time, a CT examination is not likely to give additional diagnostic
scan shows atrophy compatible with age and nothing else. information.
As mentioned, an MR scan can effectively exclude multiple
sclerosis, tumor, metastases, and hydrocephalus. Often it
is ordered to exclude these rather than to find the true
cause of most dementias. It is possible to do a nuclear FACE
medicine tomographic brain scan (brain single-photon
emission CT [SPECT] or positron emission tomography Indicated imaging for face and neck problems is shown in
[PET]) by using radioactive substances that are extracted Table 2-5.
on the first pass through the cerebral circulation. It appears
that these scans show bilateral reduced blood flow to the
temporoparietal areas in Alzheimer’s disease and scattered Sinuses and Sinusitis
areas of reduced perfusion in multi-infarct dementias.
There are also some new radiotracers that bind to amyloid The frontal skull x-ray is best used to evaluate the frontal
plaque and show increased retention in the brain of and ethmoid sinuses. The frontal Waters view (done with
Alzheimer’s dementia patients. Such studies may not be the head tipped back), is used to evaluate the maxillary
cost-effective unless you have effective therapy for these sinuses. The lateral view is used for evaluation of the
entities. sphenoid sinus (Fig. 2-25). Sinus series are often
inappropriately ordered to rule out sinusitis in children.
Sinuses are not developed or well pneumatized until
Seizures children are about 5 to 6 years old. In adults, often
hypoplasia of the frontal sinuses is seen (Fig. 2-26).
Examination of a patient with a seizure should include a Most patients with suspected sinusitis do not need sinus
thorough medical history, physical examination, and blood imaging for clinical management (Table 2-6). Sinusitis is
and urine evaluation. Particularly pertinent history includes most common in the maxillary sinuses. Acute sinusitis is
information regarding seizures (personally or in the diagnosed radiographically if an air/fluid level in the sinus
family), drug abuse, and trauma. Noncontrasted MRI is (Fig. 2-27) or complete opacification is found. After
the imaging procedure of choice, although contrasted CT trauma, hemorrhage also can cause an air/fluid level. With
scanning may be used. Imaging is usually done for persons chronic sinusitis, thickening and indistinctness of the sinus
who are otherwise healthy with a new onset of seizures, walls appear. CT is vastly superior to either plain x-rays
those who have epilepsy with a poor therapeutic response, or MRI for evaluation of the paranasal sinuses, mastoid
alcoholics with a new onset of seizures, or seizure patients sinuses, and adjacent bone. Malignancy should be sus-
with a neurologic deficit or abnormal electroencephalo­ pected if recurrent episodes occur of unilateral epistaxis
gram (EEG). Noncontrasted CT scanning is usually used with no visible bleeding site, constant facial pain, anosmia,
in patients with seizures and acute head trauma or other recurrent unilateral otitis media, a soft tissue mass, or bone
emergency pathology. Imaging is not usually needed in destruction on a sinus or dental x-ray.
children who have a suspected febrile seizure and in adults
without neurologic deficits who are in chemical withdrawal
or who have metabolic abnormalities. Facial Fractures

Zygoma
Psychiatric Disorders Fractures of the zygoma usually result from a direct blow
to the arch or to the zygomatic process. The arch and the
Imaging studies of most psychiatric patients usually have skull form a rigid bony ring. Just like a pretzel, it cannot
a low yield for diagnostic information. One must remember be broken in only one place. The view that should be
that a number of CNS abnormalities may first be seen with ordered if an arch fracture is suspected is the “jug-handle”
apparent psychiatric symptoms, particularly in older adults. view (Fig. 2-28). If only one fracture is seen in the arch,
For example, common conditions that may be mistaken for then images of the facial bones should be obtained to
a depressive disorder include infections, malignancies, and exclude a so-called tripod fracture. The tripod fracture
stroke. Patients treated for chronic alcoholism may have results from a direct blow to the zygomatic process. It
unrecognized subdural hematomas. Obtaining a thorough actually consists of four fractures, not three, as the name
history and performing a careful physical examination are suggests. The fractures are of the zygomatic arch, lateral
essential. If associated neurologic findings or disparities orbital rim, inferior orbital rim, and lateral wall of the
are noted between the psychiatric findings and common maxillary sinus (Fig. 2-29).
 Chapter 2  |  Head and Soft Tissues of Face and Neck    27

TABLE 2-5  Indicated Imaging for Face and Neck Problems

SUSPECTED FACE AND NECK PROBLEM INITIAL IMAGING STUDY
Unilateral proptosis, periorbital swelling, or mass MRI
Facial fracture Plain x-ray, CT for complicated cases
Mandibular fracture Panorex
Carotid bruit Duplex ultrasound
Epiglottitis Lateral soft tissue x-ray of neck
Foreign body Plain x-ray if calcified or metallic (fish bones not visible)
Retropharyngeal abscess Lateral soft tissue x-ray of the neck; if positive, CT to determine extent
Lymphadenopathy, nontender, single or multiple (or no decrease in CT with IV contrast (preferred) or MRI without contrast
size over 4 wk)
Solitary neck mass (febrile patient) CT with IV contrast
Pulsatile neck mass CT with IV contrast
Solitary or multiple neck masses (child) Ultrasound or CT with IV contrast
Hyperthyroidism Serum TSH and free T4 (no imaging needed)
Suspected goiter or ectopic thyroid Nuclear medicine thyroid scan
Thyroid nodule (palpable) Fine-needle aspiration (possibly with ultrasound guidance)
Known thyroid cancer (postoperative) Nuclear medicine whole body radioiodine scan
Exclude recurrent thyroid tumor Serum thyroglobulin
Suspected hyperparathyroidism CT or nuclear medicine scan
CT, Computed tomography; IV, intravenous; MRI, magnetic resonance imaging; T4, thyroxine; TSH, thyroid-stimulating hormone.

F F

F F
F
M M
E E S

M M

A B C
FIGURE 2-25  Normal radiographic anatomy of the sinuses. Typical radiographic projections are anteroposterior (A), Waters view (B), and lateral view
of the face (C).

Nasal fracture is down through the orbital floor. The Waters

Nasal bone x-rays are really useful only to look for view affords the best image to look for this. The findings
depressed fractures or lateral deviation. The latter is often that may be present are discontinuity of the orbital floor,
clinically obvious. On the lateral view the nasal bone has a soft tissue mass hanging down into the maxillary antrum
normal lucent lines that are often mistaken for fractures. (Fig. 2-31), fluid in the maxillary antrum, and, rarely, air
If the lucent lines follow along the length of the nose, in the orbit (coming up from the sinus). Blowout fractures
however, they are not fractures. Fractures are seen as dark also can occur medially into the ethmoid sinus (Fig. 2-32).
lines that are perpendicular or sharply oblique to the You will see this on the frontal skull view only as
length of the nose (Fig. 2-30). opacification (whiteness) in the affected ethmoid sinus.

Orbital Le Fort Fractures of the Face

Blowout fractures occur from a direct blow to the globe of These rare injuries are produced by massive facial trauma.
the eye. The pressure on the eyeball fractures the weak They are associated with many other smaller fractures. A
medial or inferior walls of the orbit. The usual blowout Le Fort I fracture is a fracture through the maxilla, usually
28    Chapter 2  |  Head and Soft Tissues of Face and Neck

TABLE 2-6  Indications for Computed Tomography or

Magnetic Resonance Imaging in Sinus Disease
CT scanning is indicated in acute complicated sinusitis if the
patient has
Sinus pain/discharge and
Fever and
A complicating factor such as
mental status change
facial or orbital cellulitis
meningitis by lumbar puncture
focal neurologic findings
intractable pain after 48 hr of intravenous antibiotic therapy
immunocompromised host
sinonasal polyposis
possible surgical candidate
three or more episodes of acute sinusitis within 1 yr in which the
patient has signs of infection
CT scanning is indicated in chronic sinusitis if
no improvement is seen after 4 wk of antibiotic therapy based on
culture or
no improvement is seen after 4 wk of intranasal steroid spray
CT or MRI scanning is indicated in cases of suspected sinus
malignancy
MRI scanning with and without contrast is indicated in patients with
suspected intracranial complications of sinusitis

CT, Computed tomography; MRI, magnetic resonance imaging.

FIGURE 2-26  Hypoplastic frontal sinuses. This adult has had only
minimal development of both frontal sinuses (arrows). This is a common
normal variant.

R L

A B
FIGURE 2-27  Sinusitis. A Waters view taken in the upright position (A) may show an air/fluid interface (arrows) in acute sinusitis. In another patient who
is a child (B), opacification of the left maxillary antrum (arrows) is seen, and this may represent either acute or chronic sinusitis.
 Chapter 2  |  Head and Soft Tissues of Face and Neck    29

FIGURE 2-28  Depressed zygomatic fracture. A view of the skull from the bottom (jug-
handle view) shows the zygomatic arches very well. In this patient a direct blow to the
zygoma has caused a depressed fracture (arrows).

R ANT L
1

A B
FIGURE 2-29  Tripod (zygomatic) fracture. In this patient who had a direct blow to the zygomatic process, the anteroposterior Waters view of the skull
obtained in the upright position (A) shows an air/fluid level (as a result of hemorrhage) in the right maxillary antrum (small arrows). Discontinuity of the
inferior and right lateral orbital walls (large arrows) represents a fracture. A transverse computed tomography view in a different patient (B) shows a tripod
fracture on the left caused by a direct blow in the direction indicated by the large arrows. Fractures of the anterior (1) and posterior (2) zygoma, as well as
the medial wall of the left maxillary sinus (3), are seen.

FIGURE 2-30  Normal and fractured nasal bones. A

normal lateral view (A) of the nose shows normal dark
longitudinal lines in the nasal bone. A nasal fracture (B)
is seen as a lucent line that is not in the long axis of the
nose (arrows). A fracture of the anterior maxillary spine
also is seen in this patient.

A B
30    Chapter 2  |  Head and Soft Tissues of Face and Neck

R L

FIGURE 2-33  Mandibular fracture. A panorex view shows a fracture

(arrows) through the left mandibular angle.

flattened out (Fig. 2-33). If a panorex machine is not

FIGURE 2-31  Inferior blowout fracture of the orbit. An anteroposterior available, standard oblique views of the mandible are
view of the face shows air in the orbit, discontinuity of the floor of the right
orbit (black arrows), as well as a soft tissue mass hanging down from the
satisfactory but harder to interpret.
orbit into the maxillary antrum (white arrows) and blood in the dependent
part of the sinus.
SOFT TISSUES OF THE NECK

For a discussion of cervical fractures and dislocation, refer

to Chapter 8.

Epiglottitis

Epiglottitis is usually thought of as a childhood disease,

but it can occur in adults as well. The best initial imaging
modality for upper airway obstruction or suspected foreign
body is a lateral soft tissue view of the neck. This is
essentially an underexposed lateral cervical spine view, and
the airway is usually well seen. With epiglottitis, swelling
of the epiglottis is seen easily on the lateral view, and the
epiglottis looks somewhat like a thumbprint rather than a
thin delicate curved structure (Fig. 2-34). For a discussion
of croup and pediatric epiglottitis, refer to Chapter 9.

Retropharyngeal Abscess

Retropharyngeal abscess is another cause of upper airway

FIGURE 2-32  Medial blowout fracture. A coronal computed tomogra- obstruction, as well as a cause of dysphagia. The soft tissue
phy scan shows a fracture of the medial orbital wall with hemorrhage into lateral x-ray is the initial imaging procedure of choice,
the left ethmoid sinus (large arrows). Air within the orbit (small white usually showing prevertebral soft tissue swelling. Air may
arrows) is seen in this case.
or may not be within these swollen soft tissues (Fig. 2-35).
An intravenously contrasted CT scan is often of great value
to help discern the lateral and inferior margins of the
caused by being hit in the upper mouth with something abscess and the location of the great vessels of the neck.
like a baseball bat. A Le Fort II fracture involves the Retropharyngeal abscesses can extend interiorly into the
maxilla, nose, and inferior and medial orbital walls. A Le mediastinum or laterally into the region of the carotid
Fort III fracture is a facial/cranial dissociation or a artery and jugular vein.
separation between the face and the skull. Owing to the
massive trauma required for the type III fracture, a high
fatality rate occurs from the associated brain injury. Subcutaneous Emphysema

Mandible In addition to air within the soft tissues of the retropharynx,

Mandibular fractures should be suspected especially if you should also be aware of dark vertical lines of air within
malocclusion after trauma is present. Occasionally the anterior and lateral soft tissues of the neck. If you see
temporomandibular joint dislocation is found. The easiest these, you should look at the concurrent chest x-ray, or
way to visualize these entities is to order a panorex view of order one, to exclude either a pneumothorax or mediastinal
the mandible. This displays the mandible as if it were emphysema. These are both potentially life-threatening
 Chapter 2  |  Head and Soft Tissues of Face and Neck    31

A B
FIGURE 2-34  Normal epiglottis and epiglottitis. The normal epiglottis is well seen on the lateral soft tissue view of the neck (A) as a delicate curved
structure. In a patient with epiglottitis (B), the epiglottis is swollen and significantly reduces the diameter of the airway.

R L

T
ab

A ab B
FIGURE 2-35  Retropharyngeal abscess. On a lateral soft tissue view of the neck (A), the normal air column is displaced forward (curved arrows). A large
amount of soft tissue swelling occurs in front of the cervical spine; gas, which represents an abscess (ab), is seen in the lower portion. A computed tomog-
raphy scan through the upper thorax in the same patient (B) shows extension of the abscess (ab) down into the mediastinum between the trachea (T)
and the spine.

abnormalities, and the air from these commonly dissects the medial aspect of the clavicles is equidistant from the
up into the neck. (See Chapter 3 for a full description of posterior spinous processes (Fig. 2-36). The thyroid is
these entities.) usually easily seen on CT scan (Fig. 2-37). Ultrasound can
differentiate a cystic from solid thyroid and is commonly
used to direct fine-needle aspiration of cells for pathologic
Thyroid examination (Fig. 2-38).

The thyroid is a symmetric gland that lies lateral and

anterior to the trachea just above the thoracic inlet. Large Parathyroid
goiters can compress the trachea in a symmetric fashion,
although this is unusual. More commonly, asymmetric The most common parathyroid problem requiring imaging
enlargement occurs, and the trachea is deviated to one side is hypercalcemia secondary to a parathyroid adenoma
or the other. Before diagnosing tracheal deviation, you (80%) or to hyperplasia (20%). Because adenomas can be
must be sure that the patient is not rotated. On a well- very difficult to locate at surgery, a nuclear medicine scan
positioned posteroanterior or anteroposterior chest x-ray, using radioactive compounds that accumulate in the
32    Chapter 2  |  Head and Soft Tissues of Face and Neck

FIGURE 2-36  Thyroid mass. A large thyroid adenoma has displaced the trachea to the
right (open arrows). This pattern can be simulated if the patient is rotated slightly when the
x-ray is taken. In this case, however, the medial aspects of the clavicles (dotted lines) can be
seen to be centered over the posterior spinous processes, indicating that the patient was M
not rotated, and a mass is truly present.

Sp

Thyroid
Common
carotid artery

Trachea
FIGURE 2-37  Normal thyroid on axial con- Jugular vein
trasted computed tomography scan of the neck.
The arteries are well seen because the image was Esophagus
obtained during the arterial phase of an intrave-
nous injection of iodinated contrast. The thyroid
appears whiter than other tissues due to the
normal content of iodine in the gland.

Anterior

Strap muscles

FIGURE 2-38  Thyroid nodule on axial ultra-

sound examination. The nodule contains internal
echoes, indicating that it is not a cyst. Because it Nodule
appears solid, it could be either a benign adenoma
or a carcinoma. Often ultrasound-guided fine-
Trachea
needle aspiration is done to differentiate these
entities.

R thyroid
Common lobe
carotid artery
 Chapter 2  |  Head and Soft Tissues of Face and Neck    33

Immediate Delayed

FIGURE 2-39  Parathyroid adenoma. A nuclear medicine scan

done with technetium 99m sestamibi. The initial image (A)
S shows the thyroid (Th), submandibular glands (S), and a para-
thyroid adenoma (arrow). On a delayed 2-hour image (B), the
radioactivity has faded in the thyroid and submandibular
glands.
Th

A Neck B Neck

thyroid or parathyroid or both should be done. The Suggested Textbooks on the Topic
Som PH, Curtin HD: Head and Neck Imaging, 5th ed. St. Louis, Mosby,
resulting images are very accurate in localizing the 2011.
adenomas (Fig. 2-39). Parathyroid adenomas can be Yousem DM, Zimmerman RD, Grossman RI: Neuroradiology: The Req-
imaged by CT, MRI, or ultrasound, but the interpretation uisites, 3rd ed. St. Louis, Mosby, 2010.
is more difficult.