Anatomy and Pathology of the Oropharynx, Dr. Suresh Mukherji (11-14-24)
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Hello and welcome to Noon Conference, hosted by Modality
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and previous noon conferences by creating a free account.
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Today we are honored to welcome Dr.
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Resh McCury for a lecture entitled Anatomy
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and Pathology of the Oral phn.
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Dr. McCury received his undergraduate degree from Duke
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University and his MD degree from Georgetown University.
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He currently holds appointments at multiple institutions
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and is a devoted educator
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who has been an invited speaker on over 500 occasions
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and written and edited 15 textbooks.
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We are especially grateful for his supportive modality
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and for serving as our head and neck neuroradiology advisor.
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At the end of this lecture, please join him in a q
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and a session where he will address questions you may have
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on today's topic.
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Please remember to use the q
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and a feature to submit your questions so we can get to
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as many as we can before our time is up.
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With that, we are ready to begin today's lecture. Dr.
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McCury, please take it from here
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And Okay, great. All
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right, well thanks again for having me at modality
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and uh, we, this is actually the second part
1:17
of a two part session.
1:19
Uh, we had the first one on the oral cavity
1:23
and now we're gonna talk about the anatomy
1:25
and the pathology of the oral pharynx.
1:27
So we're gonna spend the whole 50 minutes
1:30
or so talking about the oral pharynx
1:32
and um, it's really up to the modality folks, I blocked off,
1:35
uh, time
1:36
after this talk too, so we have plenty of times for question
1:39
and answer as well, so I'll just good that
1:43
that gives me the, the opportunity to,
1:45
to catch up for a second.
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And that is, you know, my son's in medical school right now,
1:48
so I can attest to the fact
1:50
that when you're actually in medical school,
1:51
we don't really get a good foundation
1:53
of the anatomy, the head and neck.
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And so all of a sudden, you know, we're asked
1:58
to evaluate anatomy and pathology of the head and neck.
2:02
And now we're really specifically just talking
2:05
about the oral pharynx.
2:06
So that's why, excuse me, I appreciate the opportunity to,
2:10
to give talks about the anatomy
2:12
and the pathology of this specific area,
2:14
which is an incredibly important area.
2:16
So we're gonna talk about the anatomy
2:19
and the pathology of the oral pharynx.
2:21
And the first thing to the remember is
2:23
that the oral pharynx is part, if you will, of your mouth,
2:28
but the oral pharynx has four separate subsites
2:31
and those include this area here, which is the tongue base.
2:35
You have the soft palate, you have the tonsil,
2:38
and you have the posterior pharyngeal wall.
2:41
So when you're looking at the sagittal images right here,
2:43
it basically starts from the level
2:45
of the circum valley papilla
2:47
and this area right here,
2:49
which is called the anterior tonsor pillow.
2:51
And don't worry about all
2:52
of this anatomy 'cause we'll go with it.
2:54
I add it in detail. The posterior wall is formed by this
2:58
muscular wall posteriorly,
3:00
which is a posterior pharyngeal wall superiorly.
3:04
It's supported by
3:05
or bounded by the soft palate inferiorly by the molecular,
3:10
and then laterally again by the tonsils.
3:13
And again, we'll talk all about the tonsils
3:15
again in great detail.
3:17
But what I wanted to say was basically the oral pharynx is
3:21
kind of this rectangle in the back
3:22
of your mouth if you will, whereas this area,
3:24
and you can see my uh, head, this area anterior,
3:28
is the oral cavity, the oral pharynx if you will, is
3:31
that area posterior to um, the oral tongue?
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I did want to talk a little bit about the embryology
3:38
and not go too much into detail,
3:41
but what I did wanna say is
3:42
that I don't really remember much about embryology,
3:46
but what I did want to really specifically focus on is
3:49
that when you look at the oral tongue here,
3:51
which is on this top right image, the circum valley
3:54
is bounded here in yellow.
3:56
So this is the boundary of the circum valley papilla.
3:59
The oral tongue is predominantly formed by the first
4:03
and second derivatives of the brachial arches
4:07
and it's innervated by cranial nerves five and seven.
4:10
But when we look at the circum valley papilla
4:12
and going posteriorly, we talk about the tongue base
4:15
and we talk about the epiglottis.
4:17
This arises from the third and fourth brachial pouches
4:21
and that's supplied by cranial nerves nine
4:23
and cranial nerves 10.
4:25
And so if you look at this schematic illustration,
4:28
the motor division,
4:29
so if you actually have a hypoglossal nerve palsy
4:33
that innervates half of the tongue.
4:34
So this is motor, but sometimes
4:37
what we forget about is taste and sensation.
4:40
So when we talk about the oral phx,
4:42
this is predominantly formed by cranial nerves nine
4:45
and cranial nerves 10.
4:47
Now I specifically mentioned this
4:48
because if you did have a patient
4:50
with algen algen meaning referred ear pain,
4:54
there are many causes to that.
4:56
But just remember cranial nerves nine
4:58
and cranial nerves 10 extend all the way
5:00
to your middle ear cavity through the nerves
5:03
of Jacobson and Arnold.
5:04
So if you do have a pace with unexplained ear pain, please,
5:07
please, please always to remember to look at the tongue base
5:11
and the pharynx because sometimes you'll pick up squamous
5:14
cell carcinomas or other tumors that will involve this area
5:18
that can cause the ear pain.
5:20
And we'll again go over that in great detail.
5:23
So the first thing that we'll talk about in the oral pharynx
5:26
is we'll talk about this area right here,
5:28
which is the tongue base.
5:30
So as you know, there are two parts to the tongue.
5:32
There's this oral tongue right here,
5:34
which you kind of stick out at.
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When I was a kid, I used to get mad at someone,
5:37
I used to stick out my tongue.
5:39
And then there is this junction right here,
5:41
which is the embryologic location
5:44
that separates the oral tongue from the tongue base.
5:47
So now we're gonna be specifically looking at this area
5:50
posteriorly to the circum valley papilla.
5:53
At the apex of the circum valley papilla is a little foramen
5:56
and that's the foramen cecum.
5:58
So this is what you look when you look at the surface
6:00
anatomy of the tongue.
6:02
Now when you look at the anatomy, what you see here is
6:05
that the tongue base is formed by these transverse fibers.
6:09
So if you look anteriorly,
6:10
these vertically oriented muscles are in the floor mouth,
6:14
which is part of the oral cavity.
6:16
But one of the questions I often get is, how do you know
6:19
where the oral cavity ends and the tongue base begins?
6:23
And that's because we see this termination
6:26
of these vertically oriented muscles.
6:28
And now we see these transverse fibers,
6:30
which are the fibers of the tongue base.
6:32
Uh, this is a CT scan again demonstrating the vertically
6:37
oriented geno gloss muscles.
6:39
And here we see the transition
6:41
of the tongue-based musculature.
6:43
So part of it is these transverse fibers that go right
6:46
to left, but realize when you look at the ct,
6:49
the tongue base has intrinsically high area fat as well too.
6:53
So it's not only the termination, the fibers
6:55
and these muscles, but you can see there's low,
6:57
more low attenuation in here
6:59
and you can see the contrast between these thick muscles
7:03
and the fat in the tongue base.
7:05
So this talk is not gonna be purely based on cancer.
7:08
So we have special talks on squamous cell carcinomas
7:12
involving the oral cavity, oral pharynx
7:14
to get into a lot of detail.
7:15
But this talk is really gonna be on differential diagnosis.
7:18
So we'll touch a little bit about the most common tumor
7:22
to involve the tongue base.
7:23
And this is squamous cell carcinoma.
7:25
So here's an example of a tumor involving the right tongue
7:28
base demonstrating the various patterns of spread.
7:32
And this is an example of squamous cell carcinoma
7:35
involving the tongue base.
7:36
So here we can see this mass is centered on the tongue base.
7:40
If we look anteriorly, we can see
7:42
that this tumor's extending anteriorly
7:44
and traversing this junction
7:46
between the geno gloss muscle and the tongue base.
7:49
So this is the classical example
7:51
of a tongue-based carcinoma.
7:54
Now when we talk about tongue-based carcinomas, I'm sure all
7:57
of you are familiar with the squamous cell carcinomas
8:01
of the tongue base, which are HPV positive.
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So any, I should say in the United States, the vast majority
8:07
of squamous cell carcinomas involving the oral pharynx
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and that's the tongue base and the tonsil
8:12
and the soft palate are HPV positive.
8:15
So I'm sure all of you're familiar with this,
8:18
but just realize these primarily involve the oral pharynx,
8:21
whereas HPV negative tumors involve the oral cavity.
8:25
I think you're also aware
8:27
that this HPV positive tumor is can be considered a sexually
8:31
transmitted disease
8:32
because HPV is oftentimes transmitted
8:35
during birth in the vaginal canal.
8:38
The one good thing about HPV positive tumors is
8:41
that these tumors actually have a better overall survival
8:44
rate compared to HPV negative tumors.
8:48
Now one little nuance that I wanted to mention
8:51
because this can be a little bit confusing, is
8:54
that when we talk about HPV it, this is human papillomavirus
8:59
and it is the most commonly sexually transmitted disease.
9:02
It is a true onco virus and the subtypes are HPV 16
9:07
and HPV 18.
9:09
Now I mentioned this in particular
9:10
because sometimes it can get confusing
9:14
because we also talk about this concept of P 16 positive.
9:19
So the point that I wanna make is
9:22
and UN one of the unfortunate coincidences is
9:26
that the most common type of HPV that involves the head
9:30
and neck and re results in these cancers
9:33
is actually the HPV 16 virus.
9:37
So this comprises about 90% of all HPV tumors.
9:40
So if you do PCR testing polymers chain reaction testing,
9:45
then you are gonna test for this HPV 16.
9:48
But on the other hand, you've probably heard about P
9:51
16 staining.
9:52
And what this is is a immunohistochemical cha uh stain.
9:57
And just by coincidence, this P 16 protein
10:02
is expressed by various viruses.
10:05
And so if you have a patient
10:07
that has a squamous cell carcinoma,
10:10
sometimes the ENT surgeons
10:12
or the pathologist will not perform the PCR testing,
10:16
but they'll just do an immunohistochemical stain
10:19
and they will test for the P 16 protein.
10:22
So I did wanna point out the difference
10:23
between the PCR testing, which is we're all familiar with
10:27
as we come off of covid versus the
10:30
immunohistochemical staining.
10:31
So when they do stain for the HPV,
10:34
or excuse me, the P 16 protein,
10:36
you can see it's darker here compared
10:38
to a normal stain here.
10:39
So it's one of those unfortunate coincidences.
10:44
So by far and away the most common tumor
10:46
that you'll end up seeing in the oral pharynx is gonna be
10:49
squamous cell carcinoma.
10:51
Now the second most common tumor
10:53
that you will see is a result of this lymphoid tissue
10:57
that's in your oral pharynx
10:59
and also part of your nasal pharynx.
11:01
And this is what was referred to as wall dyer's ring.
11:05
So while Dyer's ring has lymphoid tissue here involving the
11:09
tongue base and specifically located here in the ULA,
11:12
and we refer to this area as the lingual tonsils.
11:16
So now that we're specifically talking about the tongue
11:18
base, we know that there's lymphoid tissue here.
11:21
And this was a patient that has lymphoma that's kind
11:24
of tucked away right behind the tongue base
11:27
but anterior to the epiglottis in the region
11:30
of the lingual tonsil.
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Now these lingual tonsils can actually get pretty big
11:35
and they act can can be pretty confusing.
11:38
So this is an example of a pace that presents
11:40
with a tongue base mass
11:42
that's involving the lingual tonsils.
11:44
And you look at this and you're like, holy cow,
11:46
is this squamous cell carcinoma?
11:48
You know, what do you do? Here's another page
11:51
that has another big mass right here
11:53
that's located right in the region of the molecular.
11:56
Now for in all intents
11:58
or purposes, this looks like either squamous cell carcinoma
12:01
or it could be lymphoma and lymphoma again,
12:05
because of that predominance of lingual tissue.
12:07
But actuality this was path proven
12:10
to be lingual tonsillitis.
12:12
So you actually can get inflammation of this lingual tonsils
12:17
and give you a very, very large mass in this area.
12:21
And the only way that we can differentiate this is really
12:24
by physical examination palpation.
12:27
So these are two patients
12:28
and one of these has lingual tonsillitis,
12:31
and I have the answers here below,
12:33
but you can see this was a patient
12:34
that actually has squamous cell carcinoma
12:37
and this is what it looks like on CT scan.
12:39
And this patient ends up have lingual tonsillitis.
12:42
And this is what it looks like on clinical exam.
12:45
So the challenge that I run into every day is
12:49
that if I have a patient with throat pain
12:52
or difficulty swallowing
12:53
or sometimes with ear pain too, right,
12:56
because remember that referred pain that goes to your ear
12:58
because of cranial nerves nine and 10.
13:01
Part of the challenge that I run into is if I see something
13:04
like this, what do I include in my report?
13:07
So what I end up saying is
13:08
that if I see this increased soft tissue
13:11
that's located in the region of the lingual tonsils,
13:14
I just say there is increased soft tissue involving the
13:17
region of the tongue base and extending into the molecular.
13:20
And this can be directly evaluated
13:22
with physical examination and palpation.
13:26
And I think those of you that have seen me lecture
13:28
before know that I typically see patients on Wednesdays.
13:31
And so when I do see those patients on Wednesdays, I know
13:34
how easy it is to look back at the base of the tongue
13:37
and palpate the base of the tongue.
13:39
And if they palpated this leash in here on the middle,
13:43
this would be a rock hard mass
13:44
and they could see the squamous cell carcinoma.
13:47
In this situation it would be soft
13:49
and pliable, easily compressible.
13:52
And this is lingo tonsillitis.
13:54
So mo most occasions this can easily be seen on physical
13:57
exam, but for us it's hard to say.
14:00
So that's why I always specifically include
14:02
that my report if there's, if I do have any ambiguity.
14:07
So the most common tumor
14:09
of the tongue base is gonna be squamous cell
14:11
carcinoma followed by lymphoma.
14:13
The next thing that we have to remember is
14:15
that we can have these ectopic rests
14:18
of minor salivary gland tissues.
14:20
Now salivary gland tissues is typically seen in the major
14:24
salivary gland, so it's typically seen in the parotid gland,
14:28
it can be seen in the submandibular gland
14:30
and so on and so forth.
14:32
But when we actually look in the head
14:35
and neck, you can have the small little areas
14:38
of salivary gland tissues that get lost
14:41
and they wind up in very strange areas.
14:44
And some of those areas
14:45
where they can arise includes the oral tongue.
14:48
Here we have an illustration of the circum valley papilla
14:51
and they can also arise in the tongue base.
14:55
So as a result we can actually have various types
14:58
of minor salivary gland tumors
15:00
that arise in the tongue base.
15:02
So this is an example of adenoid cystic carcinoma,
15:05
and this is an example of a polymorphous adenocarcinoma
15:09
that we just recently saw.
15:11
So the thing is, from our standpoint, there's really no way
15:14
that we can differentiate squamous cell carcinoma
15:18
from lymphoma from these minor salivary gland tumor.
15:22
So our job is just to confirm that there is a mass there
15:25
that our physicians may see or palpate
15:28
and really to determine the full extent of the disease.
15:31
But again, from our standpoint,
15:33
there's no way to be specific.
15:35
But on the other hand we can include this in our
15:37
differential diagnosis.
15:39
So those are the three main tumors
15:41
that involve the tongue base.
15:43
Now let's talk about some congenital lesions
15:45
that can involve the tongue base.
15:48
In order to do this, we'll talk about the thyroid gland.
15:52
So the thyroid gland starts right here at the tongue base at
15:55
the level of the foramen cica.
15:58
It then has this relative descent in the neck
16:00
and it has this complex relationship
16:03
with this bone right here, which is the hyoid bone.
16:06
So here we can see the descending thyroid gland on top
16:11
it courses anteriorly, then it can actually go
16:14
behind the hyoid bone
16:15
and eventually it ends up in its resting space down here,
16:19
which is in the anterior portion of the neck.
16:21
So in the context of this talk,
16:24
we're gonna limit our discussion to those thyroid remnants
16:27
that are stuck, if you will, involving the tongue base.
16:31
So if we see a cystic mass right here
16:34
that's located in the tongue base, then this is
16:37
what we refer to as a thyroid gloss duct cyst.
16:41
And as a result, the type of surgery that's performed
16:44
by our surgeons is called the cyst trunk procedure,
16:47
where they take a cuff of the tongue base
16:50
and they always want to extend all the way down
16:52
to the anterior neck.
16:53
And this surgery is still the classic procedure
16:56
when they try to remove thyroid remnants such
16:59
as thyroid gloss duct cyst.
17:02
Now this on the other hand is not a fluid containing
17:06
structure, but these are actually
17:08
examples of lingual thyroid.
17:10
So in this particular case we can see this focal area
17:13
of increased attenuation,
17:15
this increased attenuation mass located at the tongue base.
17:18
This is actually lingual thyroid.
17:21
And on this non-contrast study,
17:23
what we see here is the high attenuation that's due
17:26
to iodine being concentrated in that lingual thyroid gland.
17:30
Now when you do give contrast,
17:32
this lingual thyroid is hypervascular,
17:35
and that's what we typically see in the thyroid gland.
17:37
We know the thyroid gland typically enhances with contrast.
17:40
So here we have robust enhancement here,
17:43
located right at the expected location
17:45
of the frame and secum.
17:47
And then when we look down in the anterior neck, we can see
17:49
that there's no masses at all
17:51
and no normal thyroid gland where it should be located.
17:55
So this is just confirmatory
17:56
that this large mass right here is in the lingual thyroid.
18:01
So that's the oropharynx.
18:03
And we specifically talked about the tongue base was
18:06
everything anterior here to the cir, uh, everything
18:09
that's posterior to the circum valley papilla.
18:12
Now what we're gonna do is
18:13
that we're gonna begin our discussion of the tonsil.
18:17
So when we talk about the tonsil,
18:19
there are specifically three components of the tonsil.
18:23
So when we look at the tonsil, the main part
18:25
of the tonsil right here,
18:26
where this lymphoid tissue is located has
18:29
a couple of names to it.
18:30
It can be either called the palatine or the fascial tonsils.
18:34
And for those of you that have ever had a tonsillectomy,
18:37
it's this part of the tonsil that's been removed.
18:40
So in general, we tend to lump all the tonsil together, but
18:44
because we're specifically talking about the oral pharynx
18:47
and if we really want to convey to the surgeon
18:50
that we're talking and using the same language, just realize
18:53
that there's a component of the tonsil here,
18:56
which is called the anterior tonsor pillar.
18:58
And there's a component posteriorly,
19:01
which is called the posterior tonsor pillar.
19:03
When we look deep to the tonsil,
19:05
it is located in this capsule.
19:08
And just deep to this capsule
19:10
is this superior constrictor muscle.
19:13
So this superior constrictor muscle forms a
19:16
lateral pharyngeal wall.
19:17
Now when you look posteriorly, we'll come back
19:20
to this a little bit later,
19:21
this is the posterior pharyngeal wall.
19:23
But now we're just gonna concentrate on this area here.
19:27
Now some of the applied anatomy that you have to be familiar
19:30
with is that this anterior tonsor pillar is in close
19:34
proximity to this superior constrictor muscle.
19:37
This constrictor muscle can extend anteriorly
19:39
and in interdigitates with the bator muscle
19:43
to form this little area right here,
19:47
which is the tego mandibular.
19:50
And just medial to this is the retromolar trigone.
19:53
So these areas right here are actually in the oral cavity,
19:57
whereas this anterior tonsor pillar is in the oral pharynx.
20:02
And this is formed by the muscle that goes in the palate
20:05
to the tongue base, which is the pelvic gloss muscle.
20:09
Now you always ask that question, well, so what you know,
20:12
why is SSH going on all of this stuff, this big tangent?
20:16
And the reason is, is
20:18
that you can have different cancers involve different
20:21
anatomical components.
20:23
So this is an example of a tumor
20:25
that's involving the anterior tonsor pillar.
20:28
So why does that make a difference?
20:30
It makes a difference between this anterior tonsil pillar
20:34
extends inferiorly along the palatal gloss muscle
20:38
to involve the tongue, but notice the location,
20:41
it's pretty anterior.
20:43
Now this tumor can extend deeply,
20:46
it can jump on the superior constrictor muscle
20:49
and then grow right here to the tego Mando ra.
20:53
The reason why that's important
20:54
because if the surgeons try to just resect this tumor here,
20:58
let's say they wanted to do a transoral robotic surgery,
21:01
this tumor is growing along this muscle to thera
21:05
and it's very possible they would have a positive margin.
21:09
I know with me in our tumor board,
21:11
if I have a tumor in the anterior tonsor pillar
21:14
and I tell our surgeon this,
21:16
it's growing anterior laterally along this buccinator
21:19
muscle, they're not gonna treat this
21:21
with transoral robotic surgery.
21:24
Similarly, oftentimes in these specific areas it's really
21:28
important to test for HPV
21:30
because a certain percentage
21:32
of these are not gonna be HPV positive,
21:35
they would actually be HPV negative
21:37
because this little muscle right here is a transition zone
21:40
between the oral cavity and the oral pharynx.
21:43
So this is a really tricky area,
21:46
but I specifically wanted to mention this
21:48
because we are talking
21:49
and having a dedicated talk on the oral pharynx.
21:53
So when you actually look in someone's mouth,
21:56
you can see this, I don't know if you're by yourself
21:58
or maybe you're sitting with a friend,
21:59
but if you wanna get to know 'em, have 'em open their mouth.
22:02
So when you open your mouth, this little anterior fold
22:05
of tissue corresponds with the anterior tonsor pillar.
22:09
Now as you're opening your mouth,
22:11
you can look at another tonsor pillar, which is posterior,
22:15
and this is what we refer to as the posterior tonsor pillar.
22:19
This posterior tonsor pillar is comprised by a muscle
22:23
that goes from the palate to the pharynx,
22:27
hence the name pal PHNs muscle.
22:29
Now these tumors are pretty rare.
22:32
I've only seen a handful that were actually felt
22:35
to be arising from the actual palolo pharyngeal muscle
22:39
or the posterior tonsor pillar,
22:41
but this just happens to be one of them.
22:43
And notice how this tumor is located much more posteriorly
22:47
than the anterior tonsor pillar.
22:49
So again, this is more of a much rarer tumor
22:52
and I, we honestly, I don't spend too much time on this
22:54
because the bulk of the tumors that we'll end up seeing
22:59
are arising from this part of the tonsil, which is referred
23:02
to as the fossils or the palatine tonsil.
23:05
So when we look at this specific piece of anatomy,
23:09
this is comprised of the lymphoid tissue
23:11
that waldy described in wall dyer's ring.
23:15
So when we look at this tissue,
23:17
it's located in the tonsor fossa
23:19
and this is where approximately 90%
23:23
of squamous cell carcinomas arise from.
23:26
So this is an example of a schematic illustration
23:29
of squamous cell carcinoma involving the tonsil.
23:32
So this is the schematic illustration.
23:34
Here's what you normally see.
23:36
And this is an example
23:37
of squamous cell carcinoma involving the
23:40
left fascial tonsil.
23:42
Now if you're reading out a study,
23:45
oftentimes you're gonna say, well,
23:47
it's a squamous cell carcinoma
23:49
and you've made the diagnosis and you're done with it.
23:52
But because you know we're specifically spending this time
23:55
on the oral pharynx, what I wanna do
23:58
is really focus on the information
24:00
that's really gonna make a difference in these patients.
24:03
Because quite frankly, oftentimes the surgeons
24:07
and the radiation oncologists already know the patient has
24:11
a squamous cell carcinoma.
24:12
The tonsil from their standpoint,
24:15
the main decision they need to make.
24:17
And you especially God forbid, this should happen to you,
24:20
is this something that I can treat with surgery
24:23
and do a tonsillectomy maybe
24:25
through a transoral robotic surgery?
24:28
Or is this something that should be treated
24:30
with radiation and chemotherapy?
24:32
And this is really where we add our specific value.
24:36
So this is an example of an exophytic tonsor carcinoma
24:40
and you can see that there's no deep extension.
24:43
So if we see something like this,
24:44
and this is the type of patient that can be treated
24:48
with a standard tonsillectomy or potentially TAs.
24:52
Now this is another example of a patient
24:54
that has a tonsor carcinoma.
24:57
So if you make the diagnosis of tonsor carcinoma
25:01
and say it's squamous cell, well that's good
25:03
and congratulations.
25:05
But let's talk a little bit more what are the things
25:07
that's gonna make a difference from a treatment standpoint.
25:11
So notice how this squamous cell carcinoma is extending
25:15
inferiorly into this space that's next to the pharynx.
25:19
And what do you call the space that's next to the pharynx?
25:21
Well that's the para pharyngeal space.
25:23
So the normal para pharyngeal space is this triangular space
25:27
that's just deep to the pharynx.
25:29
Notice how on the left hand side this tumor's extending
25:32
deeply and is obliterating the normal appearance
25:36
of the left para pharyngeal space.
25:39
So if I say this to our surgeons,
25:42
then these patients are not gonna be treated with surgery,
25:46
but they're typically gonna be treated with chemotherapy
25:48
and radiation therapy
25:49
because these tumors are predominantly HPV positive.
25:53
Another example here, look at the little apex right here.
25:56
Look at this sharp line right here that's between the fat
25:59
and the lateral and the medial oid muscle.
26:02
Notice how that's obliterated.
26:04
So if I tell the surgeons this again,
26:07
they again are gonna be a little bit hesitant
26:09
because in order to get a margin they may have
26:12
to take a piece of this muscle, which can be very hard to do
26:15
through transoral robotic surgery.
26:17
And notice how this tumor is actually growing anteriorly.
26:21
Notice my favorite stripes right here.
26:23
I always talk about my tiger stripes.
26:25
Everyone gives me a hard time about this,
26:26
but you can see the gray that you can see the black,
26:29
then you can see the gray.
26:30
So you see some nice tiger stripes on
26:33
the patient's right side.
26:34
And notice how these tiger stripes on the patient's left
26:37
side are obliterated
26:38
and this is all tumor
26:39
that's extending anterior laterally along
26:42
that superior constrictor muscle.
26:45
So these are three specific areas of spread patterns
26:48
and when you look at this image on the left, you can uh,
26:51
we've sort of indicated these
26:54
that's gonna make a difference on whether these patients can
26:56
be treated with surgery
26:58
or maybe better treated with chemotherapy
27:00
and radiation therapy.
27:03
The other thing too is that when we're looking at this,
27:06
this is a patient that's had a to a right side
27:09
of tonsillectomy
27:10
and this is a patient with squamous cell
27:12
carcinoma on the left.
27:14
And the reason I show this is
27:15
that this is something again we counter every day.
27:19
So if you're looking at something like this
27:21
and you're like, oh my gosh,
27:22
does this patient have a left sided squamous cell
27:24
carcinoma involved with the tonsil?
27:26
You know, draw a line down the middle,
27:28
compare one side to the other side.
27:30
So it is important to mention this asymmetry in the mass,
27:33
but just realize the surgeons
27:35
and the radiation oncologists can look directly in the mouth
27:39
and in this case that they can see this tumor,
27:41
this exophytic tumor
27:42
that's staring them literally in the mouth
27:45
and pun intended for that one.
27:47
And this corresponds to this squamous cell carcinoma.
27:50
So the point being, if I see something like this,
27:53
I'll go ahead and mention the asymmetry,
27:55
but knowing that you can look in someone's throat,
27:59
the surgeons can look directly and look at the tonsils
28:03
and palpate them
28:04
and determine which is the residual uh,
28:08
fascial tonsil in a patient
28:09
that had a right sided tonsillectomy.
28:11
So this is just retained lymphoid tissue on the left versus
28:15
squamous cell carcinoma on the left.
28:17
So remember the majority of
28:19
what we can see in the visceral space can be seen
28:21
through endoscopic evaluation.
28:25
Now we're gonna return to my friend here, uh, waldy
28:28
and remember Wal Dyer's ring,
28:30
we talked about the lingual tonsil here,
28:32
but remember there's lymphoid tissue here
28:35
that's involving the tonsils.
28:37
So as a result,
28:38
when we're putting together our differential diagnosis
28:41
for tumors involving the tonsils,
28:43
the second most likely is going to be lymphoma.
28:46
So this is an example of tonsil lymphoma
28:49
and this was a patient that has massive lymphadenopathy
28:52
due to lymphoma.
28:54
So in this particular case we're not gonna be able
28:57
to make a specific histologic diagnosis,
28:59
but what we can comment on on the asymmetry
29:03
and then when the surgeons look in,
29:04
they can see this mass extending into the visceral space,
29:07
they can see it's large and then they can take a biopsy.
29:11
So really our job is to confirm
29:13
that there is a mass involving the left tonsil
29:16
and it's really gonna be up to the surgeon to confirm it
29:19
and then also the pathologist
29:20
to give you the specific diagnosis.
29:24
Now part of the challenge
29:25
that you run into when you have various lesions involving
29:28
the tonsils and especially in infections is they can be
29:32
pretty confusing.
29:34
So this was a patient that we ended up seeing in our clinic
29:39
about a year ago.
29:40
This patient was um, seen, had a bit of a sore throat
29:44
and on an outside CT scan on a head ct actually it was
29:48
noticed that there was some fullness in the tonsil.
29:51
So they came to our clinic, we did a regular neck ct and lo
29:54
and behold we see this large mass involved in the tonsil
29:58
and you can see how it's obliterating the
30:00
para pharyngeal space.
30:02
So when we looked at it, the surgeons looked at it
30:04
and I actually saw this patient too.
30:06
We couldn't see a mucosal lesion
30:08
and when they palpated it was completely soft.
30:11
There was no focal mass at all.
30:13
So we kind of wondered about this
30:15
because in general patients
30:17
with tonsillitis have a pretty hot tonsil
30:20
but we decided just to wait.
30:22
And then lo and behold,
30:23
about two months later the patient came back
30:26
for a repeat Mr, we were sort of suspicious of tonsillitis,
30:29
the patient was put on antibiotics and lo
30:32
and behold we can see that
30:33
that mass right now is completely resolved
30:36
and now we can see a normal para
30:38
pharyngeal space on the right.
30:39
So this was an example of a tonsillitis
30:42
that was mimicking squamous cell carcinoma.
30:46
Now the most common scenarios that you'll see are patients
30:50
that end up having these infections involving the tonsils
30:53
and if they become really severe they can end up developing
30:57
these peri tonsor abscesses.
31:00
Now I've seen both the term peron abscess
31:03
and tonsor abscess used.
31:04
I try not to get into the debate either.
31:07
Either one of these are fine,
31:09
but what's most important is
31:11
that if you do see a fluid collection involving this
31:16
hairA region, it is important
31:18
to properly place this in the correct location.
31:21
So if we draw a line down the middle, compare the right side
31:24
to the left side, this is the normal left tonsil
31:27
and this is the para pharyngeal space.
31:30
Now this is normal in this patient.
31:32
Now on the right hand side
31:33
what we see is diffuse enlargement of the tonsil
31:37
with low attenuation involving the tonsil.
31:39
So this abscess right here is actually located in the tonsil
31:44
In this particular case, draw a line down the middle,
31:47
compare the right side to the left side.
31:48
Here's the normal tonsil here
31:51
and this is the para pharyngeal space.
31:53
In this case we can see
31:55
that this fluid collection is located in the para pharyngeal
31:58
space and the tonsil is not involved.
32:01
Why does that make a difference?
32:03
Well, it makes a difference even though it's just a
32:05
centimeter or so from here to here.
32:08
If we say that this is located in the tonsil,
32:11
then this can be drained through an intraoral approach.
32:15
But on the other hand, if this is a peri in the an abscess
32:19
in the para pharyngeal space,
32:21
then this requires a cervical approach.
32:24
So we as a radiologist, when we're looking in this area,
32:27
it's incredibly important if we see something like this
32:30
to properly place it either in the tonsil
32:33
or in the para pharyngeal space
32:35
because it directly affects how these abscesses are drained.
32:41
Now those were acute infections.
32:43
What ends up happening is that you can have
32:46
tonsillitis that's chronic.
32:48
And I can attest to this
32:49
because when I was a kid I would always have strep throat.
32:53
It was terrible. My parents always wanted
32:55
to be get my tonsils out, but I would run and scream
32:58
and shout and I was always able to get away with it.
33:01
So I never had my tonsils taken out.
33:03
But if you do have chronic infections involved in the
33:07
tonsils, what can happen is first
33:09
of all they can look kind of ugly.
33:11
These actually, you can see a
33:12
little bit of enhancement here.
33:13
This is just as severe case
33:16
of chronic infections involving the tonsils.
33:19
And you can obviously see these calcifications here which
33:23
correspond to these calcifications that we refer
33:26
to as tonsils.
33:27
So this is an example
33:28
of chronic inflammation of the tonsils.
33:30
In this case it's bilateral tons, its,
33:33
and in this particular case we can see the string
33:36
of pearls if you win involving one tonsils.
33:39
So not only can tonsils be bilateral,
33:41
but they could be multiple
33:42
and they can be unilateral as well.
33:44
And again, just as sequela of a chronic infection.
33:48
Now this can be a fuller here we're looking in the right
33:51
tonsil in the lateral wall of the pharynx
33:53
and we see this diffuse thickening involving the right neck.
33:57
And when we look in the para pharyngeal space,
33:59
we can see this obliteration
34:01
and we can see all of this hematoma
34:03
and subcutaneous thickening.
34:05
And this was an example of trauma.
34:07
So this patient had a severe trauma to the right neck
34:11
and as a result developed this large
34:13
hematoma involved in the tonsil.
34:15
Now if you looked at this on your own,
34:18
we really couldn't separate an infection from trauma.
34:21
But certainly in situations like these,
34:23
when you see something this extensive,
34:25
you should always try to get the history.
34:27
This was just an example of diffuse edema
34:30
and hematoma involving the right tonsil.
34:34
Now one of the things that I've learned over time,
34:36
and you guys may have heard me say this, is that um,
34:39
good judgment comes from experience
34:41
and experience comes from bad judgment.
34:43
So when we start looking at this specific disease here,
34:48
this specific entity,
34:49
this is a type two brachial cleft cyst.
34:52
So I always felt that second brachial cleft cysts
34:55
were always like this.
34:56
But in actuality there are different types
34:59
of brachial cleft cysts.
35:00
So when I was a resident,
35:02
I was always taught in my pediatric rotation
35:04
that you can have fistulas that go from the tonsil laterally
35:08
and those were second brachial cleft cysts.
35:10
But more commonly I'm used
35:12
to seeing second brachial clefts like cysts like this.
35:15
Well in actuality there are different types
35:18
of second brachial cleft cyst
35:20
and different types of second brachial cleft cyst can have
35:23
fistulas that extend from the tonsil
35:26
and extend through the carotid space
35:29
and extend laterally between the plane
35:31
of the carotid and the jugular vein.
35:34
So this is an example
35:35
of a type three second brachial cleft cyst.
35:38
So if you've ever seen that fistula
35:40
that extends from the tonsil extends out to the skin,
35:43
this is an example of a type three second
35:45
brachial cleft cyst.
35:47
Now if you have that brachial cleft cyst that is medial
35:50
to the plane of the carotid and the jugular vein
35:52
and adjacent to the airway,
35:54
then this is actually a type four brachial class cyst.
35:58
Now oftentimes when we look at the tonsils,
36:01
we'll stay well this is probably a retention cyst
36:04
or post-inflammatory or so on and so forth.
36:07
But just remember when we have the cysts
36:09
that are located in the tonsil, a certain percentage
36:12
of these are gonna be a remnant of a specific type
36:16
of second brachial cleft cyst.
36:18
And that is a type four brachial cleft cyst.
36:21
So this is our some of the more unusual congenital
36:24
or developmental lesions that can involve the consular.
36:28
So the next area that we'll talk about is the soft palate.
36:34
So when we look at the soft palate,
36:36
we already talked about the anterior tonsil pillar, the
36:39
and the posterior tonsil pillar and the and the tonsil.
36:43
But when I think of the soft palate,
36:45
what I always end up thinking about is this palatal arch.
36:48
So when we talk about the palatal arch,
36:50
we have these muscles extending superiorly
36:53
and then we have this arch of tissue
36:55
and this arch of tissue forms a soft palate.
36:58
We're all familiar looking
36:59
with the soft palate on the sagal images.
37:02
It's this floppy piece of mucosa
37:04
and muscle right here that ends in our little area right
37:07
here that's called a uvula.
37:09
The primary muscles that heather,
37:12
the soft palate are two Italian muscles
37:15
and these are the tensor
37:17
and the levator ve palatini muscles.
37:20
So this is the tensor veli palatini muscle.
37:22
Here we see the tensor here
37:24
and this is the lator veli palatini which l which
37:28
raises the soft palate.
37:30
So when I think of the soft palette, I always think
37:32
of the Roman arch.
37:34
So the lateral walls right here are the tonsor pillars,
37:38
the tonsor pillars that we talked about.
37:40
Then you have this communication with the soft palette
37:43
and eventually the soft palette has
37:45
to be tethered to the skull base.
37:47
And this skull base for me, this tethering is formed
37:50
by these tensor and levator veli palatini muscle.
37:54
So this is what we refer to as I think of the palatal arch
37:58
and how it's tethered
37:59
through the skull base through those muscles.
38:02
So when we think of tumors involving the soft palate, again,
38:06
like anything else, the most common tumor is going
38:09
to be squamous cell carcinoma.
38:11
So this is an example of a squamous cell carcinoma we we
38:14
just saw in clinic two weeks ago
38:16
and we can see that it's hanging from that soft palate.
38:19
Now a couple things about soft palate carcinomas that I want
38:22
to emphasize because it's oral pharynx,
38:25
they're gonna be HPV positive.
38:27
The second thing about soft palate carcinomas is
38:30
that if we go back to this slide right here,
38:33
this soft palate goes from the right side to the left side.
38:36
It's not like the tonsil is on one side
38:39
or the floor mouth is on one side rather
38:42
this soft palate goes from one side to the opposite side.
38:45
So when we do have these soft palate carcinomas, they tend
38:49
to grow circumferentially.
38:50
So this is an example of a soft palate carcinoma.
38:53
Notice when your eyes see something, we tend
38:56
to compare right to the left,
38:57
but this is more circumferential.
38:59
So sometimes soft palate carcinomas can be difficult
39:03
to detect on axial images.
39:05
So it's always important to look at the sagittal
39:07
and the corona images 'cause that'll help
39:09
us better define it.
39:11
So number one, they should be HPV positive
39:14
'cause they're oral pharynx.
39:15
Number two, sometimes they can be challenging
39:18
to identify in axial images.
39:20
And then number three,
39:21
these soft palate cancers have a tendency to metastasize
39:25
to the retro pharyngeal lymph nodes.
39:27
So this is an example
39:28
of a metastatic retro pharyngeal lymph node
39:31
that was clinically occult
39:33
that metastasized from a soft palate carcinoma.
39:36
So when you're looking at the soft palor, if for
39:39
that matter, anywhere in the oral pharynx, you always want
39:42
to see whether or not these retro pharyngeal
39:44
lymph nodes are involved.
39:46
The other thing about soft palate carcinomas is
39:50
that they can actually extend superiorly
39:52
into the nasal pharynx.
39:53
So we talked about this spread inferiorly,
39:56
but realize these soft palate carcinomas
39:59
can grow superiorly.
40:00
So here's an example
40:01
of a soft palate carcinoma in which you don't know at times
40:05
is how much is it extending superiorly.
40:08
So when we look at this area here involved
40:10
with the nasal pharynx, this is our tors tobar,
40:13
this is our opening eustachian tube
40:15
and this is the sssts of Rosen Mueller.
40:18
We're all lying down the middle.
40:19
Compare the right side to the left side
40:21
and notice the left tors tobar is diffusely thickened
40:25
and this is squamous cell carcinoma growing
40:28
superiorly up into the nasal pharynx.
40:30
Another example here, here's the TAUs tube barus.
40:33
This is all this tumor growing on the TAUs tube barus
40:37
and oftentimes this tumor is clinically occult.
40:40
So if the surgeons ever contemplated about resecting a soft
40:45
palate carcinoma, which occasionally does happen
40:48
if we tell them that this tumor is growing superiorly into
40:51
the nasal pharynx and these patients are certainly gonna be
40:54
treated with chemotherapy
40:55
and radiation therapy in the majority of institutions.
41:00
Now when we look at the soft palate,
41:02
we also have a higher incidence
41:04
of these minor salivary gland rests.
41:08
So the next most likely tumor
41:10
to involve the soft palate is not gonna be lymphoma,
41:14
but it's gonna be minor salivary gland tumors.
41:17
Remember lymphoma to tissues in the mula and the tongue base
41:20
and the tonsils, but there's very little lymphoid tissue
41:23
involved in the soft palate.
41:25
So the second most likely tumor is going
41:28
to be a minor salivary gland tumor.
41:30
Now this is an example
41:31
of pleomorphic adenoma involving the soft palate
41:35
and this is an example
41:36
of adenoid cystic carcinoma involving the soft palate.
41:39
Again, there's really no way for us to differentiate this.
41:44
If you did see a tumor involved in the soft palate
41:46
and it was high signal on T two,
41:48
as we could see in the paric gland,
41:50
well we could suggest the diagnosis.
41:53
But in general when we these patients present, it's really,
41:58
really hard to differentiate.
41:59
So we just have to include this in our
42:02
differential diagnosis.
42:04
There are some lesions that are specifically unique in
42:08
children that we may see involving the soft palate.
42:11
This is an example of a fatty lesion
42:14
that's involving the soft palate.
42:15
This happened to be a dermoid involved in the uvula.
42:19
This was a patient that had a vascular malformation in this
42:22
case it was a low flow vascular malformation
42:24
and represented a lymphatic malformation.
42:28
And this unfortunately was the most common soft tissue
42:31
malignancy to involve the soft palate
42:34
and this was rhabdomyosarcoma.
42:36
So there are some unique things
42:38
that oftentimes present in children involved in the soft
42:41
palate that we have to wear about.
42:43
We can make this diagnosis
42:45
because we can see the fatty component.
42:47
If we see something in the soft palate
42:49
that's high T two signal and involves multiple spaces
42:54
and it's soft and pliable,
42:55
we can suggest the vascular malformation.
42:58
And unfortunately in something like this,
43:00
I think it's if you see this in a child, uh,
43:02
and it's solid, then you really have
43:05
to raise the possibility of rhabdo, my sarcoma.
43:09
And then the last area
43:10
that we'll end up talking about involving the oral pharynx
43:14
is the posterior pharyngeal wall.
43:16
Now this posterior pharyngeal wall is an important area,
43:20
but it oftentimes doesn't get the love that it requires.
43:23
We spend a lot of our time talking about the tongue base,
43:26
the tonsil and the soft palate,
43:28
but this posterior pharyngeal is a pretty important area
43:32
that we will pay a little bit of attention to now.
43:35
So when you look at the posterior pharyngeal extends all the
43:38
way up to the skull base all the way down here to the base
43:42
of the crico cartilage.
43:44
Now this area
43:45
that we are talking about today is the oral pharynx
43:49
and it's predominantly comprised of this constrictor muscle,
43:53
which is the superior constrictor muscle.
43:56
So the anatomy of the posterior pharyngeal wall is mucosa
44:00
it's muscles and predominantly it's the superior constrictor
44:04
muscle with the bar
44:05
to the middle constrictor muscle forming
44:07
the most inferior portion.
44:09
And the innervation is from the pharyngeal plexus.
44:12
And remember the embryology of the pharynx.
44:15
Remember cranial nerves nine and 10.
44:16
Hopefully that's a little takeaway for you
44:18
because the pharynx is formed by the third
44:21
and the fourth brachial arch.
44:22
And nine is the nerve for the third
44:24
and 10th is the nerve for the fourth.
44:26
So we can always remember that the innervation
44:29
for the pharynx is gonna be the ninth
44:31
and the 10th cranial nerve and the pharyngeal plexus.
44:36
So just to review what we talked about,
44:38
this was a circum valley papilla.
44:40
This was frame and seum. This was the tongue-based.
44:43
When we went laterally,
44:44
this part was the tonsil anterior tonsil pillar,
44:48
posterior tonsil pillar, fascial tonsil.
44:51
And deep to this was a superior constrictor muscle.
44:54
Now if we follow the superior constrictor muscle
44:58
posteriorly, notice how it makes this 90 degree turn.
45:01
And this same muscle forms the posterior pharyngeal wall.
45:05
So it's all continuous,
45:06
but it's this segment from here to here
45:09
that we consider the posterior pharyngeal wall.
45:13
So the most common tumor
45:15
that we end up seeing in the posterior pharyngeal wall again
45:19
is gonna be squamous cell carcinoma.
45:21
And the majority of these are gonna be are HPV positive.
45:25
Now these tumors that are limited
45:27
to the posterior pharyngeal wall are overall pretty rare
45:31
and quite frankly these can be seen pretty easily.
45:34
So the surgeon can look in
45:36
and they can see this large tumor involving the
45:39
posterior pharyngeal wall.
45:41
So from our standpoint, what is some information
45:44
that we need to provide?
45:46
First of all, if we see this tumor involving the posterior
45:49
pharyngeal wall, we want to see whether
45:51
or not the retro pharyngeal lymph nodes are involved.
45:54
So if these retro pharyngeal lymph nodes are involved,
45:57
then the surgeons if they wish
45:59
to resect this squamous cell carcinoma are gonna have
46:02
to take out these lymph nodes.
46:05
Secondly, one of the true contraindications for resection
46:10
of posterior pharyngeal wall squamous cell carcinomas is if
46:14
these tumors invade the paraspinal muscles.
46:17
And these are the longest coline muscles
46:19
and we can do this with a relative degree
46:22
of confidence on mr.
46:24
So this is an example
46:25
of a posterior pharyngeal wall carcinoma
46:28
and we can see normal appearance
46:30
of the longest coline muscles,
46:32
but in this case another posterior
46:34
pharyngeal wall carcinoma.
46:35
And when we look at the T two weighted images, we can see
46:38
edema here involved in the longest coline muscles.
46:42
So if we see edema involving the longest coli muscles,
46:46
this is usually indicative of direct invasion.
46:49
And if we see this then that is a reason
46:52
that the surgeons will not operate on these patients.
46:54
So if you see that, as I mentioned
46:57
before, it's a direct contraindication,
46:59
in the old days the surgeons would go in
47:02
and try to wiggle the posterior pharyngeal wall.
47:04
This was before the days of mr,
47:06
but I gotta tell you, most surgeons I talk to now
47:09
are asking us to perform MR to see if we see any edema.
47:13
So you know, if things certainly have changed
47:15
over the last few years.
47:18
Now what are some other tumors
47:19
that can involve the posterior pharyngeal wall?
47:22
Again, number one is going to be squamous cell carcinoma.
47:26
Now these are some example of some other tumors
47:29
that can involve the posterior pharyngeal wall.
47:32
Again, they're nonspecific, you know if you are from Africa
47:36
or if you have a patient that's HIV positive.
47:39
Occasionally you can see this.
47:40
This is an example of kacy sarcoma.
47:43
If you saw this in a child, well again, the most common head
47:47
and neck malignancy in the child is going
47:50
to be a a soft tissue malignancy is gonna
47:52
be rhabdomyosarcoma.
47:54
And again, this is an example if you're from an endemic
47:57
area, this is an example
47:58
of burkis lymphoma involving the posterior pharyngeal wall.
48:02
So again, they're non-specific appearance.
48:04
In the US we don't see caps or burkis that much, but
48:08
because we do have a global audience,
48:10
you know if you are in an endemic area for caps
48:13
or burkis, especially from Africa, this is something
48:16
that you may end up seeing in your practice.
48:20
You can have a variety of congenital
48:23
or developmental lesions
48:24
that affect the posterior pharyngeal wall.
48:27
Now this is something that I commonly see
48:29
and this was a case that I just had on Monday.
48:31
This patient presented with dysphagia.
48:34
So we always want to exclude a squamous cell carcinoma,
48:38
but remember if you get, as you get older,
48:40
you can develop these big osteophytes.
48:43
So this is an example of a large osteophyte
48:46
that's resulting in mass effect involving the posterior
48:49
pharyngeal wall that's resulting in the dysphagia.
48:52
So it's not necessarily arising in the posterior pharyngeal
48:55
wall, but it's certainly displacing it.
48:57
Here's an example of a page that again that can present with
49:01
dysphagia or sometimes the surgeons will look down
49:05
and they'll see a submucosal mass
49:07
and they're not sure whether it's palle,
49:09
whether it's pulsatile.
49:11
So what we always wanna do to see is whether
49:13
or not this carotid artery can sometimes be ectatic
49:18
and extend into the retro far andal space.
49:20
And this is the reason this patient has this submucosal mass
49:24
involving the posterior pharyngeal wall.
49:26
Certainly you don't wanna biopsy that
49:28
'cause that would be a disaster,
49:30
but that's something we always want
49:31
to include in our reports.
49:33
And this was an example of a patient
49:35
that has a large fluid collection
49:37
and this was a large calcification which was alet.
49:41
So occasionally you can have vascular malformations,
49:44
in this case a low flow vascular malformation extend into
49:48
that retro pharyngeal space.
49:51
Now the most, one of the most common things
49:53
that you'll end up doing is
49:54
that if you do have a posterior pharyngeal wall tumor,
49:58
as is seen here, as I mentioned
50:00
before, these patients are oftentimes treated
50:02
with chemotherapy and radiation therapy.
50:05
So this is pre-treatment.
50:07
Then after treatment
50:08
what we have is the expected post-treatment changes
50:11
of the posterior pharyngeal wall.
50:13
So what we have here is diffuse soft tissue thickening
50:16
involving the posterior pharyngeal wall.
50:19
And if you look deep to this, this is just edema.
50:22
So this is not recurrent tumor
50:24
because these findings are symmetric, rather,
50:27
this is just thickening
50:28
and radiation changes following high dose radiation
50:31
and chemotherapy with underlying VA
50:35
with underlying edema involving the retro pharyngeal space.
50:40
Now you can have certain infections
50:42
that can involve the posterior pharyngeal wall.
50:44
This is an example of fungus.
50:47
Now for all the world,
50:48
to me this looks like squamous cell carcinoma.
50:50
So if I looked at this
50:52
and I said, wow, this looks really bad, like squamous cell,
50:55
it very well could be,
50:56
but it's really up to the surgeons to look down
50:59
and look at this and also correlate it
51:01
with any clinical findings.
51:03
It's possible the patient can have a really,
51:05
really sore throat.
51:06
They may be immunocompromised or other predisposing factors.
51:11
And this was an example of a diffuse fungal pharyngitis.
51:14
This was most likely Canada.
51:16
So in untreated Canada we could see something like this.
51:20
And if in fact these infections are not properly treated,
51:24
these infections involving the posterior pharyngeal wall in
51:28
a different case can actually pierce through
51:31
and form a fistula into the retro pharyngeal space.
51:35
So this was a patient that had an untreated
51:37
and infection involving the posterior pharyngeal wall.
51:40
This patient developed a fistula
51:43
and unfortunately developed an abscess involving the retro
51:46
pharyngeal space.
51:48
And we can say, I see
51:49
how it's displacing the posterior pharyngeal wall
51:52
an anteriorly.
51:53
So again, a bit of a rare complication,
51:55
but it's something we should always keep in mind.
51:59
So in summary, what we did over the last 15 minutes
52:02
or so is that we talked about our friend, the oral pharynx.
52:06
And so what I wanted to leave you with was
52:08
that remember the oral pharynx is this rectangular area in
52:11
the posterior portion of your mouth.
52:14
We talked about those four areas involved in the tongue
52:17
base, the soft palate, the tonsil,
52:19
and the posterior pharyngeal wall.
52:21
And my hope is that over the last af the last 50 minutes,
52:25
you have a better understanding of the anatomy of this area
52:28
and you have a better understanding
52:30
of a differential diagnosis that's gonna allow you
52:32
to take better care of your patients.
52:34
So thank you very much for your attention
52:36
and I'm happy to answer any questions.
52:39
Thank you so much for that awesome lecture Dr. McCury.
52:42
We will open the floor to questions.
52:43
So if you've got one, go ahead
52:45
and toss it into that q and a feature.
52:48
And there is one in there already, Dr.
52:50
McCury, if you wanna pop that open. Okay.
52:53
Or I can read it to you. You tell me.
52:55
Uh, let's see, where should we start here?
52:58
Um, should we start?
53:00
You, you, uh, go ahead
53:01
and read the first one so I
53:03
know where you're starting from, Ashley
53:04
For sure. Um,
53:05
is there any role for spectroscopy, excuse me,
53:08
in evaluating head and neck masses?
53:12
Yeah, um, that's a good question.
53:13
I mean I spent probably 20 years of my career
53:16
doing MR Spectroscopy, the head and neck.
53:19
Um, the challenge with head and neck.
53:21
So I mean there is a role if you have a patient
53:23
that can hold still
53:24
and then you can place your voxel in the exact location.
53:28
And the biggest challenge with head
53:30
and neck, uh, specifically neck spectroscopy is the motion
53:34
and then also the interfaces
53:36
because if you are performing MRS of the head
53:39
and neck, the spectroscopy does not like various interfaces
53:43
and it doesn't like bone and it doesn't like air.
53:46
So the challenge that we ran into spectroscopy,
53:49
especially when we were trying to do two dimensional CSI, is
53:53
that when we took our overall voxel, if we included
53:57
that voxel air, bone
53:58
and soft tissue, it would end up giving us a
54:01
really poor shim.
54:03
So as a result it wasn't very helpful.
54:05
But if you do have a patient that can hold still
54:08
and maybe if you did something in the neck, uh,
54:11
the lower neck as opposed to the oral cavity, oral pharynx,
54:14
then it's possible to get a pretty good shim
54:16
that can help you evaluate um, uh, some
54:20
of these indeterminate tumors.
54:25
How often do you see A SCC from the oropharynx metastasize
54:29
into the pituitary gland?
54:32
Extremely rare. Very, very rare.
54:35
In fact, there was a case recently
54:36
that we didn't necessarily think it was metastasis,
54:39
but uh, sometimes if a patient is put on immunotherapy you
54:43
can get pituitary hyperplasia,
54:45
but in generally it's pretty rare to um, uh,
54:49
it's pretty rare to see uh,
54:51
oropharynx squamous cell carcinoma
54:53
metastasized to the pituitary.
54:59
Is MRI neck superior to PET CT for staging of
55:03
orphan genal ca? Excuse me?
55:07
Yeah, uh, no, that's a great question.
55:10
So one thing that I didn't get into,
55:12
but I can, I can talk about it right now is that, um,
55:15
lemme just get some water here.
55:19
Um, when we are
55:24
evaluating the head and neck,
55:25
and I'll answer this in, in two parts, is
55:31
an MR probably is, is is more sensitive
55:34
to detecting abnormalities than ct.
55:37
Um, so when I am, when I am in Europe, um, the majority
55:41
of the images that I'll see in the oral pharynx or MRS.
55:45
In the US we tend to do more cts than MRS
55:49
for head and neck and in head and neck tumors.
55:52
And part of the reason is the following part
55:55
of it is it's pretty much, i, I don't wanna say standard
55:58
of care, but if you have an oral pharynx cancer in the US
56:03
most patients end up getting a CT and or a PET CT
56:07
because we want to look for distant metastases.
56:11
And part of our healthcare system in the United States is
56:14
that people have a fairly high um, burden when it comes
56:19
to financial uh, issues.
56:22
So they may have what we refer to as a copay,
56:25
so they're gonna have to pay part of that.
56:28
Um, so from my standpoint, when we're trying
56:30
to decide whether to get a CT
56:32
or MR in general, if something is
56:35
below the soft palate then I like to recommend a CT
56:39
and a PET CT 'cause the patients are
56:41
already gonna get it anyway.
56:43
Um, and then in general you can make your decision making
56:46
process off of that.
56:47
But on the other hand, you know, um,
56:50
if you do an MR you can probably see the lesion better
56:54
but the MRS are actually fraught with more motion artifact.
56:59
And also if in the US if you get the MR in addition
57:02
to the ct, it is gonna be a bit more
57:04
of an out-of-pocket pay.
57:05
So it's not as straightforward as you would like to be,
57:08
but if someone asked me, do you see lesions better on CT
57:12
or mr, then I would say Mr.
57:14
Uh, number two regarding PET cts.
57:17
Um, the reason we get the PET cts is not
57:20
to evaluate the primary site, rather it's to look
57:25
for distant metastases.
57:27
So for instance, if the surgeons are going
57:29
to potentially resect a consular carcinoma, um,
57:33
and it may be a T two lesion, they just wanna make sure
57:35
that there's no distant metastases.
57:38
So that's the reason for getting the PET ct.
57:40
It's not necessarily to evaluate the primary site, it's
57:44
to evaluate distant metastases.
57:47
And the only thing I will add too is that part
57:50
of the reason we get PET cts, at least in the US is
57:54
that many centers in the United States
57:56
for radiation oncologists, they end up measuring
57:59
or contouring the tumor when they treat
58:01
before radiation therapy with pet.
58:04
In addition to the CT as well too.
58:06
So right now I think it's relative standard of care
58:10
that many centers will contour based on the anatomic
58:14
abnormality and the biologic abnormality too.
58:17
So that's a long question, a long answer,
58:19
but it was, uh, I saw a couple of questions to that,
58:22
so I wanna give a thoughtful answer.
58:26
Awesome. Do you have the q and a box open now?
58:30
I do. I'm trying to figure which one. Okay.
58:31
Yeah, I got it now. Okay.
58:33
I got it now. Yeah. You want me to?
58:35
Yeah, 'cause I'm gonna keep
58:36
butchering those words, otherwise
58:38
No, I'm gonna turn you into a head and neck radiologist.
58:42
I think you've heard me talk so many times now, Ashley.
58:45
I think, uh, I think it's good.
58:48
Um, yeah, someone asked for CT
58:50
or MR for oral pharyngeal malignancies from Omar, uh, Omer.
58:54
Um, so as I mentioned
58:56
before, I think MR is probably better to detect them,
58:59
but just realize, um, a higher percentage of MRS are going
59:03
to be affected by motion artifact, whereas with cts
59:08
with multi detector imaging, for me,
59:09
it's gonna be a more reliable study.
59:18
Are there more questions, Ashley?
59:20
I just see the last one I have is from Shaul.
59:23
Are there more questions that popped
59:25
up or am I not seeing them?
59:27
Yeah, it's the um, Q and a. Oh,
59:31
Q and A feature. Oh,
59:32
sorry. Yeah. Do you see? No worry.
59:33
Yeah, there's a, there's a web couple in there.
59:37
Hold on for a second. Oh, there's a Q and a.
59:40
Yeah, I was doing web chat. Okay. Sorry about that.
59:43
Um, okay. Oh, here we go.
59:46
Yeah, I got, um, as much time as you gonna wanna take,
59:48
like I said, I blocked off some extra.
59:50
So for a patient with obstructive sleep apnea,
59:52
how effective is MR in assessing posterior pharyngeal wall
59:56
and soft palate thickness?
59:58
So, that's a really good question.
60:00
Um, I have to admit, I don't have a lot
60:03
of experience with Mr.
60:05
I know about 15 years ago, uh,
60:09
there were several studies
60:11
that were looking at dynamic imaging using MR
60:15
for soft palate thickness.
60:17
In general, what I end up seeing is a lot
60:19
of cone beam cts in patients with obstructive sleep apnea.
60:24
So I, that's as pretty much as much
60:26
as I know regarding this.
60:27
So I think it certainly can be helpful.
60:30
Um, but I don't think there are many that many.
60:33
I think if you had to ask someone what study they're using,
60:36
I think they would probably end up doing cone beam ct.
60:41
Um, the next one is test for HPV and two types mentioned.
60:46
Do they need to be done both. And what's my advice?
60:48
So this is a great question.
60:50
Um, they're all great, great questions.
60:53
Um, because they make me think, um,
60:56
and you know, I just wanna re let you know
60:59
that sometimes when, when I answer these,
61:01
they're, they're really my opinion.
61:02
I, I've gotten old enough to know that, um,
61:05
sometimes when it comes to medicine, not everything is cut
61:07
and dry their opinions.
61:08
But I can tell you that I've asked this question
61:11
numerous times to our pathologists,
61:14
and this is what they tell me.
61:16
The most accurate way to determine HPV positive
61:22
tumor is to test for PCR.
61:25
So polymerase chain reaction is the most accurate way
61:28
to determine HPV positivity.
61:31
The immunohistochemical staining for the protein P 16
61:37
has an accuracy of about 85 to 90%.
61:40
So you're gonna get about a 10% false negative break.
61:45
Now some places will do I eight immunohistochemical staining
61:48
'cause it's just quicker and it's very, very easy to do.
61:52
And some places don't have the setup to do the PCR testing.
61:55
So to specifically answer your question,
61:58
PCR is the most accurate,
62:00
but IHE, if you will, is the most convenient
62:02
and it gets you through most cases.
62:06
Um, the next one is, how early do you scan your patients
62:10
after primary resection
62:11
of oropharynx cancers or other tumors?
62:14
So that's a great question too. I like to do three months.
62:18
Um, and we wrote, you know,
62:20
a paper years ago following radiation chemotherapy.
62:23
We always like to wait three months.
62:25
And the reason is, is
62:26
because I can tell you I've been conf confused
62:31
and made incorrect diagnosis because of performing CTS
62:36
and MS too quickly after the completion of surgery.
62:41
So when the, when you do do resections,
62:43
like bigger resections of the oral cavity
62:45
or advanced oral pharynx cancers, you know,
62:48
you can have a lot of inflammation
62:50
involved in the soft tissues.
62:52
Um, so I like to wait three months.
62:54
Um, and that's just my opinion.
62:56
Um, others may do less, may do more,
62:59
but again, I just saw a recent case
63:02
that my colleague showed me literally two weeks ago where
63:05
a patient was being treated with radiation
63:07
and chemotherapy in the middle of treatment
63:09
or one month, I think it was like one month.
63:12
Oh no, it was actually in the middle of treatment.
63:14
There was this huge response, diffuse enhancement
63:17
and tumor looked like it was growing
63:20
and then they did the imaging three months later
63:22
and the tumor went away.
63:23
So just realized that if you image too quickly,
63:27
you end up having the toxicity effects of treatment.
63:30
Now that's kind of called pseudo-progression.
63:32
Um, but in the old days we didn't call it pseudoprogression,
63:35
we called it acute toxicity of treatment in general.
63:38
Three months gives times to everything to, to settle down.
63:43
Um, let's see, what's the next one there?
63:47
Um, hold on for a second, Ashley.
63:50
So, so I did the how early do you scan?
63:52
Um, yes, real, uh,
63:55
does the tego mandibular have any function?
63:59
Um, yeah, so the tego mandibular, um, it sort
64:04
of connects everything.
64:05
Uh, it's not a functional, um,
64:08
it's not moving like a muscle does.
64:10
So it, it does it's function as primarily
64:12
as you mentioned, connect.
64:14
So it does form a connection.
64:16
So the tego mandibular,
64:18
and I mentioned this in the oral cavity talk, is that, um,
64:23
let's see, can you still see my screen or did I lose you?
64:26
Ashley? We can see it. You. Okay.
64:30
So the tego mandibular
64:35
is located here
64:36
and this is where the bator muscle interdigitates
64:39
with the superior constrictor muscle.
64:41
So it brings these muscles together
64:43
and the inferior portion of the tego mandibular attaches
64:47
to the posterior aspect of the mandible at the myeloid line.
64:51
And then the superior aspect of thera extends
64:54
to the hook of the hamula.
64:55
So it has this area that connects these two anterior
64:59
and posterior, but Thera has a cephalad and cauda extension.
65:03
So it's sort of where everything comes together.
65:10
Uh, let's see, let's see. What is the Q and A thing here?
65:15
Let's see. It's hidden on my zoom. There we go.
65:17
Um, okay, so the next one.
65:21
How does MR compare
65:22
to other imaging modalities like CT or endoscopy?
65:28
Um, well to answer this question, it's clear
65:32
that endoscopy is the best way
65:33
because someone can, they can see the tumor.
65:36
You know, the role of imaging is sort of to confirm
65:39
what our referring physicians see at endoscopy.
65:43
But the main role is really to look for that deep extension.
65:46
So as I mentioned before, MR is superior to CT to look
65:50
for small lesions.
65:51
So I have, I think in the oral cavity talk I gave several
65:54
examples where you could not see the tumor on CT
65:58
but you could see it on mr.
66:00
So I think MR is superior to CT for detecting subtle lesions
66:04
and probably also deep spread.
66:06
But just realize if you're gonna do an mr, you have
66:09
to make sure your techs are experienced
66:13
and they counsel the patients to hold still
66:17
because you know when your average acquisition is three
66:19
to four minutes, if that patient just moves a little bit
66:22
during that three minute time,
66:24
your whole sequence is gonna be disrupted.
66:26
So that's why we tend to use a little bit more ct.
66:31
Um, what are the primary MR indicators
66:35
for early detection of oral pharyngeal wall carcinoma?
66:40
Um,
66:42
so that's a good question.
66:46
I think the early MR indicators would
66:50
probably be in a patient that's symptomatic
66:53
if you see an asymmetrical mass.
66:58
So for instance, we'll see a lot of patients
67:00
that end up having uh, dysphagia and if we're doing an MR
67:05
and we see either of abnormal focal mass that's midline
67:09
or that's pyramid line, then
67:12
that would probably be the earliest indicators of tumor.
67:15
So if I see something like that in a patient with dysphagia,
67:20
then I'll go ahead and ask the patient the, the, I'll go
67:23
and recommend in my report that these findings be correlated
67:26
with direct visualization and palpation or endoscopy.
67:30
So that's how, that's how I manage uh, things
67:34
because you know, you can see a lot of
67:36
strangeness at times in the posterior pharyngeal wall.
67:39
So that's what I end up saying.
67:43
Um, what is the most common misdiagnosis
67:46
of the oral pharynx on a scan
67:48
that was done for something else?
67:50
Um, right.
67:52
So I think, I don't know if it's a misdiagnosis or not,
67:55
but I probably would say, um, again,
67:59
I'm gonna say in my experience
68:01
'cause good judgments comes from experience
68:03
and experience comes from bad judgment.
68:05
I think the two most common things would be
68:08
number one, the tonsils.
68:09
Um, oftentimes the tonsils can be kind of tricky
68:14
because they, you the lymphoid tissue in the tonsils tend
68:18
to atrophy over time.
68:20
They just tend to shrink.
68:22
So I think sometimes what ends up happening is that in 35
68:25
or 40-year-old patients,
68:27
some patients can still have plumpy tonsil
68:29
and especially I've noticed and it's never been reported,
68:31
but if I see something that's a little bit more heavyset,
68:35
um, patients that are heavyset tend
68:37
to have bigger tonsils in general.
68:39
So sometimes I'll see uh, uh,
68:42
people will misdiagnose tons carcinomas
68:45
or if there's an asymmetry,
68:46
again they'll call tonsor carcinomas.
68:48
The next thing is, that's area
68:50
that I see here involving the tongue base
68:53
and the lingual tonsils.
68:55
Uh, you can misconstrue the lingual tonsils for tumors,
68:59
but again, as I tried to emphasize in the talk
69:02
that if you see something like that,
69:04
especially in the oral pharynx, you know,
69:06
just say in your report that I see an asymmetry,
69:09
but this can be correlated
69:11
with direct visualization and palpation.
69:13
So you know, I've never really had an
69:15
issue recommending that.
69:17
Um, but that's what I would suggest.
69:19
The one other thing too is that
69:22
if you actually look at this case, this is a good example,
69:25
once we start heading down into this gloss of tons
69:28
or sulcus here between the tongue
69:31
and the tonsil, again we can see asymmetry.
69:34
So if I see something like this again, again just correlate
69:38
with visualization and palpation.
69:43
Um, so what is the defined cranial
69:47
and coddle borders of the Yeah, so the cranial border
69:52
is going to be the soft palate and the coddle border.
69:56
And I thought I mentioned that but I'll just go ahead
69:58
and mention that again.
70:02
The coddle border is going to be this area right here,
70:06
which is down by the veac.
70:08
So the specific earing, I didn't specifically mention it,
70:12
but there is a fold of tissue
70:15
that runs from the lateral wall of the pharynx to the um,
70:21
epiglottis and that's referred to as the um,
70:24
fingal epiglottic fold.
70:26
So it runs in the pharynx of the epiglottis
70:28
and that's the Fargo epiglottic fold.
70:30
So that's the technical area that's hard to see on imaging.
70:35
So in general, a good approximator is gonna be the base
70:38
of the mlic, so right here from the vallecula.
70:40
So that's why I tend to use the inferior as the ULA
70:44
and the superior as a soft palette.
70:50
Let's see, uh,
70:53
how do I approach eagle syndrome?
70:56
So what, that's a good question.
70:58
So eagle syndrome is a calcification
71:03
of the stylo hyoid ligament.
71:05
So the stylo OID ligament runs from the S styloid process
71:09
and attaches to the top of the hyoid bone.
71:13
And I gotta tell you, it is kind of controversial.
71:17
Um, I had one case where
71:21
I saw the calcification, the stylo hyoid ligament.
71:23
And I gotta tell you, the majority
71:24
of the times it's incidental.
71:26
So I will be just doing a regular N CT
71:29
for like a parotid mass
71:31
and they'll end up seeing calcification
71:33
of the stylo hyoid ligament.
71:35
And I'll just mention it,
71:37
but I remember there was one case where I didn't mention it
71:41
and then the surgeon sent the case back to me
71:43
and said, you, can you please mention the eagle syndrome.
71:46
So what I end up doing for eagle syndrome
71:49
and what eagle syndrome is, it's calcification
71:52
of the stylo hyoid muscle
71:54
and the patients will either present with dysphagia
71:57
or they can present with the clicking sound.
72:00
So when they swallow you can have a click
72:02
and that click is felt to be due to the hyoid bone moving
72:06
and somehow because the ligament's calcified,
72:09
you can get a click sound.
72:11
So what I end up doing is I don't say the patient has eagle
72:14
syndrome, I will just comment on the calcification
72:18
of the stylo hyoid ligament and just leave it there.
72:21
And then it's really up to the physician
72:24
is whether to syndrome.
72:26
About 30 years ago I learned the difference
72:29
between a disease and a syndrome.
72:31
So a disease is something that we can see
72:34
or diagnose a syndrome.
72:36
What I was told is a combination of
72:38
of different clinical findings
72:40
and when they all come together it's a syndrome.
72:43
Now some of those findings may be radiologic,
72:46
but on the other hand a true syndrome is
72:49
our clinical findings.
72:50
So when I see syndrome like this,
72:52
I know it's more than just calcification,
72:54
the hyoid ligament,
72:56
but they have to have the associated clinical findings
72:59
to be considered the syndrome.
73:02
Um, the next question is what kind
73:06
of MR was done like T one, T two or proton density?
73:11
So you know, I'll give you my uh, approach on uh, MR
73:16
is that the, there are so many sequences
73:20
to choose from, from mr.
73:22
Um, to me the best type of MR is the shortest one.
73:25
And what I mean by that is when I think of doing MRCT,
73:29
I like to think of a hundred patients
73:31
and from my standpoint,
73:32
those a hundred patients are
73:34
gonna have to pay for their study.
73:36
And so when I'm trying to figure out the best study
73:38
to use is what study can I get
73:41
that's gonna be the most diagnostic.
73:44
Um, and so what I like to do is try to keep it as short
73:48
as reasonably possible.
73:49
So we have dedicated MR protocols
73:53
for the nasal pharynx, the oral cavity,
73:55
the oral pharynx in the neck.
73:58
So I like to do acts a sagal T ones without,
74:03
then I like to do axial T twos,
74:06
then axial T ones pre and post
74:09
and then post with fat suppression.
74:12
And then if there's a tumor
74:13
that's involved in the oral cavity, the oral pharynx, I like
74:17
to do a perfusion sequence
74:18
but it's not the standard um, T one perfusion.
74:22
I like to use a dynamic gradient echo sequence, um,
74:25
because I find that the most reliable.
74:29
I think um, if you do do the standard protus,
74:31
you the quantitative techniques,
74:33
you can get beautiful images and it can be helpful,
74:36
but there's so much variability in profusion even when it
74:40
comes to brain tumor profusion.
74:41
Now to map it out into the head
74:42
and neck, it even becomes even more confusing.
74:45
So I like to use this T one dynamic gradient echo sequence
74:49
and for me it's been a great way to identify tumors
74:53
and also to help differentiate recurrent tumor
74:56
from post-treatment changes.
75:00
Um, what imaging modality is most useful
75:03
as a follow-up undergoing chemo
75:05
and radiation for oral pharyngeal tumors?
75:08
Um, I probably would say PET CT for that one.
75:11
Um, so I think that's sort of standard.
75:14
Uh, but on the other hand if you do do PET CT is
75:18
to please make sure that the person reading the PET CT
75:23
has some understanding of head
75:25
and neck anatomy and head and neck cancer.
75:28
Um, and also when they do do the PET CT is
75:32
to make sure that the patients don't talk
75:35
and they don't move because I can't tell you how many times,
75:39
um, I've seen patients
75:41
that have had PET cts following treatment with chemo
75:43
and radiation therapy and there's diffuse uptake in the
75:47
tongue and then it's read out
75:49
as diffuse recurrence involved in the tongue
75:51
and then it gets sent to us to look at it, our tumor board
75:54
and when we go in and examine the patient's completely soft
75:58
and I have to tell the surgeons that, you know,
76:00
this is probably due to artifact
76:02
because the patient was probably talking.
76:05
So I think pet CT is the way to go,
76:07
but if you do do it, um, you have to make sure
76:10
that they don't talk or, or uh, smoke
76:14
or anything like that after you inject the contrast.
76:17
Those are just some practical issues that,
76:18
that I've run into. Um,
76:21
Dr. McCury, let's
76:22
do one or two more
76:24
and then we will wrap noom conference up
76:26
for the day. That's cool with you.
76:28
Okay, yeah, that's good for me.
76:30
Um, let's see, two more then real quick. Let's see. Um,
76:34
Yeah, pick your favorite.
76:35
Alright, let's see.
76:37
I about, um,
76:42
so um, let's see, what's the best
76:46
for lymph node MRCT?
76:48
I think either one is fine.
76:49
I tend to use, I tend to use more CT than an mr uh,
76:54
just because again, we do it more often,
76:56
but I think MR is just as good for me.
76:58
I like to do CT in a good quality CT
77:01
because the vessel's in hands
77:03
and it's very easy for me to, um, to uh,
77:08
help distinguish between lymph nodes and vessels.
77:10
So I tend to, to use more CT than mr.
77:15
Um, let's see, let's see.
77:19
So what's the most sensitive way
77:22
and specific for prevertebral invasion?
77:25
I think the,
77:27
it is looking at the axial T two weighted images.
77:30
So we do axial T two weighted images with fat suppression.
77:34
What I look for is the edema in the prevertebral muscles
77:38
and i, I can show that
77:39
and then we'll just end it, we'll just end it there.
77:42
But I think if I look at the posterior pharyngeal wall, um,
77:46
hopefully you can see this Ashley, it's,
77:49
if I look at this one, this white arrow is pointing at the
77:52
normal muscle here
77:53
and then on the fat suppressed T two weighted images,
77:56
we can see this edema involving the muscle.
77:58
So this is indicative of prevertebral muscle invasion
78:01
or prevertebral fascia invasion.
78:03
So just to be clear, there's this fascial layer right here
78:08
and then below the fascial layer is the muscle.
78:10
So we sort of combine
78:13
prevertebral fascial invasion versus muscle invasion.
78:17
So I think it's the axial T two, uh,
78:19
images with fat suppression.
78:22
All right, Ashley, that was the two.
78:25
That was the two and actually it organically stopped.
78:28
So I think folks have asked all their questions.
78:32
And thank you so much Dr.
78:33
McCorey for this lecture
78:35
and for hanging out for a little while
78:36
to answer all these questions.
78:39
Oh, it's my pleasure. Always a pleasure to do it
78:41
and um, hope to do it again sometime.
78:45
Awesome. And thank you to everyone else
78:47
for participating in our NOOM conference
78:49
and asking such great questions.
78:51
You can access the recording of today's conference
78:53
and all our previous noom conferences
78:54
by creating a free account.
78:56
We'll also email out a link to the replay later today.
79:00
Be sure to join us next week on Thursday,
79:02
November 21st at 12:00 PM Eastern, where Dr.
79:05
Deborah Baumgarten will deliver a lecture entitled A Case
79:09
Space Review of Adrenal Lesions.
79:11
You can register for that@mriline.com
79:13
and follow us on social media
79:15
for updates on future noon conferences.
79:17
Thanks again for learning with us and have a great day.
Suresh K Mukherji, MD, FACR, MBA
Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging
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