DOI: 10.1148/rg.235025045
Dynamic Maneuvers in Local Staging of Head and Neck Malignancies with Current Imaging Techniques: Principles and Clinical Applications1
Philippe Henrot, MD,
Alain Blum, MD,
Bruno Toussaint, MD,
Philippe Troufleau, MD,
Joseph Stines, MD and
Jacques Roland, MD
1 From the Department of Radiology, Centre Alexis Vautrin, Ave de Bourgogne, 54511 Vandoeuvre-lès-Nancy, France (P.H., P.T., J.S.); and the Departments of Radiology Guilloz (A.B., J.R.) and Head and Neck Surgery (B.T.), Hôpital Central University of Nancy 1, France. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received March 4, 2002; revision requested April 8; final revision received February 10, 2003; accepted February 13. Address correspondence to P.H. (e-mail: p.henrot@nancy.fnclcc.fr).
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Figure 1a. Squamous cell carcinoma of the right buccal vestibule. (a) Axial CT scan shows a tumor (arrow) but does not clearly demonstrate which wall is involved. (b) Axial CT scan obtained with the puffed cheek technique shows involvement of both the buccal mucosa (white arrow) and the gingival mucosa (black arrows). (c) Coronal reformatted image obtained with the puffed cheek technique shows involvement of the right cheek (white arrow) and the gingiva (black arrow). * = buccinator muscle.
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Figure 1b. Squamous cell carcinoma of the right buccal vestibule. (a) Axial CT scan shows a tumor (arrow) but does not clearly demonstrate which wall is involved. (b) Axial CT scan obtained with the puffed cheek technique shows involvement of both the buccal mucosa (white arrow) and the gingival mucosa (black arrows). (c) Coronal reformatted image obtained with the puffed cheek technique shows involvement of the right cheek (white arrow) and the gingiva (black arrow). * = buccinator muscle.
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Figure 1c. Squamous cell carcinoma of the right buccal vestibule. (a) Axial CT scan shows a tumor (arrow) but does not clearly demonstrate which wall is involved. (b) Axial CT scan obtained with the puffed cheek technique shows involvement of both the buccal mucosa (white arrow) and the gingival mucosa (black arrows). (c) Coronal reformatted image obtained with the puffed cheek technique shows involvement of the right cheek (white arrow) and the gingiva (black arrow). * = buccinator muscle.
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Figure 2a. Squamous cell carcinoma of the retromolar trigone. (a) Axial CT scan shows a tumor (arrow), but it is unclear whether there is buccal involvement. (b) Axial CT scan obtained with the puffed cheek technique shows tumoral thickening of the retromolar trigone (arrow). The mucosal surface of the cheek is preserved (arrowheads).
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Figure 2b. Squamous cell carcinoma of the retromolar trigone. (a) Axial CT scan shows a tumor (arrow), but it is unclear whether there is buccal involvement. (b) Axial CT scan obtained with the puffed cheek technique shows tumoral thickening of the retromolar trigone (arrow). The mucosal surface of the cheek is preserved (arrowheads).
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Figure 3a. Squamous cell carcinoma of the anterior floor of the mouth. (a) Axial CT scan shows a tumor of the right side of the anterior floor of the mouth and the mandibular gingiva (*). It is unclear whether there is involvement of the lower lip (arrowheads). (b) Sagittal reformatted image shows the lower extent of the tumor at the floor of the mouth above the geniohyoid and mylohyoid muscles (arrow), but the tongue is not clearly distinguished from the gingiva. The lower lip and the gingiva are still apposed (arrowheads). (c) Axial CT scan obtained with the puffed cheek technique shows that the anterior floor of the mouth is inflated. The medial limit of the tumor is clearly seen in the midline (arrow). It is still unclear whether there is involvement of the lower lip (arrowheads). (d) Sagittal reformatted image obtained with the puffed cheek technique shows that the tumor involves the gingiva (arrow) but does not involve the tongue. The lower lip is separated from the gingiva and appears preserved (arrowheads). * = inflated buccal vestibule.
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Figure 3b. Squamous cell carcinoma of the anterior floor of the mouth. (a) Axial CT scan shows a tumor of the right side of the anterior floor of the mouth and the mandibular gingiva (*). It is unclear whether there is involvement of the lower lip (arrowheads). (b) Sagittal reformatted image shows the lower extent of the tumor at the floor of the mouth above the geniohyoid and mylohyoid muscles (arrow), but the tongue is not clearly distinguished from the gingiva. The lower lip and the gingiva are still apposed (arrowheads). (c) Axial CT scan obtained with the puffed cheek technique shows that the anterior floor of the mouth is inflated. The medial limit of the tumor is clearly seen in the midline (arrow). It is still unclear whether there is involvement of the lower lip (arrowheads). (d) Sagittal reformatted image obtained with the puffed cheek technique shows that the tumor involves the gingiva (arrow) but does not involve the tongue. The lower lip is separated from the gingiva and appears preserved (arrowheads). * = inflated buccal vestibule.
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Figure 3c. Squamous cell carcinoma of the anterior floor of the mouth. (a) Axial CT scan shows a tumor of the right side of the anterior floor of the mouth and the mandibular gingiva (*). It is unclear whether there is involvement of the lower lip (arrowheads). (b) Sagittal reformatted image shows the lower extent of the tumor at the floor of the mouth above the geniohyoid and mylohyoid muscles (arrow), but the tongue is not clearly distinguished from the gingiva. The lower lip and the gingiva are still apposed (arrowheads). (c) Axial CT scan obtained with the puffed cheek technique shows that the anterior floor of the mouth is inflated. The medial limit of the tumor is clearly seen in the midline (arrow). It is still unclear whether there is involvement of the lower lip (arrowheads). (d) Sagittal reformatted image obtained with the puffed cheek technique shows that the tumor involves the gingiva (arrow) but does not involve the tongue. The lower lip is separated from the gingiva and appears preserved (arrowheads). * = inflated buccal vestibule.
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Figure 3d. Squamous cell carcinoma of the anterior floor of the mouth. (a) Axial CT scan shows a tumor of the right side of the anterior floor of the mouth and the mandibular gingiva (*). It is unclear whether there is involvement of the lower lip (arrowheads). (b) Sagittal reformatted image shows the lower extent of the tumor at the floor of the mouth above the geniohyoid and mylohyoid muscles (arrow), but the tongue is not clearly distinguished from the gingiva. The lower lip and the gingiva are still apposed (arrowheads). (c) Axial CT scan obtained with the puffed cheek technique shows that the anterior floor of the mouth is inflated. The medial limit of the tumor is clearly seen in the midline (arrow). It is still unclear whether there is involvement of the lower lip (arrowheads). (d) Sagittal reformatted image obtained with the puffed cheek technique shows that the tumor involves the gingiva (arrow) but does not involve the tongue. The lower lip is separated from the gingiva and appears preserved (arrowheads). * = inflated buccal vestibule.
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Figure 4a. Tumor of the retromolar trigone with involvement of the buccal mucosa and buccinator muscle. (a) Axial T1-weighted MR image obtained with a cannula in the mouth shows separation of the buccal mucosal surface involved by a tumor (black arrow) and the gingival mucosal surfaces (white arrow). * = signal void of the cannula. (b) Axial T1-weighted MR image obtained with fat saturation and gadolinium contrast material shows the extent of the tumor and the buccal involvement (arrows). (c) Photograph obtained during direct examination of the oral cavity shows the involvement of the buccal mucosa.
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Figure 4b. Tumor of the retromolar trigone with involvement of the buccal mucosa and buccinator muscle. (a) Axial T1-weighted MR image obtained with a cannula in the mouth shows separation of the buccal mucosal surface involved by a tumor (black arrow) and the gingival mucosal surfaces (white arrow). * = signal void of the cannula. (b) Axial T1-weighted MR image obtained with fat saturation and gadolinium contrast material shows the extent of the tumor and the buccal involvement (arrows). (c) Photograph obtained during direct examination of the oral cavity shows the involvement of the buccal mucosa.
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Figure 4c. Tumor of the retromolar trigone with involvement of the buccal mucosa and buccinator muscle. (a) Axial T1-weighted MR image obtained with a cannula in the mouth shows separation of the buccal mucosal surface involved by a tumor (black arrow) and the gingival mucosal surfaces (white arrow). * = signal void of the cannula. (b) Axial T1-weighted MR image obtained with fat saturation and gadolinium contrast material shows the extent of the tumor and the buccal involvement (arrows). (c) Photograph obtained during direct examination of the oral cavity shows the involvement of the buccal mucosa.
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Figure 5a. Normal hypopharynx. (a) Axial CT scan obtained during quiet respiration shows that the mucosal surfaces of the piriform sinuses are apposed (arrows). (b) Axial CT scan obtained during the Valsalva maneuver shows that the piriform sinuses are inflated and their walls are well depicted (arrows).
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Figure 5b. Normal hypopharynx. (a) Axial CT scan obtained during quiet respiration shows that the mucosal surfaces of the piriform sinuses are apposed (arrows). (b) Axial CT scan obtained during the Valsalva maneuver shows that the piriform sinuses are inflated and their walls are well depicted (arrows).
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Figure 6a. Squamous cell carcinoma of the left piriform sinus. (a) Axial CT scan obtained during quiet respiration shows that the mucosal surfaces of the left piriform sinus are apposed (arrows); therefore, no evident lesion is observed. The postarytenoid soft tissue and the posterior pharyngeal wall are apposed. (b) Axial CT scan obtained during the Valsalva maneuver shows tumoral thickening of the lateral wall of the left piriform sinus (arrows). The postarytenoid soft tissue and the posterior pharyngeal wall are separated and clearly depicted. Arrowhead = level III adenopathy.
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Figure 6b. Squamous cell carcinoma of the left piriform sinus. (a) Axial CT scan obtained during quiet respiration shows that the mucosal surfaces of the left piriform sinus are apposed (arrows); therefore, no evident lesion is observed. The postarytenoid soft tissue and the posterior pharyngeal wall are apposed. (b) Axial CT scan obtained during the Valsalva maneuver shows tumoral thickening of the lateral wall of the left piriform sinus (arrows). The postarytenoid soft tissue and the posterior pharyngeal wall are separated and clearly depicted. Arrowhead = level III adenopathy.
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Figure 7a. Squamous cell carcinoma of the right side of the hypopharynx. (a) Axial CT scan obtained during quiet respiration shows a tumor (*). Apposition of the mucosal surfaces does not allow identification of the involved wall. (b) Axial CT scan obtained during the Valsalva maneuver shows the tumor, which involves the right aryepiglottic fold (*).
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Figure 7b. Squamous cell carcinoma of the right side of the hypopharynx. (a) Axial CT scan obtained during quiet respiration shows a tumor (*). Apposition of the mucosal surfaces does not allow identification of the involved wall. (b) Axial CT scan obtained during the Valsalva maneuver shows the tumor, which involves the right aryepiglottic fold (*).
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Figure 8a. Differentiated squamous cell carcinoma of the nasopharynx. (a) Axial CT scan obtained during quiet respiration shows a tumor of the right and posterior walls of the nasopharynx (arrow). The left margin of the lesion is not clearly seen. (b) Axial CT scan obtained during the Valsalva maneuver shows that the left and posterior walls of the nasopharynx are separated. The tumor is located on the posterior wall (black arrows) and right wall (white arrows). The left wall is preserved (arrowheads).
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Figure 8b. Differentiated squamous cell carcinoma of the nasopharynx. (a) Axial CT scan obtained during quiet respiration shows a tumor of the right and posterior walls of the nasopharynx (arrow). The left margin of the lesion is not clearly seen. (b) Axial CT scan obtained during the Valsalva maneuver shows that the left and posterior walls of the nasopharynx are separated. The tumor is located on the posterior wall (black arrows) and right wall (white arrows). The left wall is preserved (arrowheads).
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Figure 9a. Normal larynx. (a) Axial CT scan shows the normal appearance of the larynx during quiet respiration. The true vocal cords are abducted. (b) Volume-rendered image shows the upper airways during quiet respiration. The true and false vocal cords are poorly seen (arrows). (c) Axial CT scan obtained during phonation shows that the true vocal cords are thin and adducted. The ventricles are properly inflated (*). (d) Volume-rendered laryngogram obtained during phonation clearly shows the true (arrows) and false (*) vocal cords. The laryngeal ventricles are well demonstrated (arrowheads). The piriform sinuses are inflated.
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Figure 9b. Normal larynx. (a) Axial CT scan shows the normal appearance of the larynx during quiet respiration. The true vocal cords are abducted. (b) Volume-rendered image shows the upper airways during quiet respiration. The true and false vocal cords are poorly seen (arrows). (c) Axial CT scan obtained during phonation shows that the true vocal cords are thin and adducted. The ventricles are properly inflated (*). (d) Volume-rendered laryngogram obtained during phonation clearly shows the true (arrows) and false (*) vocal cords. The laryngeal ventricles are well demonstrated (arrowheads). The piriform sinuses are inflated.
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Figure 9c. Normal larynx. (a) Axial CT scan shows the normal appearance of the larynx during quiet respiration. The true vocal cords are abducted. (b) Volume-rendered image shows the upper airways during quiet respiration. The true and false vocal cords are poorly seen (arrows). (c) Axial CT scan obtained during phonation shows that the true vocal cords are thin and adducted. The ventricles are properly inflated (*). (d) Volume-rendered laryngogram obtained during phonation clearly shows the true (arrows) and false (*) vocal cords. The laryngeal ventricles are well demonstrated (arrowheads). The piriform sinuses are inflated.
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Figure 9d. Normal larynx. (a) Axial CT scan shows the normal appearance of the larynx during quiet respiration. The true vocal cords are abducted. (b) Volume-rendered image shows the upper airways during quiet respiration. The true and false vocal cords are poorly seen (arrows). (c) Axial CT scan obtained during phonation shows that the true vocal cords are thin and adducted. The ventricles are properly inflated (*). (d) Volume-rendered laryngogram obtained during phonation clearly shows the true (arrows) and false (*) vocal cords. The laryngeal ventricles are well demonstrated (arrowheads). The piriform sinuses are inflated.
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Figure 10a. Tumorlike nodules of the true vocal cords that manifested as hoarseness. (a) Axial CT scan obtained during quiet respiration shows apposition of the thickened true vocal cords (arrows). (b) Axial CT scan obtained during phonation shows a nodule of the right true vocal cord (arrow). The nodule is clearly visible due to tension of the true vocal cords. (c) Volume-rendered laryngogram obtained during phonation shows the thickening of the true vocal cords (black arrows). The false vocal cords (white arrows) and laryngeal ventricles (arrowheads) are clearly seen. (d) Coronal reformatted image obtained during phonation shows the thickening of the true vocal cords (arrows). The false vocal cords (*) and laryngeal ventricles (arrowheads) are also seen. (e) Image from endoscopy shows two lesions of the true vocal cords. Histopathologic evaluation revealed Reinke edema (pseudocysts).
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Figure 10b. Tumorlike nodules of the true vocal cords that manifested as hoarseness. (a) Axial CT scan obtained during quiet respiration shows apposition of the thickened true vocal cords (arrows). (b) Axial CT scan obtained during phonation shows a nodule of the right true vocal cord (arrow). The nodule is clearly visible due to tension of the true vocal cords. (c) Volume-rendered laryngogram obtained during phonation shows the thickening of the true vocal cords (black arrows). The false vocal cords (white arrows) and laryngeal ventricles (arrowheads) are clearly seen. (d) Coronal reformatted image obtained during phonation shows the thickening of the true vocal cords (arrows). The false vocal cords (*) and laryngeal ventricles (arrowheads) are also seen. (e) Image from endoscopy shows two lesions of the true vocal cords. Histopathologic evaluation revealed Reinke edema (pseudocysts).
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Figure 10c. Tumorlike nodules of the true vocal cords that manifested as hoarseness. (a) Axial CT scan obtained during quiet respiration shows apposition of the thickened true vocal cords (arrows). (b) Axial CT scan obtained during phonation shows a nodule of the right true vocal cord (arrow). The nodule is clearly visible due to tension of the true vocal cords. (c) Volume-rendered laryngogram obtained during phonation shows the thickening of the true vocal cords (black arrows). The false vocal cords (white arrows) and laryngeal ventricles (arrowheads) are clearly seen. (d) Coronal reformatted image obtained during phonation shows the thickening of the true vocal cords (arrows). The false vocal cords (*) and laryngeal ventricles (arrowheads) are also seen. (e) Image from endoscopy shows two lesions of the true vocal cords. Histopathologic evaluation revealed Reinke edema (pseudocysts).
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Figure 10d. Tumorlike nodules of the true vocal cords that manifested as hoarseness. (a) Axial CT scan obtained during quiet respiration shows apposition of the thickened true vocal cords (arrows). (b) Axial CT scan obtained during phonation shows a nodule of the right true vocal cord (arrow). The nodule is clearly visible due to tension of the true vocal cords. (c) Volume-rendered laryngogram obtained during phonation shows the thickening of the true vocal cords (black arrows). The false vocal cords (white arrows) and laryngeal ventricles (arrowheads) are clearly seen. (d) Coronal reformatted image obtained during phonation shows the thickening of the true vocal cords (arrows). The false vocal cords (*) and laryngeal ventricles (arrowheads) are also seen. (e) Image from endoscopy shows two lesions of the true vocal cords. Histopathologic evaluation revealed Reinke edema (pseudocysts).
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Figure 10e. Tumorlike nodules of the true vocal cords that manifested as hoarseness. (a) Axial CT scan obtained during quiet respiration shows apposition of the thickened true vocal cords (arrows). (b) Axial CT scan obtained during phonation shows a nodule of the right true vocal cord (arrow). The nodule is clearly visible due to tension of the true vocal cords. (c) Volume-rendered laryngogram obtained during phonation shows the thickening of the true vocal cords (black arrows). The false vocal cords (white arrows) and laryngeal ventricles (arrowheads) are clearly seen. (d) Coronal reformatted image obtained during phonation shows the thickening of the true vocal cords (arrows). The false vocal cords (*) and laryngeal ventricles (arrowheads) are also seen. (e) Image from endoscopy shows two lesions of the true vocal cords. Histopathologic evaluation revealed Reinke edema (pseudocysts).
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Figure 11a. Squamous cell carcinoma of the right side of the glottis. (a) Axial CT scan obtained during quiet respiration shows a tumor of the anterior commissure (arrow). (b) Coronal reformatted image obtained during quiet respiration shows the tumor (*). However, the true and false vocal cords are poorly seen, so the local extent of the tumor remains undefined. (c) Volume-rendered image shows the upper airways during quiet respiration. The larynx forms a wide airway indistinguishable from the trachea below. The scalloping of the airway corresponds to the lesion (arrow). (d) Coronal reformatted image obtained during phonation shows the right laryngeal ventricle (arrow). The tumor (*) is located solely below the ventricle; therefore, involvement of the supraglottic structures is ruled out. (e) Volume-rendered laryngogram obtained during phonation shows the right laryngeal ventricle (arrowhead). The subglottic scalloping represents the lower extent of the tumor (arrows).
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Figure 11b. Squamous cell carcinoma of the right side of the glottis. (a) Axial CT scan obtained during quiet respiration shows a tumor of the anterior commissure (arrow). (b) Coronal reformatted image obtained during quiet respiration shows the tumor (*). However, the true and false vocal cords are poorly seen, so the local extent of the tumor remains undefined. (c) Volume-rendered image shows the upper airways during quiet respiration. The larynx forms a wide airway indistinguishable from the trachea below. The scalloping of the airway corresponds to the lesion (arrow). (d) Coronal reformatted image obtained during phonation shows the right laryngeal ventricle (arrow). The tumor (*) is located solely below the ventricle; therefore, involvement of the supraglottic structures is ruled out. (e) Volume-rendered laryngogram obtained during phonation shows the right laryngeal ventricle (arrowhead). The subglottic scalloping represents the lower extent of the tumor (arrows).
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Figure 11c. Squamous cell carcinoma of the right side of the glottis. (a) Axial CT scan obtained during quiet respiration shows a tumor of the anterior commissure (arrow). (b) Coronal reformatted image obtained during quiet respiration shows the tumor (*). However, the true and false vocal cords are poorly seen, so the local extent of the tumor remains undefined. (c) Volume-rendered image shows the upper airways during quiet respiration. The larynx forms a wide airway indistinguishable from the trachea below. The scalloping of the airway corresponds to the lesion (arrow). (d) Coronal reformatted image obtained during phonation shows the right laryngeal ventricle (arrow). The tumor (*) is located solely below the ventricle; therefore, involvement of the supraglottic structures is ruled out. (e) Volume-rendered laryngogram obtained during phonation shows the right laryngeal ventricle (arrowhead). The subglottic scalloping represents the lower extent of the tumor (arrows).
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Figure 11d. Squamous cell carcinoma of the right side of the glottis. (a) Axial CT scan obtained during quiet respiration shows a tumor of the anterior commissure (arrow). (b) Coronal reformatted image obtained during quiet respiration shows the tumor (*). However, the true and false vocal cords are poorly seen, so the local extent of the tumor remains undefined. (c) Volume-rendered image shows the upper airways during quiet respiration. The larynx forms a wide airway indistinguishable from the trachea below. The scalloping of the airway corresponds to the lesion (arrow). (d) Coronal reformatted image obtained during phonation shows the right laryngeal ventricle (arrow). The tumor (*) is located solely below the ventricle; therefore, involvement of the supraglottic structures is ruled out. (e) Volume-rendered laryngogram obtained during phonation shows the right laryngeal ventricle (arrowhead). The subglottic scalloping represents the lower extent of the tumor (arrows).
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Figure 11e. Squamous cell carcinoma of the right side of the glottis. (a) Axial CT scan obtained during quiet respiration shows a tumor of the anterior commissure (arrow). (b) Coronal reformatted image obtained during quiet respiration shows the tumor (*). However, the true and false vocal cords are poorly seen, so the local extent of the tumor remains undefined. (c) Volume-rendered image shows the upper airways during quiet respiration. The larynx forms a wide airway indistinguishable from the trachea below. The scalloping of the airway corresponds to the lesion (arrow). (d) Coronal reformatted image obtained during phonation shows the right laryngeal ventricle (arrow). The tumor (*) is located solely below the ventricle; therefore, involvement of the supraglottic structures is ruled out. (e) Volume-rendered laryngogram obtained during phonation shows the right laryngeal ventricle (arrowhead). The subglottic scalloping represents the lower extent of the tumor (arrows).
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Figure 12a. Squamous cell carcinoma of the right wall of the oropharynx. (a) Axial CT scan shows that the right part of the oropharynx (*) is poorly seen due to dental amalgam artifact, which results in blind areas and poor contrast. Arrow = adenopathy. (b) Tomogram obtained with the open mouth technique shows the levels for performing additional CT with the mouth open. (c) Axial CT scan obtained through the open mouth shows that the previously shadowed areas are visible and the contrast is improved. A tumor is evident (arrow).
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Figure 12b. Squamous cell carcinoma of the right wall of the oropharynx. (a) Axial CT scan shows that the right part of the oropharynx (*) is poorly seen due to dental amalgam artifact, which results in blind areas and poor contrast. Arrow = adenopathy. (b) Tomogram obtained with the open mouth technique shows the levels for performing additional CT with the mouth open. (c) Axial CT scan obtained through the open mouth shows that the previously shadowed areas are visible and the contrast is improved. A tumor is evident (arrow).
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Figure 12c. Squamous cell carcinoma of the right wall of the oropharynx. (a) Axial CT scan shows that the right part of the oropharynx (*) is poorly seen due to dental amalgam artifact, which results in blind areas and poor contrast. Arrow = adenopathy. (b) Tomogram obtained with the open mouth technique shows the levels for performing additional CT with the mouth open. (c) Axial CT scan obtained through the open mouth shows that the previously shadowed areas are visible and the contrast is improved. A tumor is evident (arrow).
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Copyright © 2003 by the Radiological Society of North America.
