Head and Neck Cases

Case 1

7-year-old child with painful proptosis of the right eye.

Contrast-enhanced MR imaging is presented in representative axial and coronal plane.

There is an irregular non-enhancing collection in the medial part of the right orbit, shown by measurement. Also there is intense enhancement of the ipsilateral ethmoidal sinuses and the maxillary sinus and soft tissues along the medial aspect of the right orbit. This is an abscess, complicating sinusitis. Additional observation of extensive orbital cellulitis is also obvious. Potentially a very serious situation as venous thrombosis and extension of septic thrombi into the intracranium  through cavernous sinus is a potential complication

Case 2

2-week-old infant with feeding difficulty.

Axial CT examination of nasal cavity are provided. Why perform CT in such a young infant for feeding difficulty? Well this case shows the importance of making proper use of imaging options. This patient was a mouth breather, as he was not able to breathe through the nose. There is gross narrowing of the anterior nasal cavity, whereas posterior nasal cavity is normal. Such findings can be seen in some mid-facial syndromes. In an another entity , choanal atresia,  narrowing of the nasal cavity is often in the posterior part , as a component of Vomer dysplasia

Case 3.  

1-yr-old , mouth breather.

Soft tissue neck lateral view is provided. Any observation of Importance? This is one of the frequently performed examination in pediatric/ENT practice. Observation in this radiograph should include the airways--in the region of the nasopharynx, oropharynx, laryngo-pharynx and upper trachea. Also note should be made regarding adenoidal and tonsillar shadows. Careful scrutiny should be made in the upper cervical spine and prevertebral space. In this case you will notice that there is enlargement of the adenoidal and tonsillar shadows with reduction in the nasal pharyngeal airspace. Another important observation is the increase in the soft tissue in the lower prevertebral region. Usually any soft tissue thickness more than that of the AP dimension of vertebra in the adjacent region is abnormal. In a slightly older child up to upper 3-4 vertebral level, soft tissue thickness is less than one third of the AP diameter of the vertebra.

Case 4

6-month-old child with fever and neck rigidity

In view of earlier exposure to a similar radiograph, you might have observed increased soft tissue thickness in the prevertebral region, starting right from C1/C2 level, extending down. You should see whether there are any air pockets in the soft tissues, which will indicate that lesion is likely to be an  abscess. Another important thing to look for is possible radiopaque densities due to foreign bodies–like fish bones. 

This patient had a further contrast CT evaluation. Do you have a diagnosis now? Well,  diagnosis of retropharyngeal abscess should be made in this case. You will see that hypodense collection is noted in the retropharyngeal region, predominantly on the left side in the upper part, confluent below. Indeed most of the retropharyngeal abscesses result from necrotic retropharyngeal lymph nodes on either side of the midline. Normally there may be a partial or complete midline septum, which will be destroyed in large abscesses. There may be bilateral non-specific lymphadenopathy. Middle ear catarrh may be present due to eustachian block. Careful attention should be paid to the adjacent vessels, especially jugular veins for possible thrombosis. Did you notice a subtle intraluminal defect in the jugular vein? Radiology trainees should explore this entity further, also should revise the anatomy of the prevertebral spaces and compartments.

Case 5

This young adolescent male presented with difficulty in breathing and recurrent nasal bleed. If you have carefully observed the sections, the diagnosis is clearly evident. This is another Aunt Minnie Case of a Juvenile nasopharyngeal angiofibroma. Attention should be directed towards demonstrating the epicenter of the mass. Often, the sphenopalatine region – pterygopalatine fossa is the epicenter. Note the widening of the left pterygopalatine fissure. Bone bowing and destruction could be a feature. In this case, extensive destruction is noted in the medial wall of the left maxilla and skull base. The lesion is extremely vascular, supplied by the external carotid branches. Pattern of the extension is of interest when planning surgery. Vasular studies are useful in planning embolisation, which is often performed before surgery.

Case 6:

This is a 60-year-old patient with the difficulty in speaking, hoarseness of voice and occasional dyspnoea.

Familiarity of normal structures and normal variations are essential for making observations in the sections of the neck. If you carefully observe in this case that there is a asymmetry in the orientation of laryngeal apparatus, due to a soft tissue mass in the posterior part of piriform fossa, extending down to the level of the right vocal cord. Involvement of the laryngeal cartilage is an important information for patient management. Due to large number of variations in the calcification of the laryngeal cartilage, sometimes the decision is difficult. In this case there is obvious destruction of right thyroid Lamina. Surger is preferred over radiotherapy if laryngeal cartilage is involved.

Case 7:

58-year-old male presented with the throat pain, difficulty in swallowing a few months duration. Contrast-enhanced images of the neck are available at various levels. You can note that there is a grossly enhancing soft tissue mass in the posterior part of right pyriform fossa. Description of all masses should include physical dimensions, epicenter, pattern of spread and involvement of important adjacent structures and lymph nodes. In this case you can notice necrotic, enhancing lymph nodes at level 2 on the right side. It is also important to document peri-nodal spread and vascular occlusion/encasement if any. Axial measurements above 11mm are considered abnormal. Level II nodes tend to be bulky, measurement  up to15mm may be seen in begin processess.

Case 8

17-year-old male with the recurrent nasal block, difficulty in breathing with stunted growth. Coronal images of the paranasal sinuses are provided

CT of the sinus requested occasionally in cases of recurrent sinusitis. Acute sinusitis generally presents on imaging with the air-fluid levels in the sinuses. Chronic hypertrophic sinusitis shows polypoidal mucosal hypertrophy, opacification of the sinuses with thinning of the wall. Sometimes sinus contents may be hyperdense. Chronic sinus disease is noted in patients with known bronchial allergy, dyskinetic- cilia syndrome, cystic fibrosis and Wegner’s granulomatosis. This patient had cystic fibrosis.

Case 9

40-year-old male with neck swelling of long duration. CT images in the coronal plane are provided. Perhaps this is a very simple diagnosis. There is a large lipoma on the left side of the neck.  What is the plane of the swelling? This is where radiographic analysis comes in the picture. This is located in the superficial cervical plane. Often benign lesion tend to be limited to the space. Invasion across planes may be one of the signs of malignancy. Trainee radiologist are recommended to review the anatomy of the neck planes.

Case10

53 year old male patient with difficulty in swallowing and trismus.

Contrast-enhanced axial coronal and sagittal images are provided. Certainly you will observe an enhancing mass on the left side, located in the oropharynx. The task here is to make a systematic analysis of the disease location and extent. Lesion is epicentered in the oropharynx extending anteriorly to the posterior aspect of the tongue,superiorly to the retromolar region-infratemporal fossa and inferiorly extending to the suprahyoid neck. Concept of epicentre and pattern of spread is very important in the analysis of neck masses. Special attension to be paid to look for perineural extension. If suspecious on CT, contrast enhanced MRI need to be performed. Also defining the lesion in relation to the anatomical compartments are helpful for the surgeons.

Case 11

60-year-old male with the trismus and right facial pain.

Contrast-enhanced coronal and sagittal reconstructions of CT neck are provided. This is a classic case to show mass in the infratemporal fossa, extending to the intracranial space. Abnormality is seen as an enhancing mass in right infratemporal fossa with extension to the intracranium in the form of a localised bulge in the region of the foramen ovale. This pattern is fairly typical, leading to a localised bone destruction, permeation and extension into the adjacent subdural space in temporal fossa. It is important to identify whether there is an additional perineural spread along the trigeminal nerve and branches, better demonstrated with contrast-enhanced MR technique.

Case 12

This is a middle-aged lady with a large swelling in the anterior part of the neck presenting with the dry cough. 

CT examination is presented with images in multiple planes. You might notice that I am not trying to challenge you with this case, rather show how imaging can add value to the assessment of a clinically obvious mass. This is a large multinodular goitre showing necrotic areas. Both lobes of the thyroid are hugely enlarged. Also there is an extension of the mass into the upper mediastinum. We can see that the trachea is grossly compressed and displaced, the right tracheal wall showing a large indentation with compression of air column.

Case 13

2-year-old child with the swelling at the medial aspect of the left eye since birth. 

Axial CT images are provided in the soft tissue and bony window. This is a good clinical case. Location of the lesion itself is somewhat diagnostic of the entity. On imaging we have a homogeneous soft tissue density along the medial aspect of the left orbit. Lesion is outside the plane of the orbital cone. No special features are noted in the image in terms of the calcification or abnormal soft tissue density. Do you have a diagnosis? This is an orbital dermoid. The differential diagnosis like a sebaceous cyst, lachrymal sac lesion or any soft tissue tumour in this location can be entertained. Why do you think we looked at the bone. Of course there are two major reasons- one is to exclude a bone defect due to rare entities like an encephalocele. Second, secondary focal bone remodeling or deformity of can be seen in some cases of a dermoid. Occationally intrensic charecters of the lesion like fat and calcification may be shown.

Case 14

This is a 3-year-old child with difficulty in breathing. Lateral view of the nasopharynx is provided.

There is a simple observation on the radiography. Nasopharyngeal air space is not seen, instead the space is occupied by soft tissues of the adenoids. Adenoidal measurement is shown in the second radiograph (orange line) normally this soft tissue is less than 15 mm. Additional soft tissue is also noted in the region of oropharynx (circled by a green circle). This combination may lead to considerable airway obstruction and sleep apnoea. 

Case 15

52-year-old male patient with neck pain and fever. 

Contrast-enhanced CT images are provided in the axial, coronal and sagittal planes

Lesion is quite obvious in the form of a lobulated hypodensity with  a subtle minimally enhancing wall. Lesion is located posterior to the carotid sheath, causing anteromedial displacement of vascular structures. Also lesions are oblong extending down just behind the sternomastoid. This patient had no abnormalities in the oropharynx and larynx. The possibilities include collection secondary to necrotic nodes, often due to tuberculosis. Malignant nodes with necrosis can mimic this appearance. Often areas of enhancement are asymmetrical and intense. Spine is normal in this patient.

Casr 16

60-year-old patient with difficulty in swallowing. Patient had a painful swelling on the right side of the neck for a period of few weeks. CT with contrast of the neck is provided with reconstructions in the coronal and sagittal plane.

There are two major observations in this examination. One is that of a soft tissue enhancing abnormality in the post-cricoid region extending downwards, likely representing a neoplastic process. Second abnormality is seen as an irregular hypodensity with air pockets on the right side neck adjacent to the thyroid cartilage. Second abnormality is likely to be a complication either due to  a fistulous connection from the invasive mass or iatrogenic event if attempts are made to pass NGT or any tubes to negotiate the growth. Air pockets in the abscess can result from either event. This painful swelling is unlikely to be a necrotic lymph node in our case. Occasionally necrotic nodes in a pyogenic setting can show air pockets due to gas forming organisms.

Case 17

44-year-old male with pain while swallowing.

MRI images without and with contrast are provided. Some time is required to look at all the images provided. Detection is not difficult as lesion stands out as an area of T2 hyperintensity on right side of the palate, at the soft and hard palate junction on right side. T1-weighted images are  also providing important information. Lesion is somewhat well defined, nearly homogeneous with subtle areas of the necrosis/cystic changes. Location of the lesion and morphology point to a possibility of a adenoid cystic carcinoma. These lesions tend to be more localized and lobulated as against the infiltrative lesions of the squamous carcinoma. Systematic analysis however is a must; all the surrounding structures including bones and lymph node imaging must be performed. Signs of regional perineural spread should be looked for in the form of enlargement of the neural foramina, nerve enlargement and/or enhancement.

Case 18

8-year-old child with the breathing difficulty, a soft tissue nasopharyngeal mass was seen by the ENT surgeon

CT images and the Sagittal reconstructions are provided.

This is an Aunt Minnie diagnosis. Things to observe opacification of left maxillary sinus, soft tissue density in the left nasal cavity, homogeneous, hypodense nature of the soft tissue and well-defined rounded margin of the density in the oropharynx– all point to a diagnosis of antro-choanal polyp. Notice that the medial wall of the left maxilla is defective.

Case 19

10-month-old child with irritability, poor feeding and suspected the swelling around the left ear.

CT plain, contrast-enhanced images and bone windows of the petrous region are provided. This is one of the classic presentation of the mastoid disease in the child. It used to be more frequent in the past. Clinically it is called the Bezold abscess. You might notice on the CT scan that there is a destructive lesion of the mastoid involving middle ear and external auditory canal on the left side. This is result of bone involvement secondary to chronic recurrent otitis media. Did you notice the position of left malleus? I am sure, you have noticed the bone defect in the mastoid and the adjacent diffuse soft tissue swelling. Role of imaging in this context is to look for intracranial extension, dural sinus venous thrombosis and any signs of meningitis. In this patient intracranial structures were normal.

Case 20

25-year-old female with facial swelling for 4 years duration. On examination there is  painless, boggy compressible swelling in the left Malar area.

MR examinations are provided in various planes with the T2 weighting. (T2 and STIR)

Lobulated T2 brightly hyperintense lesion (Light bulb lesion) is noted in the soft tissues of the left side of cheek extending into the buccal space and retro-antral region. Lesions do not have aggressive margins. There is no indirect evidence of vascular components. There is mild mass effect. These lesions tend to be either lymphovascular or lymphatic malformations. Sometimes lesions have fatty components leading to T1 hyperintensity.This condition can be a mixed venous malformation or a lymphangioma. Lymphatic malformation.

Case 21

21 year old female with right facial fullness. Investigated elsewhere with a diagnosis of a soft tissue lesion. Axial and sagittal T1 and T2-weighted images are provided.

One more typical presentation of a skin covered vascular-lymphatic malformation. Lesions are bright in T1 and T2 sequences.Hence lipomatous components may be predominant in this lesion. Occasionally T1 brightness in the lesion may be due to subacute haemorrhage, in that context lesion may be very painful clinically and may have a h/o sudden increase in the swelling in the recent past. Detailed mapping of vascular elements need to be carefully scrutinised in any suspected vascular malformation in the face. Study can be supplemented with contrast  enhanced dynamic angiography. There is a lot of scope to look at additional informations about malformation like perfusion patterns, vascular vs, interstitial components etc.  with MRI, information derived might sometimes help in planning therapy and in patient follow up.

Case 22

57-year-old male patient with pain while eating. Patient is a known tobacco chewer. Mouth opening is limited.

CT examination of the oral cavity is provided.

CT of the oral cavity is done with a technique called puffed cheek CT(PCCT), in which a patient blows his oral vestibule to distend the vestibular cavity during the study. This technique is very much required for detecting relatively small lesions in the oral cavity. Observations are fairly simple in this case. There is asymmetrical distension of the oral vestibule, left side not showing adequate distension. Reason for lack of distension is clear. There is thickening of the buccal-mucosal complex of the vestibule on the left side almost extending from the canine to the retromolar region antero-posteriorly. Also some fat stranding is noted from the posterior vestibule to the region of anterior margin of masseter. Superior-inferior extent of the lesion is shown in the coronal view, wherein lesion extends up to the inferior Ginvo-Buccal sulcus. There is no involvement of the medial pterygoid or infra temporal fossa(ITF).  And no obvious bony erosions are noted, which should be specifically looked for in the bone window. This is an extensive squamous cell carcinoma of left side of the oral cavity.

Case 23

58-year-old patient with severe headache, nasal bleeding and nasal block.

CT and MR images of the nasal cavity are provided.

This patient, as obvious in the images, has a mass in the left upper nasal cavity which is causing bone destruction involving the medial wall of the ethmoid, nasal bone and cribriform plate. Lower nasal space is intact. Part of the disease is bulging into the left orbit. More important information required in this patient can be obtained with a contrast-enhanced MR. As it is obvious in the MR, there is intracranial extension of the disease in the form of an enhancing soft tissue in the region of the cribriform plate and the adjacent medial naso-orbital roof. Margin of enhancing mass is somewhat irregular, indicating dural transgression. This can be a typical presentation of an olfactory neuroblastoma. Some nasopharyngeal carcinoma as can present with the similar features

Case 24

This is a 4-day-old infant with an external ear abnormality. Axial images of the CT of petrous bone are presented. 

Though a two decade old exam, findings are obvious in the study. When ear abnormalities are suspected, observation starts from the external ear, all the way to the neural posterior fossa intracranial structures. CT is superior for detection of bony anomalies. Whereas MRI is required for assessment of the neural structures. In this case you will notice that the external ear is abnormal, represented by a soft tissue nodule. You will also notice that there is absence of external auditory canal, area represented by an atresia plate – bony structure adjacent to the middle ear. Middle ear cavity is partly developed and opaque. There is some ossicular structure present. Inner ear structures appear to be normally-developed and symmetrical. In view of the potential treatment option with cochlear implantation, radiological evaluation of the ear has taken an important role. Very precise interpretation, specifically tailored to the surgical need has become a need of the hour.

Case 25

A 25-year-old male presented with a complaint of fullness in the throat. ENT examination revealed a suggestion of mass-effect on the right lateral aspect of oropharynx.

Plain and contrast-enhanced CT images are provided. 

This is an old examination, and the presentation is intended to enhance your ability to observe certain basic anatomical facts in the cervical region. To start with I will pose a question,  Is there an abnormality in the examination? In the CT examination of the neck one of the important landmarks which can help us to precisely locate the abnormality is the fat in the parapharyngeal space. In this patient parapharyngeal fat planes are preserved on the left side but you do not see them clearly on the right. On careful scrutiny, perhaps with minimal magnification of the image, you will see a lobulated ,hypodense, soft tissue density on the right side, around which fat planes of the parapharyngeal space  are enveloped. Did  you notice the location of the carotid sheath? If you did not notice it in the plain scan, you can see in the post-contrast study. This abnormality is anterior to the carotid sheath, extending into the parapharyngeal space without invading it. So this lesion is, either arising from the anterior carotid sheath or located in the parapharyngeal space itself. MRI examination perhaps can add something more in localizing this lesion. Differential diagnosis would include neurogenic tumours, salivary-rest tumors ( pleomorphic adenomas), lymph nodes  and mesenchymal tumours. This patient did not undergo surgery at our institution.

Case 26

A 52 year old female presented with the gradually increasing painless soft tissue swelling on the right side of the face and cheek.

MRI examination (plain and contrast-enhanced) of the craniofacial region is provided.

This is an interesting illustration with a variety of imaging observations. Complete interpretation of this entity is challenging and a learning experience. Initially you should concentrate on T2-weighted images and corresponding T1-weighted images. You will notice that there are many areas of  intense T2 signals separated by hypointense septae. Lesion is predominantly in the subcutaneous soft tissues at the level of the mandible. Additionally you will notice that there is a similar abnormality filling up and expanding the right maxillary sinus. Lesion does not have clear borders, and appears to insinuate into masseter. Character of the lesion on the MR signal highly suggest a possibility of  fluid-filled spaces separated by septations. Subsequently look at the gadolinium enhanced images. You will see extensive enhancement and the lesion is extending to surrounding tissue planes, mainly along the infra-temporal and temporal fossa. Maxillary sinus component of the lesion shows peripheral enhancement however contents do not. The question is are we dealing with a benign process or a malignant one? Predominantly cystic/fluid component of the lesion leads to an impression of a benign process. However lesion is not respecting boundaries. This unique combination is seen in the vascular malformation, particularly the mixed arterial venous type of a vascular malformation. Lympho-venous malformation also simulates this appearance. Cystic hygroma shares many observations of this lesion, but lacks vascular elements. The larger venous components sometimes occupy sinus spaces, like in this case the cavity of right maxillary sinus. Final impression is not easy to make on MRI alone. You need to look at the CT scans and to appreciate some important elements, 1. Look for phleboliths in the soft tissues  2.look for bony changes in the form of proliferation,expansion, remodelling and coarse trabecular pattern.

You are additionally provided with CT images in the axial plane without and with intravenous contrast. You will notice very similar information regarding soft tissues, showing density with cystic spaces with septation. Density of the lesion is variable. Multiple phleboliths are noted in the soft tissues. Bone shows remodeling, not destruction. Also you will notice that the right maxillary sinus shows fluid contents.  probably due to a large venous aneurysm occupying the sinus cavity.

Case 27

A 31-year-old male patient had a recurrent headache and a hearing abnormality. He was investigated and subsequently operated. We have few preoperative images and plain and contrast-enhanced postoperative MR examination.

This was one more good referral case. If you look at the initial T2 and FLAIR images, you will see the extent of lesion. Lesion is extending obliquely from medial mid skull base to petrous region with some changes extending to the mastoid. In the T2-weighted images the lesion is somewhat circumscribed, Lobulated and shows T1 brightness. There are few T2 hypointense areas within. Lesion is located posterior to the lateral pterygoid muscle. Part of the lesion in the mastoid process appears to represent fluid-filled mastoid air cells, as the septations are preserved. All these areas are bright on FLAIR sequences and are bright on diffusion-weighted imaging, showing diffusion restriction. Any guesses about the diagnosis? This is a typical exam case for the resident. Bright on diffusion, bright on T2 and FLAIR is a combination that you often see in  a cholesteatoma, in this region. This is likely to be a case of a congenital cholesteatoma with the involvement of the petrous apex and adjacent infratemporal fossa. Changes in the mastoid air cell appear to be secondary to compression of the eustachian tube. This patient underwent surgery. Postsurgical MR shows a surgical bed in the left temporal fossa, mostly containing T1 hypointense foci? Residual calcific elements.  Lesion has been removed,confirming the diagnosis. Extensive enhancement is noted in the adjacent infra-temporal fossa.

Case 28

Given images demonstrate an abnormal head shape. Is it a form of craniosynostosis or a positional plagiocephaly? Indeed this is a likely question that will be asked on imaging. Craniosynostosis should have signs of sutural obliteration or fusion. Usually deformities center around the suture involved and secondary remodelling in the rest of the skull. On the other hand positional plagiocephaly is due to prolonged positioning in a particular position, in the setting of a soft skull bone or a premature baby. Sutures are preserved in positional plagiocephaly.  Our patient has a large head due to communicating hydrocephalus. Additionally there is flattening of the right posterior aspect of the skull, mostly involving the occipitoparietal region. We are able to see the unfused sutures. In patients with positional plagiocephaly, deformity follows the rules of a parallelogram– flattening on one side is compensated by a bulge on the other, so that overall volume is maintained. 3D imaging helps to understand skull deformity better. Occasionally early fusion is better appreciated on the 3D surface rendered images.

Case 29

A 7-year-old male presenting with epistaxis and nasal block for 6 months duration.

Axial contrast-enhanced and coronal bone window images are provided.

This is an additional case of a mass in the nasopharyngeal region. As mentioned earlier epicentre of the lesion is of great importance in identifying likely sites of origin. You will notice that there is a large intensely enhancing mass on the right wall of the nasopharyngeal region with an extension to the adjacent posterior right nasal cavity. Despite the large mass bone is not significantly destroyed. Opaque right maxillary sinus is probably due to ostial occlusion by the elements of the mass.

Lesion is seen to displace the parapharyngeal space laterally. No obvious enlarged lymph nodes visualised in the examination. In this age group intensely enhancing lesions in this location is generally an  angiofibroma. Though typically they arise in the location of sphenopalatine foramen, location of the lesion can be located along the lateral pharyngeal wall or occasionally in the nasopharynx.

Case 30

This 2 yr-old child was brought to the consultation because of a swelling in the tongue and difficulty in feeding. Child had previous hospital visits and had imaging studies. MR imaging is the ideal modality for characterising soft tissue masses in the head and neck region. You have been provided with plain and contrast enhanced MR examination.

Several images and mixed imaging characters of this patient can make the interpretation extremely difficult. A systematic approach is recommended starting with the lowermost section and moving upwards for additional observations. I expect you to see a T2 hyperintense well-defined lesion on the left side of the tongue, almost occupying the ipsilateral half of the tongue. Part of the lesion appeares to extend down into the submandibular region. Lesion appears multiloculated. Any idea what could be aetiology? 

Well, I hope you have some suggestions and must also be looking for additional lesions!  There are lesions with a T2 bright areas in the nasopharynx perhaps arising from the left lateral wall of the nasopharynx. There are some additional foci of T2 brightness in the posteromedial aspect of the right parotid gland.  Most of the lesion on T1-weighted images has mixed signal with the predominant low T1 signal in the tongue component. Nasopharyngeal lesions demonstrate areas of T1 brightness.  There are additional images with contrast provided for gathering more clues about nature. Lesion appears to enhance intensely in the region of the tongue with some non-enhancing areas. However, the quality of the contrast enhanced imaging is not very great. At this stage it is supposed to provide some diagnosis.  

In this young patient such lesions can be either lymphatic or vascular origin. Cystic hygroma/lymphangioma or frequent lesions in the face and tongue in particular. Some of this complex malformation can have a vascular element as well.  Can we suggest any additional possibility?

We have a CT examination with a soft tissue window and the bone details in this patient. There are no additional information about the lesion of the tongue which appears to go with the MR observations. Nasopharyngeal lesion shows small foci of calcification and fatty components. Considered in isolation, nasopharyngeal teratoma can present with this appearance. In this patient this can still be a component of vascular lesion containing foci of fat and phleboliths. Bony structures are not involved in this patient.

Case 31

This is a 11-year-old child with nasal obstruction; epistaxis and headaches who came to the institution for a second opinion.

MR examination plain and contrast is provided.

This is a diagnostic challenge in terms of localization of the lesion as well as predicting the pathological nature.

In all the sequences the lesion stands out as a T1 hypointense, T2 bright abnormality in the region of the nasopharynx, epicentered along the right postero-lateral wall. Extent of the lesion is extensive- anteriorly extends to the right nasal cavity occluding the drainage of the right maxillary sinus. Also involves the right orbital apex. Posteriorly it extends to the clivus, inferiorly extends to the infratemporal fossa. Superiorly it extends into the sphenoid sinus and sella turcica leading to displacement of carotid siphon.  There is extensive enhancement lesion with some non-enhancing components in the right maxillary and the ethmoidal sinuses.  There are some additional observations like extremely enlarged lingual tonsils. Based on this observation and age of the patient some differential diagnosis can be entertained. Important thing to realize is that there is an aggressive nasopharyngeal lesion and some changes which are present secondary to ostial occlusion of sinuses, overall appearance is contributing to the apparently huge mass. The etiology for such abnormality can be categorized as follows. One group will consist of PNET tumours, either soft tissue or bony origin. The second group of diseases should include sarcomas. Lymphoma is another entity which is present with such an extensive involvement.  Nasopharyngeal carcinoma, pleomorphic adenoma are seen in adults. This patient had an undifferentiated sarcoma.

Case 32

21-year-old female, difficulty while chewing. Had history of fever before.

CT examination of the maxillofacial region is provided.

I assume you have noted sclerotic changes in the left mandibular head and ramus on the left side. The bone is expanded, sclerotic and shows some amount of spiculation/remodeling along the medial and lateral aspects. Temporomandibular joint space appears preserved. There is a soft tissue element on either side of the ramus with the bulging lateral pterygoid muscles and masseter. No obvious collection is visualized. Do you think this is likely to represent a Neoplastic process or an inflammatory process? Although theoretically both possibilities have a reasonable chance of being correct. But there are more findings in favor of the inflammatory process. In fact this is a case of a sclerosing osteomyelitis of the mandible with surrounding inflammatory changes in the masticator space and infratemporal fossa. In children with similar appearance can be seen in patients with Caffe’s disease. Patient was treated with antibiotics and showed a good response. FNA/core needle biopsy may be needed in borderline cases.

Case 33 : 32-old male presented with the left upper limb pain and weakness on exertion.

Case 33

32 old male presented with the left upper limb pain and weakness on exertion. He was evaluated with the cervical spine frontal and lateral views and MR examination without and with intravenous contrast.

This is a test for the resident and I expect them to make an observation on plain radiography and plan for discussion. In an examination situation, few observations made on the plain radiograph should make sense and initiate discussion. Any positive observations? What are the other important negative observations?

I will be glad if you have noticed soft tissue swelling in the lower neck, apparently increase in the prevertebral space. There is an air lucency oriented longitudinally. (Likely representing air in oesophagus) Bony structures are normal. There is no enlargement of the intervertebral foramina. Now you scrutinise the MR examination.

With the multiple images provided you have to follow a systematic strategy. Initially look at the T2 parasagittal images upper right. You will be able to see that intervertebral foramina at the C7/T1 level is obscured by an oval lesion. Lesion is T2 hypointense with this hyperintense centre. If you follow this in the rest of the sequence with contrast, you will realise that it is an oblong lesion along the exiting nerve root of brachieal plexus. It shows intense enhancement except for the necrotic center. We are dealing with a schwannoma of the left C7/T1 nerve root. There is minimal mass-effect on the adjacent vascular structures and the scalene muscles

Case 34

Evaluation of proptosis can be tricky, when it is bilateral and subtle. CT imaging provides measurements. Anterior part of the cornea is measured from the plane of inter-zygomatic line. Normally measurements are less than 23 mm from anterior part of cornea. Posterior sclera approximately measures 9–10 mm mm

Aetiology for proptosis may very from systemic disease to local pathology. Amongst the systemic disease thyroid orbitopathy is a leading cause. It is also associated with thickening of the muscles.Commonly involved muscles are inferior rectus, medial rectus and superior levetor.

Local disease of the orbit and adjacent sinuses and bony structures can also lead to unilateral proptosis. Sinus pathology, lymphoma, pseudo-tumor and hemangioma are frequent causes. Some interesting and unusual causes of proptosis include carotid-cavernous fistulas and neurofibromatosis.

Case 35 

3-year-old child with a history of a neck injury in a RTA, limited neck movements.

Plain films frontal and lateral views of the cervical spine and a CT examination is provided.

In young children there is flexibility of the musculoskeletal system. Ligamentous injury is more prevalent than the obvious bony injuries.

Plain radiographs in this patient demonstrate a minor subluxation C2/3 level. Some radiolucent area is suspected in the posterior element of C2. The Atlanto-odontoid distance is slightly wider. But the most striking observation is a prevertebral soft tissue swelling. Interestingly CT examination does not demonstrate evidence of bony injury. Also the atlanto-odontoid relation is also normal. Findings are most likely to be ligamentous hyperflexion neck injury.

Case 36

Neonate with breathing difficulty.

CT examination of the nasal cavity is performed. Since you already seen an example nearly similar to this, it may be a straightforward diagnosis. This patient has a bilateral choanal atresia, classical observation with narrowing of the posterior nasal apertures. Also there is a membranous occlusion. Unilateral involvement can go unnoticed in the neonatal period. The abnormality may be part of CHARGE syndrome wherein apart from choanal atresia, cerebral and cerebellar anomalies, coloboma, congenital heart disease, genital abnormalities and ear/petrous bone abnormalities can be present.

Case 37 : 

There is a child with soft tissue swelling in relation to the left eye with the inability to perceive light.

Single CT images of the brain and axial images of the orbits are provided. In the given CT ibrain mages there are of no abnormalities. In the orbital axial images, you  will note that there is a small tag of soft tissue at the lower part of the sclera extending to adjacent subcutaneous soft tissue. Proximally there was extension to the adjacent cornea which was showing an anterior bulge. There is anterior coloboma with absence of lens. Clear radiological diagnosis in this entity is difficult. Mass lesions arising from sclera-corneal junction could be considered. However these observations do not explain observations in the eyeball and aphakia. The lesion was resected. Evaluation of the specimen revealed a choristoma, lesion containing neural tissue. Entity is described as anterior segment epibulbar choristoma. Choristoma is a tumor-like mass consisting of normal cells in an abnormal location. Patient had a left eyeball prosthesis.

Case 38

Soft compressible neck swelling in pediatric age often turn out to be lymphatic or vascular malformations. This patient has a localized , unilocular, subcutaneous  swelling on right side.There are few thin sepations appreciable on CT. This are no major vascular elements. Sonography or MRI may throw further light regarding internal structure. This lesion has features of macrocystic lymphatic malformation.

Case 39

Ultrasound and CT imahes of neck are provided. Clinical presentation is very similar to the earlier case, except for location of the lesion. Midline lesions below thyroid can be due to thyroid remnants. Hence it is important to document the thyroid anatomy. Lesion is well defined, does not have retrosternal component. Internal nature of this lesion shows' low level internal echoes. Differential diagnosis include, sebaceous cyst, dermoid cyst or a lymphatic malformation

Case 40

A 23-year-old lady with a bluish swelling of the lower lip and cheek is evaluated with the MRI, MRA and selective angiography. Have you made your observation in the MR examination?. Soft tissue swelling of the lower lip is obvious, showing areas of signal voids (seen as dark spots). This is due to rapid blood flow in the enlarged vessels. There is thickening of the subcutaneous tissues and signal voids are extending to the chin. Additional information about the extent of enlarged blood vessels is shown on the MR angiography. There is gross enlargement of the branches of facial arteries which are extending to the vascular malformation in the region of lower lip. In different phases of MR angiography you will sequentially observe enlargement of both facial arteries, internal maxillary arteries feeding the vascular components and interstitium of the malformation. Selective angiography of the facial artery demonstrated arteriovenous shunting through a leash of blood vessels (nidus). Enlarged anterior facial veins are noted. Nidus is also visualised in the form of the diffuse contrast opacification. Arteriography is not performed for diagnostic purposes as information is available from other imaging modalities like CT, MRI and sonography. Angiography is needed for evaluating the feasibility of interventional therapy. Lesions when small, supplied by defined vascular territory, can be managed with embolisation using varieties of interventional options. However in the facial region due to abundant supply from vessels from both sides, and which network of vessels requires a different management Strategy.

Case 41 :

We have a set of x-rays from this patient starting with the lateral view of the nasopharynx. Observation in the radiograph of nasopharynx is simple, in the form of increased prevertebral soft tissues and obliteration of the nasopharyngeal airspace. Bony structures are normal. This observation along with the clinical impression of enlarged tonsil may suggest a reasonably large mass in the Oro/naso-pharyngeal region. 

Subsequently we have an MR examination which demonstrates a large mass left parapharyngeal region centred on the oropharynx. Lesion is T2 bright, extends from mucosa to the parapharyngeal soft tissues. There are areas of mucosal and lesional contrast enhancement. Also an ulceration is demonstrated along the lateral aspect. There is no obvious regional lymphadenopathy. This is time for differential diagnosis. In the present context inflammatory lesions of the tonsil/oropharynx is likely. Other differential diagnosis can include tumours of the tonsillar bed or lymphoma. This patient had a histological diagnosis of lymphoma. Majority of the tonsillar lymphoma B-cell lymphomas. Large majority of the lesions are advanced at presentation. Tonsillar lymphoma generally present in elderly male with a median age in the second decade.

Patient has a further CT evaluation of the abdomen. No evidence of other lymph nodes are visualised. Incidentally there is calculi in the gallbladder, slightly unusual in a patient. There are few followup CT images, after a contrast study of the upper GI. Deep ulceration is appreciated in the region of the oropharynx with reduction in the size of the mass.

Case 42

Acute painful parotid swelling are generally due to suppurative parotitis. These were common in the earlier days. Now with due antibiotic coverage, incidence has fallen. Our patient we have a painful cystic lesion with moderately defined borders. This is a parotid abscess. Post drainage there was complete recovery.

Case 34

Findings are subtle in this patient. We have axial CT and MRI images. Did you identify the abnormality? Well abnormality is seen in left petrous apex in the form of localized T1 hypointese, T2 hyperintense lesion. On CT lesion is hypodense. This lesion may represent fluid filled petrous air cells due to apical petrositis. Only tangeble DD is a congenital cholesteatoma. Associated inflammatory signs suggest apical petrositis as a likely posssibility. It is important to familiarise with pneumatisation pattern of the skull base. Occationally process of pneumatisation is very extensive. Some ares of practical importance are petrous apices , roots of pterigoid plates and anterior clinoid processes

Case 45

This patient presented with a painful trismus and the left facial swelling. Presentation is somewhat acute. Axial CT images without and with contrast are provided. Main observation is that there is a circumferential soft tissue density in the masticator space. This space houses the muscles of mastication, masseter, pterygoid and temporalis–is tightly bound by a fascia. What is causing the swelling? I hope you will make two important observations. One is regarding the mandible which is somewhat irregular and appears eroded. The second important observation is the presence of tiny air pockets randomly  spread in the soft tissues. When you see this kind of combination you are looking at an acute abscess, in this instance probably secondary to an osteomyelitis of the mandible. This patient had a dental procedure before this episode. The density of the lesion is not purely cystic so there is a sizable phlegmonous component. Incidentally there is some mucosal disease in the left maxillary sinus and non-specific regional lymphadenopathy.

Case 46

This case is presented more like a spot image. I am sure you will make a clear diagnosis of Lipoma, most likely located in the subgaleal plane. On CT like, as are easy diagnosis, characterised by low HU values. Scalp lipomatous may be associated with the local bony changes. Sebaceous cysts sometimes mimic, generally have a higher density. Did you notice that lipomatous lesions are present bilaterally? . The crude 3D surface rendered image of the good old day, is attempted using a free software.

Case 47

Young female with a facial deformity and abnormal dentition. Intentionally I have provided you with the 3D images to make you look at the clinical issues from a different angle. On these images certain observations can be easily made. You will appreciate what is causing facial deformity. 1. There is thickening of the left half of the mandible 2, there is an abnormal dentition with outward angulation of the teeth. Do you see the abnormal angulation maxillary teeth as well? Canine teeth almost project horizontally. What do you think is the likely cause? Intrinsic bone lesions like fibrous dysplasia can cause bone changes like this. Did you see any additional abnormality?  If you are familiar with the 3D facial images, you will appreciate that there are increased vascular components in the region. Grossly dilated, tortuous, and untapering lingual arteries and additional vessels are noted. This patient had a large vascular malformation of the tongue resulting in a grossly enlarged tongue–macroglossia. Part of the deformity is due to the huge tongue. Additionally there is bone hypertrophy. These cluster of observation are note in mixed venous malformations.

Case 48

This is a 25-year-old male with painless neck swelling. You had two axial CT images one without contrast with contrast opacification. Just with these two images can you make a sensible differential diagnosis?  I am certain that you're noticing this large, well-circumscribed oval lesion with peripheral enhancing soft tissues and relatively hypovascular centre on the left side of neck. You will also notice that the displacement of adjacent structures is very smooth– sternocleidomastoid, saliva glands and paraspinal muscles are displaced around the lesion with the intact tissue planes. Where are the carotid vessels? Well, this is the most important question to ask. You will see that carotid vessels displaced far anteriorly, lying close to the submandibular gland. This establishes the lesion in the posterior aspect of the carotid sheath, either in the posterior compartment or beyond the carotid sheath posteriorly. Benign morphology of the lesion and the location of the lesion indicate this could be a neurogenic tumour. This patient had a vagal schwannoma.

Case 49

This patient, elderly lady with a beetle chewing habit presented with painful tongue movements. Axial CT images with contrast are provided. It is important to identify subtle differences in the density of oral cavity structures for identifying abnormality. Normally muscles are somewhat isodense, and enhence to some extent. There are fat planes between the muscles which help to provide outlines and information for assessment. Salivary glands are hypodense, show enhancement, nearly symmetrically arranged. Vascular structures enhance intensely. Enhancement of the oral mucosa is variable, generally uniform. Though CT provides relevant information, technically MRI is a superior modality for evlauatuion of tongue.

What is your observation in our case? We do see enhancing soft tissues on the left side of the tongue, which extends across the midline in the posterior half. There is a deep ulceration along the lateral border of the tongue. Posteriorly lesion appears to be inseparable from the adjacent retromolar trigone presenting as a soft tissue density. These features are highly indicative of a malignant lesion of the tongue. Important observations to make is the extent of the disease to contralateral part of the tongue, into retromolar trigone, oro-pharynx and distant spread. Encasement of the neurovascular bundle (lingual artery, nerve) is an important component of assessment, Regional lymphadenopathy at level 1,2  and other levels has to be scrutinised. 

Case 50

This middle-aged patient with snoring and throat pain was evaluated with an MRI examination of the neck. Did you make necessary observations and a possible diagnosis? A homogeneous, well-defined nasopharyngeal lesion is noted with the mild T2 hyperintensity and marked T1/FLAIR hyperintensity. Lesion is centred in the superior wall of nasopharynx with partial obstruction of the posterior nasal posture. There are indirect signs of obstruction of the nasal cavity. Laterally the lesion appears to displace rather than invade the pterygoid muscles. What is the likely differential diagnosis? In this location there are two major contenders for diagnosis one nasopharyngeal carcinoma(NPC)  or other a lymphoma

Nasopharyngeal carcinoma. generally presents as an  asymmetric, invasive, ill defined mass without associated gross lymphadenopathy,(when compared to lymphomas). Regarding lymphoma, T-cell lymphoma or NK/T cell lymphoma are more frequent  in Asian geography, B-cell lymphoma in the West. Lymphoma lesions are homogeneous, well defined, may have intermediate signals in T1 images and hypointense-hyperintense on T2, a reflection of the variable to high cellularity. Occasionally diffusion restriction may be seen in the densely cellular lesions. This patient was diagnosed with B-cell lymphoma.

MRI can help to differentiate killer cell T-cell lymphoma versus B cell large cell lymphoma. ENKTLs were located in the nasal cavity, with ill-defined margin, heterogeneous signal intensity, internal necrosis, marked enhancement of solid component, whereas DLBCLs were more often located in the paranasal sinuses, with homogenous intensity, mild enhancement, septal enhancement pattern, and intracranial or orbital involvements . Using a combination of location, internal necrosis and septal enhancement pattern of the tumor accurate differentiation can be made between ENKTL and DLBCL 

Case 51

A 55-year-old patient with the painful chewing and mild facial swelling is investigated with CT examination of the mandible. You have bone and soft tissue windows. Observations are simple in the form of an expansile, well corticated osteolytic lesion in the angle of the mandible–extending to the ramus and body respectively. Medially, the cortex is breached. There are some loose teeth in relation to the anterior aspect of the lesion. Soft tissue windows show intralesional loculated components. Lesion shows attenuation values between 20-30 HU. No signs of invasion of the surrounding muscles. This makes case for an osteolytic mandibular region with mixed features. ( benign-aggressive) One entity that fits this description is ameloblastoma. Radiolucent lesions of the mandible can be of odontogenic or non-odontogenic origin. Odontogenic group represents conditions like dentigerous cyst, radicular cyst, keratocyst and ameloblastoma. Nonodontogenic osteolytic lesions in the mandible include simple bone cyst, eosinophilic granuloma, giant cell granuloma and occasional metastasis. This patient underwent surgery and diagnosis of Ameloblastoma was confirmed. 

Ameloblastoma represents a tumor arising from the dental lamina, comprising 10% of odontogenic tumors. Lesion presents at 4-6th decade. Typically located in the posterior mandibular body. Although behaving like a benign lesion, some of them metastasise. Histologically they can be uni-cystic, multicystic, extraosseous or desmoplastic. Soap-bubble Appearance is one of the observation on imaging 

Case  52

A 36-year-old male patient with the neck swelling was investigated with a CT and MR examination of the neck.

This is a teaching case for neck spaces. Neck spaces constitute various compartments mostly defined by thickened cervical fascia, described as the superficial middle and deep cervical fascia. For most anatomic parts they separate the contents of the individual space, thus limiting the extension of disease from one space to another to some extent. Many exceptions do exist due to anatomic variations and specific disese spread pattern. Imaging identification and interpretation of neck spaces takes importance in disease localization and diagnosis.

 Which space do you think this lesion is located in? When you compare the left parapharyngeal space (PPS) from the contralateral space, the typical appearance of fat in the left parapharyngeal space is missing.Instead, there is an oval, large slightly heterogeneous lesion is noted lying obliquely in left PPS, displacing the airway medially and deep lobe of parotid gland laterally. There are some areas of fat density within the medial part of the lesion. Exact position of the carotid vessel is not evident in this examination. (was located posteriorly in the post contrast study). This location and appearance are typical for a lesion in the parapharyngeal space. Radiology residents are requested to go to anatomy and radiology references for description and importance of these spaces.

In the MR examination lesion is very well defined, confirming that the parapharyngeal space shows near homogeneous mild T1 hyperintensity and markedly T2 hyperintensity. The lesion shows multiple cystic areas, the largest locule lying laterally. Coronal views are very helpful in displaying the anatomy of the lesion and its relation to the pharynx medially and parotid gland laterally. MR appearance is that of a benign tumor. You can notice the clear separation of the lesion from the pharyngeal constrictor muscles. This patient was operated and found to have pleomorphic adenoma, a salivary rest tumor from the remnants of the salivary glands in the PPS. Post-operative studies reveal some postoperative changes in the parapharyngeal space. No significant tumor residue is noted 

I have included some diagrams along with this case. Complete description is not the intention of this web-based work. However, diagrams may refresh your memory about the location, extent of various spaces and likely ‘residents’ of the spaces. A list of lesions arising from each space should be made to facilitate interpretation.

Case 53

23-year-old patient with a nasal block, headache and slight proptosis. CT examination and follow-up studies are presented.  In this case you notice that there is opacification of the right ethmoid sinus. The contents of the sinus are hyperdense. And there are signs of expansion and partial destruction of the lateral wall of ethmoid sinus leading to proptosis. Lesion is extending down to the middle meatus resulting in occlusion of the ostia of the right maxillary sinus. With this information we can conclude that this patient has a chronic sinus disease, most likely fungal etiology. Signs of aggression and hyper density of contents are indications of a fungal involvement. Patient underwent endoscopic surgery and the ethmoidal lesion was completely cleared. However, the patient returned with recurrence on the contralateral side. Appearance is quite like what was observed on the right side. Subsequently that was also addressed leading to well aerated clear sinuses. Aspergillus is most likely a fungus involved in this case. Unlike mucor-mycosis the progress of the disease is slow. Imaging assessment is very important in defining the extent of the disease. Particular areas of interest at the medial orbital wall (lamina papyracea) and cribriform plate–to exclude intracranial extension.

Case 54

Next patient was an international visitor with gross facial deformity and a growing swelling around the mouth. He was treated with surgery elsewhere and came with the set of investigations done elsewhere. Perhaps this is of the most grotesque lesion in the region of face, aptly called as Leontiasis Ossea. It is a very advanced manifestation of fibro-osseous lesion of the facial bones. Fibrous dysplasia is the most likely cause. There is gross enlargement and architectural distortion of facial bones leading to obliteration of the nasal cavity. Maxilla and Mandible are affected mostly with the subtle involvement of the temporal bones. While most of the lesions appear to be sclerotic with some non-ossified areas, there is a predominant soft tissue component in the anterior part of the maxilla. Since this is growing aggressively, histological evaluation is essential for this lesion to exclude malignancy.

From the imaging perspective there are two elements to notice.  One is to appreciate the earlier 3D reconstructions. The second element is added here - A vascular study of the facial bones in fibrous dysplasia. You have multiple angiographic studies performed by selective catheterization of internal maxillary, facial and lingual arteries. You will notice that the lesions do have increased vascularity and a prolonged capillary stain. Generally angiographic studies do not have a great role unless one of the non-ossified components present with a severe bleed.

Case 55

Next patient is a rare disease involving the eye. Our young patient had a leukocoria on clinical examination. CT images are provided. You notice that the left eyeball is smaller, showing areas of multiple plaque like calcification in the posterior chorio-retinal area as well as in the lens. This condition is due to a condition, exudative retinitis (also called as retinal telangiectasia or coats disease)

This is a disease of the young patients, the majority present unilaterally. In the early stages of the disease exudative areas may be seen as choroidal hypodensities, showing contrast enhancement. Associated retinal detachment is often seen. Calcification however is a relatively rare observation. Small globe is a late finding. Persistent hyperplastic primary vitreous and the retinopathy of prematurity and retinoblastoma are the differential diagnosis.

 Case 56

A newborn with an enlarged, protruding tongue was investigated with an MR examination. This neonate had  an alarming clinical appearance with a mass bulging out of the mouth  with no possibility for oral intubation. Degraded quality of the MR image is partly due to a restless patient who was difficult to sedate.

Not many are fortunate/unfortunate to see such unusual cases. There is a unilocular cystic lesion in the tongue, which appears to be in the midline. There are no other elements in the lesion in the form of calcification, fat or formed elements.

Differential diagnosis of such large midline cystic tongue lesion are not many. Foregut duplication cyst, dermoid cyst of the tongue, a large macrocystic lymphangioma and the thyroglossal cyst can be considered. This patient did not have the features of a dermoid. Thyroglossal cyst tend to be more posterior in location. Macrocystic lymphangioma rarely symmetrical on both sides. This patient was diagnosed as a foregut duplication cyst and operated successfully. I have included an example from the literature. I recommend that the residents should read an excellent review by Matthew A. Haber on this unusual topic. 

Pediatric Tongue Lesions: An Often-Overlooked but Important ... Matthew A. Haber et al.https://www.ajronline.org ›   doi › abs › AJR.19.22121

Case 61

A- 9-year-old child with blindness in the right eye and decreased vision on the left was investigated with an MR study. This MR examination is very interesting in terms of observations. Right lobe is relatively small. The right eyeball demonstrates T1 hyperintense, T2 hypointense lobulated contents behind and confluent with the lens. There are subtle abnormalities on the left eyeball, in the form of thin septations within the posterior chamber,somewhat circumferentially arranged. Optic nerves appear small bilaterally. Rest of the orbital structures are normal. In this case we are likely to be dealing with a developmental anomaly with complicating subacute haemorrhage involving the right globe and some adhesions/fibrosis involving the vitreous chamber of the left eye. Typically in this age group conditions like PHPV or Coats disease can be considered. In a younger patient other differential diagnoses like retinoblastoma or retinopathy of prematurity can be the primary cause. Visualised intracranial structures are normal in this patient

Case 62

An 8-days old child with the external ear abnormality was evaluated with a CT of the petrous bone and CT brain.

It is obvious from the images that the external auditory canals are not present. Middle ear cavity however appears developed with an ossicle shown (malleus). Cochleae appear normal bilaterally. There is an enlarged vestibule on the right side, enlargement extending to superior semicircular canal- unusual anomaly. This is an unusual combination of external auditory canal and right vestibular apparatus. Additionally,this patient demonstrates hydrocephalus due to aqueduct narrowing.

Case 63

MR examination of a 5-year-old female child is presented. Patient has an asymptomatic swelling of the nose with an adjacent swelling.

Patient  has a subcutaneous soft tissue density merging with the nasal cartilage and extending to the adjacent cheek. Medial part of the lesion is somewhat circumscribed and shows T1 hypointense and T2 hyperintense structure. There are small islands of fat on the lateral aspect. Lesion partly enhanced homogeneously along the medial aspect. Differential diagnosis of lesions of this morphology is straightforward. Either we are dealing with a case of haemangioma or a mesenchymal lesion like fibro-lipoma.

Case 64

Sonography of the orbit is the domain of ophthalmology. During my practice I had a chance to perform a few of them, mostly in the neonates. It can be done with the high resolution transducers, during our time the maximal available transducer was 5-6 MHz. Now 12-15 or more MHz transducers are available for this purpose. Great details can be obtained with a higher frequency transducer. Proper labelling of the views are important for retrospective evaluation of the exam. We can perform closed eyelid or open eyelid techniques with abundant sterile jelly. Open technique needs local anaesthetic drops. Normally chambers of the eye and the details of the lens are clearly visible. Optic nerve head and the distal part is also visible. In the examination, multiple echogenic membranes are identified in the posterior part of the globe. There is a small focal projection anteriorly. Patient had retinal detachment. Contralateral orbit is normal.

Case 65

This case ideally to be presented at the spot radiograph. Since many images are present, I have included them in the section. Did you notice the abnormality?  There is a metallic foreign body in the posterior aspect of the right nasal cavity. Incidentally there is opacification of maxillary sinuses. Any idea as to the nature of this foreign body?  This can be a metal foil or a small aluminum component of a toy. I do not recall the post removal observations.

Case 66

2-month-old Child had a compressible swelling at the medial aspect of left orbit. Contrast enhanced imaging of the orbits were performed. Findings are straightforward in the form of a homogeneously enhancing lobulated opacity causing regional mass-effect.  There is no intraconal extension. No bony remodeling or defects noted. There are small dilated vascular structures demonstrated along the lateral aspect. Coronal views show part of the lesion extending above the globe. Findings are typical for a cavernous/capillary hemangioma. Hemangioma constitutes a very common condition in children. There are well established classifications based on morphology, clinical behavior and now incorporating some genetic information.

Case 67

This 7-year-old child was involved in a whiplash injury. Painful limitation of neck rotation was clinically present. Plain radiography and images of CT evaluation are presented. Observations are straight forward. There is soft tissue swelling anterior to the atlas. No obvious bony injuries noted.

Line diagram on the radiograph is not my way of making a diagnosis or impressing anybody. This was done by a neurosurgery colleague. Patient underwent a CT which shows a minimally displaced fracture of the odontoid tip. This is a relatively rare injury. Incidental note that anterior and posterior arches of the atlas are not fused, a normal variation. Clue to the normal variation is available in the coronal reconstructions, wherein relation of lateral mass and the Axis are maintained.

Case 68

This neonate had a sharp pointed nose deviated towards the right side. Facial Deformities are an important consideration for a patient. Sometimes structural information is required for management, thus imaging plays an important role.

CT examination was performed in this patient. You can appreciate that the anterior part of the nasal vestibule is blocked by soft tissue content. There is deformity of the nasal bone, both of them oriented towards the right side. Deviation of the nasal cartilage is also evident. However the main nasal cavity ‘proper’ demonstrates parallel orientation of the nasal space and a near-normal development of maxillary bones. Exclusion of anomaly of anterior,mid and posterior nasal cavity is important in this case. This deformity could be due to foetal malposition and subsequent bone/cartilage modelling abnormality.

Case 68.

MRI plain and contrast enhanced study of the neck was performed in a child with the rapidly growing swelling on the left parotid region and adjacent ear. The skin was reddish pink leading to a suspicion of a vascular lesion. MR images are somewhat characteristic, showing T1 hypointense cutaneous and subcutaneous lesions with the T2 hyperintensity. Grossly enlarged vessels with a signal void are noted in the subcutaneous tissues proximally and distal to the lesion. There are specks  of T1 hyperintensity in the lesion of the ear? areas of bleeding or foci of fatty components. T2 images show a somewhat heterogeneous pattern. There is intense enhancement of the lesion following IV contrast. This combination of observations are characteristic of a vascular malformation, perhaps a hemangioma in a phase of proliferation (RICH) is a likely diagnosis. In this phase lesions look very aggressive with large vessels, parenchymal proliferation and intense enhancement. Subsequently Involution of the lesion may be seen.

Case 70

A 3-year-old child was investigated for cervical lymphadenopathy. Patient had painless lymphadenopathy. Neck movements are minimally restricted. CT imaging with contrast and a coronal T2 MR image available.

Examination demonstrates multiple enlarged lymph nodes at level 2 and level 5 bilaterally. Lymph nodes have a globular appearance and slightly heterogeneous enhancement. MR image confirms somewhat T2 hyperintense homogeneous,symmetrically enlarged lymph nodes bilaterally. Close to the skull base there are necrotic irregular collections separated by an enhancing wall. There is confluent bone destruction of the occipital bone. Lesion extends up to foramen magnum breaching the lateral wall. Anteriorly lesion shows destruction of the petrous apex and part of the basi-occiput on the left side. Small intracranial extradural pockets are suspected. Cerebral and cerebellar parenchyma were within normal limits. In a child this pattern either indicates an aggressive malignant lesion like rhabdomyosarcoma, lymphoma or hematopoietic/marrow disease like histiocytosis. This patient had a diagnosis of histiocytosis X. A detailed discussion of the topic is provided elsewhere.

Case 71

This patient was involved in a road traffic accident, had superficial facial injuries. Patient was evaluated with a CT scan. Interpretation of this series is a routine exercise. To look for all subtle and obvious injuries. Carefully scrutinise and make your observations.  I note that there are fractures involving the orbital roofs with focal herniation of part of the orbital contents into the frontal sinuses. You will also notice defects in the planum sphenoidale as well as posterior part of the cribriform plate. There is a focal bulge into the right posterior ethmoid? a Blowout injury. Fluid contents are noted in the sphenoid and ethmoid sinuses. Axial views show mild left proptosis and somewhat undulating contours of the lamina papyracea. With this illustration I have attempted to show a very subtle bony injury that can take place in the anterior cranial fossa. We are aware of classical blowout injury of the orbit with a teardrop in the maxilla. In this patient to see teardrops in the ethmoid as well as frontal sinuses. I am sure this observation is of some curiosity.

Case 72

This is also part of the nasal series. The 4-year-old patient presented with intermittent nasal bleeding . You are provided with CT images of paranasal sinuses. What do you think is the likely diagnosis? Obviously nasal blockage due to the soft tissue component is evident in the left anterior nostril. This can be due to any soft tissue mass-like polyp, tumour or vascular malformation. But in this patient there is an observation that leads to a likely diagnosis. Again note that both maxillary sinuses and ethmoidal sinuses are totally opaque. Also there is slight remodelling of the sinus cavity with very large maxillary openings. This patient is a known case of cystic fibrosis with extensive nasal polyposis. The polyp projecting into the left nasal cavity is symptomatic with a bleed

Case 73

A 10-year-old, male patient had a mild painless swelling in the right parotid region. Patient was evaluated with sonography and CT scan.

Most information is available on sonography, there is a slightly heterogeneous,hypoechoic, well-defined superficial lesion in the parotid gland with a slightly bulging contour. On Doppler assessment there was vascularity in the central part of the lesion. Power doppler options were not available at the time. CT examination does not add too much information, except that lesion is hypodense compared to the rest of the parotid gland. There are prominent veins along the deeper aspect. No gross enhancement was obvious. This patient did not undergo any procedure further, and so final diagnosis is not available. In the differential diagnosis we should consider haemangioma, a lymph node or a rare benign salivary tumour. Intraparotid lymph nodes are fairly common observations, size may vary. If you notice this patient has grossly enlarged adenoids, it might indirectly give a clue to the reactive lymph node in the parotid gland.

Case 78 : 30-yr-male with left parotid swelling.

Case 79

Patient with a history of orbital trauma. CT evaluation with the multiplanar reconstruction is a standard for evaluation of suspected orbital foreign bodies. Apart from a routine assessment of the bony structures, orbital soft tissue should be scrutinized for presence of foreign bodies. Do you see any foreign bodies in our example? Obviously, we do not see any metallic foreign body. But there is an abnormal soft tissue density at the inferior aspect of the globe in the region of the inferior rectus muscle. When you carefully observe you see an area of radiolucency and a linear radiodensity lying obliquely in the orbit. This is a wooden foreign body which is located deep in the orbit. In the evaluation we should look for possible air pockets in the vicinity–sometimes a clue to the subtle small non-opaque foreign body.

Case 80 : 24-yr-female with greadually increasing left facial swelling.

Case 81 : 20-yr-male with left nasal block and recurrent headache

Case 82: Two young patients with discharging neck sinuses