~4'
C H A PT E R
r-
Diagnostic Imaging ofMaxillofacial
I and Fascial Space Infections
Angelo M. DeIBalso
Richard E. Hall
iagnostic .maging h;u assum~d a central role in
D (he management of p:lcitnts wit h deep'Iu.ted
hud and neck infections. Inform acio n gained
from VanQUI diagnosric srudies, upt'ci.Uly computed to-
mography (CT). is es~ntial in accurattly delineating the
:onuomical uttnt of rM prouss, demonsttuing surgically
dnirublc abSUS$a :and fluid (oikcriol1$, and demonstrat-
mg;and USCSSlng usocia.ted I:omp!ic:uions. In addition,
cr-gulded n«dle upiration of nuid collections can ~
UKd to obu.1n rruterial for microbial aJWysis. This chapter
eumincs the role of dugnosric inuging in the [{urmen!
of p:lUcnts WIth hud and neck infKDoru.
IMAGING MODALIT IES
The modem diagnostic armamcn t:uium contains anum.
ber of diITerent .maging modaliries that un be used in the
OlSSU$mcnt ofhud and neck pa.t.hological conditiolU.
PlAIN FILM EXAMIN ATION
Diagnostic Imaging of muillofacial and fuei;&! space d,s-
orders often ltans with some form of a pLain film study.
Pmor:amlc radlogr:aphs are commonly obtainm .f Ihe in-
Ilamrnatory process mvolYe.S Ihe or:al or p<U1lonl region ro
rule OUI patholOS'Cll conditions of odontogenic; origm and
demonstrate the extem of the proctSs.'7 Anu roposlerior
~ lateral Views of the cervic;&! soft tissues are especially
Imporranl If palency of Ihe airway is a concern (P;gure
~1); thue VltWS ale upccially mdic.um In lhe Ireatment of
inflam matory or ,nfectious processcs involving Ihe sub-
mandIbular, parapharyngul, Or reuopharyngul spaces
that un UU5ol' all·way compromlSC.
COMPUTED TO M O GRAPHY
CT has become ,he 1110St Wldtly used and readIly aV:Ollable
adv:oncmlmag.ng mo,b"!), for the evaluauon ofhud and
62
n«k infections. In contrast to plain film radiogra ptu in
which informatiOn is directly recorded on film, cr irru.gu
are computer generated. In cr, digitized data are obtaintd
by the rolado n of ~ 1: ray source and dew::[or arrayaboul
a stnlcrure in either Ihe axial or the direcr coronal plane.
TheK det«tors measure the intensity of a fine bum of ra-
diation passi ng through the object. This information is
then scm 10 a computet", which determines the physiCll
densities of many small volumes of tissue making up t/w;
larger structure through a series of complex mathematial
equations. TheK smaJ.J volumes, o r voxds, arc assigned a
numerical value rdative to water. These numerical values,
or cr numbers, art expressed in Hounsfidd units (HU).
Examp les of commonly cited CT numbers include air
(- 1000 HU), fat (-80 to - 100 HU), """ater (0 HU), blood
(60 to 110 HU), and bone (1000 H U). The final cr im~ge is
composed of many two-<Iimensional picture elements, or
pixels. E-lch pixel cOl"TCsponds to the avenge density of one
~xel. The final CT image is displa~d using a gny sc.tlf,
WIth Ihe more negarive numbe rs appearing toward the
bla.c~ end of the scale. and the more positive numbers 0lF"
peanng towan! Ihe white end of the gray scale.
Termsoftco u.wd in the CT displayofim.llges ate the II'''·
dow/coft and Ihe wirsdow width.ll The lov.-e5t value of the cr
number range being dispJ.a.~ is determined by the WIndow
level, whcreu the wi ndow width, or range of numbers dis-
pl~)'("d, detCtnlincs t he contras t (degree of difference in
b~ghllleu or darknus) being displa~. A number oftcch-
m'lU<".$ are a~,]able 10 enhance the diagnostic YIeld of a cr
study. Thcsc mclude imaging at a level and window width
combinallon in order 10 emphasiu bone or soCt tissue, 11:.
form.mmg In dIfferent planes, and using iodmated (ontrOl5I
media. lodmaled COIlHasl medium adrmmslered mtr~ .
vcnously before and/or dunng I he study C:l../\ greOltly enhance
Ihe dlagnosllc yield of a study by demonslr:allng Ihe lou.
Itton. of norm~1 V"~_u I~r structures and enhanCing patho-
OSICai processes Or structures such as abscess walls. Major
adv:I..Iltages orCT IJ\ Ihe ev~J uation of head and neck fasCIal

A wion, oc a\'Cragc. of all proton magnroc momcnlS, is row:ed
• rarnrter1I ace varied, the ima#I dw: are obaincd anphas.izc
• mUmiry, or bri~ on a gi""n _ightcd sequenc~ Fat
'"...... 4·1 A. An(Crapo'uno.. ........ of .h. no<m&' cer.Ocal '"Otway.
Th. nonnal urvical airway (..,.,..,..,.) .hould &PfH'a, symmotrical
o'~nh. moddle thi ...fof,h. ur.Oc:al.pjn~. I. """"~ II."" d"'inct
should ... in tho proximal ••gmon, of til. ,rachu (.,~ •• J)
8, LaI~.I .. cw of c""";cal airway. In .h•• dull th. Wld,h ofth.
pt~rubul $Oft 'i......, at 'he C3 1.....1 .hould nO' v:<: •• d 7 mm
(It 20 mm U Ih. C7 kvel.
J~. mf«rions include (1) ITs amhry (0 rudi.ly &.SKSS the
ln~ty of CO<tical bone, (2) dw: $hort lilm$ reqUlmJ for cr
a.anumoon, (3) the rudy av:oilabiliry of cr $em"e.., Ul<I
(4) the l'I!]atlYdy lQW cost of ;1 cr study comparffl ....nh nug-
lIelie ruomuu:. imaging (MRI) s[udlu. Major adv,mce'
fIICn(S In cr [Khnology iu"" indudtd the dewlopment of
the helical or spiral cr scanner and the mulnd.,tCtot cr
kanner. n.tse ad~c.menrs have gl'l!ady rl'ducrd Ih. urn.
"'.«fed to 5.("an ;I. give" area. Scans that formerly look~·
tQJ minutes (0 p<'rform an now be per(om,ed In less than
'" mlnUI,"- nllS is esp«ially importam forp~!1ents who h2\'I!
hmntd abillty.o n:m~ln Sfill btaU$( of.he d.scomfon 2$-
SOc,~.td wuh variou5lnfbmmatOI)' pro«(SSI's.
MAGNbilC RESONANCE IMAG ING
MRI d I h fionuu'g ".d,ano" (0 gen.. ·
ncs nor. IOYO \'C l e use 0 b n of a m~gn'nc
,uf 'mages bu. ,nstead I"f'lies on acorn ,lUno ,
fidd .... wI rild,ofnquency energy. In an MRJ sys.em .he po.
.~. OJ pl.:aud on a $I<ong "'"'gmt><: fie]d and.he hyd<Og<'n
.... Onu arc aIk.owW 10 al'gn '" lhe wRCtion orm.. fidd. n"$
.ilignrt>l'm .. then altmd by pulswg ..diofrcqucncyeoo.rgy U\
the form ora rad..o wa"" ptrp"nd.icubr 10 m.. ",",gottie fie]d.
This typic.ally ruulu in a l8O-dtgrtt shift in du: o~m:u.ion
of some of du: hydrogrn nuclei such tha.t du: bulk rTl2g~ti_
~way from 1M dinction ofthc magmcic fidd, typic.ally by 90
degrees.. Ca.sarion of dl( rad..o wa"" ruult:s in a retum of the
bulk magneriurion toward the original6dd direc:tion. Emis-
sion of radiofrequmcy mttg)' from these protoN U U\qr re-
turn (oward me equilibrium lute is detected and UKd to
gcnen..te d.i.agnoaX irNga..A major acMnl2ge oiMRl a.u
cr is iQ abilil)' (0 genel":lU images in nor only .he axial
pl20el bu. also thc direct coronal and sagimtl planes..
MRl images are descrilxd in tamsofbangailit:r Tl-or
n-Mipud images. TI ..fus to a n.te COlUlan. ~I whieh
magnctic polarization 01 rdaxarion occurs about the longi-
tudinal Or Z axis. Stated more simply, Tl mea.suru 10M rate
~t which riuue becomes magncrized. The n constant is IDe
=c at whkh Ipim become disorganiud. as a rault oflocal
inhomogeneities in the fWd. When diffettru irNging~ •
TI 01 n chancttriscics of a group of tissues in an imaglng
pia=. TI images provide good loNt'omial dcWJ. whcrus
1'2 images ~ Y'Cf)' smsirivc in deteaing disuse processu.
The final imagoc gt'ncnud in an MRl system. is governed
by the hydrogen atom densil)' and TI and T2 time con-
stants. Duc:ripcions of a tiBuc: or laton often rerer ro SlpM
and highly prottirw:cous tissues charaaerisricaUy produ<e
high signal imeruity on Ti-_ightcd imagu.lnfhmma-
tory procesus, tumors, and fluid collccrionll usually ha""
low signal inlensity on TI-_ighted sequences and higb
signal intensil)'on T2 sequences reflecting their Increased
water content (Figure 4-2). Strw:turc~ appunng dark on
T] and T2 'mages irKlude rapidly fl"'\ing blood,dcnse cal·
cificatlon, and organized fibrous tissue.
The ~ o(intravenous MRl contrast agenu can demon·
stra.te the vuculanty of " l<$ion, which an be important tn
neoplastic and innamm~toty luions. The most widely
used MRl contrast agent 15 g~dolinium-d1(thylenelri­
amine pcnraacctic acid (DPTA).ln contrutlO Ihe ioch-
n~tcd contrut agents und in IT sc~nning, rhe inna·
wnous contrUt agems used in MRJ sc~nning are safer,
WIth advers.. ruerions occurring only rudy.
NUCLEAR MED ICINE
Although cr and MRI prOVIde v<cellent an~lomlC~l mfor.
marion abom the tiSSues understudy, one maJOr dr;iw~k
i. their inabdllY 10 prOVIde slgnllican, ph}'$lolo);lCal ,nfor·
maUon about these llssucs..]n contrasl, radlOnuci,df ,m~g·
'ngcan provide uccllent mforma"on ,.bom va"ouS phys·
iologica] and p.athologia] proctSSl'S This capab'lIty Un
resuh 10 urller dtrccuon before morphologICal d'~"gcs
Ixcomt ~dfn!
,"
I'i,ure "·2 MRI Jnn of munca,or.pac~ colluhus 'Hulling from
a mand,bular molar penap.ul ab~"... Axial Tl · and T2 ....... ,Shc.d
,mag.. lhrougl> maOl>c:ator .p.c~ and Aoorof mo",h On .h. Tl
sequtnce ,I>( "Ihe m..... I,... (WIJ'1/K a,,,,,,,) and mtd,.1 p'"rygold
(cwwH_) ""'Kkt .~.r .rw;fuMd in $<.1< and dtmonWlt.
d«~.$Cd ",NI ",,0""1y {AI. DuruHd .. ",.1 'I>IO"SI'1 of th.
marrow w;,htn .... mandibl. ",floc..... of ma""", tckma. On ,h.
T2·_"hud ~nc:" ,,,,.. ntd ..,,,,,I onttn.I{y" sun ",,,h,n
rnusdes .nd "",ndibulu ""'ITOW ,n6Oc.au"l~. Co.\I.uc ""'th
""'m.I .• ~~"I $lrUCIur. on ,h. ",I., (8).
lUd,onuchdc imllging mvol~s fht use of ... dlopharrru-
cemicals, conSISting of an organic substance SptCltiC for II
gi""" ,iuue 01 ~lrUClUre and a nonspecific radionuc1idcla-
~~tU~U:!~=~~~~; :~:·~::~':·;~~:~~~cr~~~~u~
half.life of 6 J hours and unduS"'"" lsommc (.anl/orrn._
lion to ""rc by rtlc'"-'mg a gamnu. phmon In rad,onuchdf
,"lagmg. rhe numbotr and dismbunon of gamnu rays "m,,·
red from llw ~Jonuchde In cht tuUtni dunng a 5tt ~nod
art d .. ttcttd by a gamma ClJllen and der'c!...:! In rht final
Imagr. R.lId,onlJchde Image s art often referred ro a~ dy
.... "'1(, Of "",,,', ,,"a~e~ ~"allllc ",>ages Or flow Stud,~~ are
F''K'''''' .... 3 IUdionuclMle. bone!aln '" a pariMI: w«h chronOc: os-
"rO/Tl)"!Iltis ofrM P"'nwou",.nd mandIble.. A, lniaalflow phu"
.ap,.. imtMdi.J.cdy .ft........ 1nJK" ..... of-rc-4bd..d mfthylene
diphosphono.." den'lOflSlJ'tolH flow in the venltk of~ Mad.nd
Md:; howewr, no &«UmIJb.1>On of aClMty in tho mandible _ ... 10
sogg~ an O~eornyeliti5. Sullie: lmag.. obu.in...:! Ommedi.J.'ely aft ...
(8) and at S houn aft ... (e) rhe inJKuon demonnr;art progrn_
uptako ofthe ..dioph.rmac .... ricalln the mandIble and p~m;ax­
ilia. Th" o_all pattern is conSIStent WIth chrOnic OS,to~"t's,
obtain"':! during and/or imme<iiartiy aftU inJ«tion and act
int~ded TO dcmonsrn.(e blood flow to an Mea, an organ or
lesion's vuo.Jiariry, or both (Figure ....3). Slatic im;Jges act
obtained after inJKtion or :lfur an appropriate ~riod for
uptake TO occur; theR im;Jgcs art int .. ndcd to visualite a
specific organ or slrucrure or TO benu del.mcate a physio-
logic.al or pathological process.
R.adionucLde bollt scanning IS panicul:uly tl5tful in ,he
evaluation ofinflammalory and neoplastic conditions In-
VQlving .he osseous maxilloracial strucrurcs.ll ....'2.') These
studIes demonstr.lre O5$COUS 1Il\'Oh'l'mcnt befo~ wanges arc
evident On standard pbm films. In convcntional radlogra.
phy, apPTOJurm.tdy 60% of the mmeral conlCn! or ~ p~ch(}o
logically invol;,:d Sl'gmem of bone mUSt bot lost before th(
pathological changt$ bKOllle evid(nt. R.:.d;opham,a<;(UcK:W
{omlllonly u~ In bone 5(Olllnmg ale """'TC·pho:splu.le com.
pounds such as polyphosphale, pyrophosphonau, hydroxy.
e'hylcne dlphosphona,e (!-IEDI'), and merhylene dLphos.
phorulc (M ])1'). Ah hough the exact me.::h:l.m~ms und(rlymg
thf up,ak( ortht phosphate Ly honc alf nor fully undn.
 " ., 01" 1"'4~'"1. "1 M ,v..:;"J~<"'1 • ..J l'.m..1 5p~. 1"1" "o~, 65

flood, adso' I){ ,on '<> th~ hyd mxyapa",~ ~u, j atcIS be h~

to rUy an ,mportam rok f~tors "'lIuc"" IllI' II", upu.kc of

r~ophnrn;>Ctu"c~ by bonc "'d " de ,cg.o;;.tI blood II"".
boO'! famu uon rate, and C'.Xlraction effiClenq eonu"Ofl "'_
d,oaloON for rad'onuchd~ bor>escan 'oel ude o;kn"""S"~lion
ofp("n~ o.K<:oncbry m.w~nciCl , metabohc and dys.
]>Woe: bomd~rd~, and dJrr~rwnanon becwe..n ce UuhuJ
;and O$Ic<.IIT~ms. ~,rr~rwn:mng becwe..n ccUul,us and o~.
,eomyt:ltus IS ~peaaUy Important dmte:o.Jly lnd IS rudJly ac.
,
co<1'phshed ~m.g a t hrte- or fou ... ph~ rad,onuclide bone
pi\. SHtu.en~ Im.agc:s of th.: area under study an: obu",ed
dunng "'J«tlon, ~uJcing '" a radionud;d~ arunogram
~ 4-1, A), follo....ed by an unnvdUle R.J.ric 01" blood pool
,m>ge."'lht: arunogram inugc:s obc.llncd dun ng phaw 1 of
the srody dcmonstr.lle ~ YUCUbnl)' in OS(C<)mj'C],US
Of cdIuliw. The blood pool,nu.gcs demonstrate onc:rused
Jt _ upuke in cdJulitis and in mvoIved kIft ti$:suc OYCI"'
I)1ng" lOcus of osrro.myditis. The SC'COnCI ph~ of th.: mKiy
IS obt:uncd approXImately 2 hours after injKcion and
o;\tmonsrnItes ina=scd osseous upt"akc in OStfOt11)'dlns (Fig.
u~ 4-3, 8). ~ u:ird P~ is pcrformtd approximately 5
hours after mJecnon (FIgure 4-1, q. In patients with 05-
teonl)'l'hris a continued in<=uc in the aaivity ~f the ph ..._
maccuria.l in th.: itwolved bor>e rW.tM: to surrounding nor.
ma! bone Ihould occur computd with the- nrio :u: 2 hours.
!~ also an be obuined u 24 hours after injection; m=
iONgCS constitute the foutth phase of the Study and should
•
demonstrate incrtucd. :accumubrion of radJophMmaccuti-
cal m a""..., involved by osceomydi[is. Th~ IU(f images
sommmcs ~ referred co u the fourth phase of the bon~
~

In addition to [ccimmum<antaining radiopharmaccuti·

00, othtt agcttes used in th~ rv.alu.ation of acute or chronic
osttom~litis include "Ga citrate and "'In· labeled lcuko-
cytcs.1C,t4 Gallium sc.mning is useful,n the dctKtion of a
n"mbecof nc<:lplastic and i~matory conditions, partie·
uJuIy salivary abnomulitics because inm;LScd $almry gland
"JXake C:lll OCC[1T in malignant salivary tumors, Iymphom~
ilCUte and chronic inJUmmauon, postirradiation siaJ.adeni·
Iil, abxcsscs, and active s:u-coidosis. Patients ""h ~'" sac·
coidosis frequently demonstrate ,nacued uptake by the
parotid and bmmal gUn<k Gallium suntUng ",VOMs [nc
lll{D.vmous admtnistrarion ofl ro S me, of""Ga citrale and
~ obt::uncd u 6, 24, <48,and n hours after adnunistn·
F:gut'e 4-4 A, Ultrasound o f submand ,b ular .. goon demon"",, -
ing a btanch,al deft ern. A sonol ""."t a' .. d ....... d of ""urna]
echo... (.~) is noud . ""OU$'''' .nhanc. mC"I. typoCaJ of
')'SIs, .. ""P"'stnlcd by th<: « hoge"", &1"'" ~rwach the cyst ,......
normal. «""",nic submand,bular gland .. <kmonott'alod (Iooos.,..
""""'-Is) B,lJk<uo"nd .... m'natoon of lh< ngftt ~rot>d demon--
"""'"lan~!( ohad<Jw;ng .... 1oI"h in 1M hi,,", of"'" ",hi
parotid ( • ...-J. (From DolDaI><> M l, cd"or: ~-rs.
Ph,tadol~"', 1990, WB Saunden..)

lion. AlLhough gallium sanning IS an cxucnwly useful ''''''g'

ong [ool,.t cannot totally differentiate bcrwcen an mflam ·
onatory and a neoplastic process, and (a.I.sc·negau"", rnults
can occu'Wlth an encapsulated, ,nacll"'" abscess.
Taggmg of ",hlte blood ctlls (WaCs) w,th "' In a!lows
for l he tidy locahzing of acute mnamml'ory procfSus_
WBc nggmg is ach,e"",d by isolat,on and ,n VltrQ labeltng
ofWRCs from a ",no"s sample Th~ la btled wacs " t
Ihtn 'nJect~d back ",10 tht pallen. and ,m aSIllS 's prt-
f.... mtd a' J and 24 hours after " ,)u [lo n
ULTRAsONOGRAPI IY
•• a d,a, nos ([ ( , ,,,,, I In
UI t ruonography has been ust d ~
~h r t ateu 0 f [he c~ . 1 ~tr
[)U<>Y; '0 . h;u no ' l",r n used u-
II
tenSl\'dy 'n the evaluation of mllam matorv Itsions ,"volv-
ing ,he h~ad and nK k,l4·w On~ major h",;t anon of ult ... -
sound is 11$ ,nabtlny to I.,..,,(, ra,e o.u~ous srruC[Urc5 such
as the mutlla and mand, ble. Co" s~q,,~ nt ly,!lS usc 's re·
~'''n td 10 afUS o f the ,nu,llo fanal "S,o" "hue .he
sound wa~ dOC's 1\01 h~"f III pcn~(ra(f N>ne (e j:. superfi-
n I.l lobe o f 1'~,uu J, lowc, "':un llof~(lal ,tS'"'' (sub·
mand ,b ular [" angle anti neck]). UI,rasound" me l'ul,,,
d ,ffurn llall ng b~ ...·etn sol,d and qs".- ma"u and 'n
demons ,ratl ng Iht rcla[ ,o",h,p of ,h~$~ ",a~....s 10 V.l"OU~
S!ru, m r.. (hgure 4 .4) An ec ho",orpl",lo~><~1 d u s,fi ca
, [()n of soft '''' lit ht ad and n", ~ ".dhll~. <o""s" ng o f
«Icrna, mlihr.u~, pru.bsCf», :U1d Kho-po<:>r ~tld «ho-fru
~bK~s.s, has bt:(n r(fX>ned ''''' Ultruound .s useful '" th~
cv..Ju~(ion of sialohth. !II p~t.ems with acule obstructi""
$.~Io~denms or III whom contrast si~lography was cOn -
tra.indicatro. bt:ause of a known h'itory of lod.ne ..Jlug)'
In these casu, the s.alollth appurs as a fonl «hostnic
density uhibiung acoustic shadowing'l (FIgure 4-4, B).
MAXlUOFACIAL AND FASCIAL SPACE
ANATOMY
MlDFACE AND PARANASAL SINUSES
The paind m:uallu an: the keystones of the maxillofacial
$kekron. Locatro. within u~h maxilla is a pyr=tid..J air-
Iilkd s~ commonly known :u the -rrw:llWy smus'" (Fig-
ura +5 through <I_7).':U The Lateral w;all of the maxin~, or
inr~temfX>ral surface, upara(es the infruempo~l fOS5~
,
from the mv,]lary sinus; the med.al w~11 of the m~1J
n..sal surr~ce, forms a signifiatU pontOn of (he lalcta] ~
of the nasal ~aV1ty. The $u~nor, or orb~lal surfact, of I
maxillary bone forms the greatest port ton of the flOat ht
dIe orb" (roof of the sinUS),Kpanti ng the muiUarysu, Of
from the OlblL Su~romediaUy, the ethmomax.11.uy p~
separatU the maxIlla,! sinus fro m Ihe ~thmoid.:il r ttllt
(Figure 4-8). The ;mtenor w..J1 o f tile m:uol,la proVides COt,.
tour ro the midface and upacates the maxrlbry sinus frOm
the adjacetU subcutaneous ciuua of the face, The po~
rior wall of the sinus uparatcs the maxillary sinus ffOnl
the pterygopalatine foua spacc. Th e muillary Slnu.lts
drain into the middle meatus, in dose proximity to dIe
duelS d~injng the frontal sinuscs and anterior cthmoid
air cells. Thi, dose pr-arimityof dnining ostia is onl p.lth.
way o( 'pread of inf«tion (rom one ,inus to anOthlr.lo
Each maxillary sinU$ may haY't rhrce atcruions or reces.ses
cxlending into adjaccnt structurcs. The alY'tolar rcctu is &
,

E F
"

r.,.... <14 W~'en' >'leW ofjn'3nuaJ >inuon <kmon~"""I.ht

&ono:al, .... rnood •• nd rnDil~'Y SInuses and .djac.... wuo:tvrn.
(Fro ... 0.1&&1.., AM, ed"aoc M.,,;llor-o-l,-:ollJ. PhIladelphIa.
Im.W8Sau"'O""")

~ntral extension into t he alveolar ridge, the orbital feCes.

~nu me apial most portion orrn.. $!nus, mel [~ry-
8Om.cic ruess uprcunts pneumacizuion of che m.. duJ
Kgment of the :t:ygoma. Th.. alveolar r«ess 1$ often inu.
matcly relaced 10 , h .. coou of the maxilhry mobn..· 1lus
dose proJCimiry ~~ fo r the uruuion of odonlogfruC In-
fections fro m Ih .. mo~ [0 mesinus..... pprorimu..1y loti
to IS'IIo o f b<1Cltri.al sinusios infe<:lIons involving Ihe n\U'
illuy sinus arc of odoncogenicorigin. Once;m inf«tlon of
odom ogenic Ot ocher origin hilS involved rhe sinus, it (all
extend th rough che sinus to involve any structure border-
ing the sinus.
Th .... chmoid bone hI'S d ....p 10 the maxilla..lr is an im-
po rcU11 utuomical bridge buwccn the pa.ircd muillu
and bilSe of rh .. skull (Figure .-9). Th .. ethmoid bone is
composed ofbi!acuaJ, pynmid.u..dla~ bodlU [crmtd
the Ld'.1""tb, uch COnl;unmg S (0 18 mdivtdu;u air
uUs. 1.1,1',1.1 These air cells an often collttt;vdy nfum:l to
:u an nm"OId Sin," and au divided imo an(erior, mIddle,
and pOJurior groups. P.ach group has a diffe..,nt drainage
pacttrn. The tthmold IJrcell, art separated from the m"".
iIlary sI.nuus by the tthmom:U-iIlary piau and (rom the
sphenoId smusu by the tthmosphenoid septum (Figure
4· IO)U The I:ueral portIon of each nhmoid labyrinth
forms a large segmtnt of the medial orbital ,,';>.11. ThIS seg-
mtnt o(the tthmold IS known as tht orbu;ol plut o(the
et hmOId bone, Orum,,,,, IX'ftYra<ra The bmlna p;oI'Y' 2Cta is
;0 ,da •• vt'ly ,h'n tx>nt 'hat can .tadlly allow tht tJllenSlOn
of ethnlOld ~"'\l''''i luthe [.. bl(
Pa~nual $l!lU,U a'f also locatcd in tht fronul and
sphenO'd bo"n. Tht frontal smusts arc paorN, oftcn

'Rtft"""t.l. 41, 101, 102, 107, 124, 129

 bono bolow,he Hila .ure,ta.. The ""dIme spheOOld ,,,,UKS
Ut ulUmatdy rd.t":!.o a numbor of.mport.. m.uuc.",r.
",clud"'g .he orb .. , p ..UJlary, opci, chiasm, ca"".nous "
nus, and ",!(mal carocod arlenes_
like 1M frontal !.Inus, t.hcsphtOOld .;nuses can demon·
'''a•• variable dtgr." of pneum.u~ion. The twO of.en
uymmctriallinusu aN: Jtparared by an imr.u.nu$ sep-
IUm and infrequently communjcat~ The Hptum is u,u-
.Uy lOCal..:! in the midline anteriorly and usually dev,ues
to one side posteriorly (JtC Figure 4-10).
An important f1,Ulciiona!. enlit)' u; u.., osciomcu.1 com-
plu, which is. functionalemity composed of the mIddle
{urbin.ale and meat\1$, nhmoid bulla, hiatus gmtlunuu,
uncina •• p.ocus. ostium oftht maxilluy sinus, and ,n-
fundibulum (JtC Figure 4-5). 'The ostia. of all. pannuaJ ,,-
nuses, aapc for the pDSlCrior ethmoid air cells.nd sphe-
noid sinuses, optn into the complex. The middle mUtuS
(".... ,., Cald_ll's _ . PouMor roo( oftM m&lOlI~'Y !.In", is lont":! lH:tw«.n [he middle mferior rurbinales on [he
("""""'"_). a!\ten<>< roo( ofm., maxdla'Ys,nus("","""',~ la(~ral wall of.he nasal cavity. Loc.aud in the aphalad gg-
_). """,,"ary !.In", (M), ~hmomOlloliary piau: ("""10 .rrt>wIoad) m~nt of the m.ddle meatus is [he ethmoid bulla.. The .. h-
,.'""'" ( - ' IH«* .rrvw) and POOl~rior Hgmenl of.h. lam'~ moid bulla receives drainage from the middle ethmo,d:;ur
JIIWacu (..", bl.od ..rrvw), Wptrior orbi.,.1 fissura (S). roof of "lis bv means of oma located on or above the bulla.. L0-
th< f1~mcod !.Inus (_" bW .. rrowItuJ), ethmoid sinus (E), •• m·
cated immedi.tely below the ethmoid bulla is a grOQ~
I>""'~'" or I' ..... ,nnom,nata (fl/Jid .Aliu .~), ...,~rior r'"
w' ofnau,1 cavity (N), medi.I_1I ofch. maJeilta'Y"'''''''''' (solid known as the bu>nu ~",;u.n#is.lnferiorly. the bwr.u ~....u.­
ioIoo* ~), (oramen rD<undum ("fH!O wIoiu ~), and ".om is delinuted by a ridge known as the........ut, proem.
livnul WlUS ('1 alt demonwa'ed. (From DcISaI ... AM, edicore The anttrior ethmoid air ails can drain directly .nto the
~ -r£ Philadelphia, 1m, W8 Saundtn.) amenOr scgmtnc of the hiatus gmilunMis known :as the
nl,,,,o,d '"foM'"''}''''' or inco the frontonas.al ducl. The
fron.o~ duct, "",,eh draiN <he frona.lsln\1$, may dr:;un
in front of, above, or wr«t!y into the ethmoid infundibu-
lum. The ouium oftht ma.rillMy sinus is 1oa..ted posterior
[0 (he ethmoid infundibulum. In the ostiome.ual complu

the dr.t..ining ostia an in dO$f! proximity, which :allows for

.ht rapid sprud ofinftcrion from one sinus to a.nother.ln
addition, anatomical abnormalities of one or more com-
pantntJ oflhe c»tiomtatal complu can impair smus ~n­
lilalion, dr.inage, Ot boch, Ihell'by facilitating the deycl-
opmtnt of a sinus;lis. .

DIAGNOSTIC IMAGING OF TIlE MlDFACE

AND PARANASALSlNUSES
Pb.in Film Studies DugnaSlic imagrngof mllamm.rory
pmctSIU involvmg the m,dface usually startS wllh plain
film study, whICh gtnually consislS o f a faCtal bone Or
paranas.al "nuses senn. Esgnrial views Iha[ muSt IH: In-
cluded In any SOldy oflht miMace and parana.salsinu,,"s
ut the Waters, Caldwell, and lateral vie,,·s. Addi.ional
l.itWS such :1$ a POStHOanlerior or submtntovcrttx (SMV)
, .• rw also mar bo ntedrd to tvall,a., (he patten. fully. The
Wa.ers. Caldwell, lutral, and SMV vicws art ",tended .0
dtmo'Hlr~ .. mnammalOry processu inl'Okmg Ihe para-
na5"-1 S"1U"'~
The W~t.rs ",ew ptOl'ld.. opunul visual,z;1."On of antt
..or b ... 1S.ru<'UfU fr« of .upcnmposrd postt"Or S[tUC-
[url::l su<h as .hr pttrous rod&<, oft"" temporal bone (set F'g
urtS 46 and '-.8). Particularly u~f,,1 In ,ht"'.... uatlon oftht

.'
•
m:>l"ll~'" "n"~s, .h,s '"leW pt"''KI''5 Of''''uJ ".ua.il1..lll0n of
70 0nJ.,.J M~MVlI~ft<'-'
IbN smus, mfenol
,he 1... ,.",1 and ",ed,"] walls r I Ie nl=", ( r r
<)
o{,hforb" rOO 0
o rbital (p;olp~ble orbital) nm, an'd noor
,~_ d monsffille5 the '.menor
,he sinus). The Warers VIe'" ~ e .
po
newn ofthe mMulwail of,,,,, orb" fr« from sup",m
",._ imnnrtaru SIr\letu", of,tn
po5e<i pC>SltnOr StgITltnrs. "" r---
Identified on ,he Wa~ and Caldwell Views 1.1 ,h••,hmo-
nwolIary platt, a bony platt sqI=tung me ~hmOld ':" (db
and muillaly linus (:itt Figure ....9). [)esttUctlon of dus plait
indicau:s a ~ or an IggJUo$'Yf infbmnW:ory pro«SS.
llu:: aMoIar!'«US, a nomW exwWon of the nu.n~ 5"
nus, oftm \J intunardy rd.ufd to the rooa of ,he rnaxilbry
mola.-s. This dose rdationship can rfiulr in Ih. 'pr.... d of
odonrogtnic infcroons to ,M maxillary liinuw. Although
nor coruidend the pollTIM)' __ for the ev:Uuwon ~ Hh- "!
maid and fionral slnUSQ, the War", v>ew can ~ Infor-
nu.Oon coo«ming tht'tr StatuS becallK il .s ,h. only ....ew
tlw. projects Ihe anterior and posterior .mmo,d c.Us ,"de-
pcruknr 0( ach ocher.'" The anterior ethmoid >.if ct,lls .0.11'
pro;eaed supaioriy intO the. medial upect of the orb", and
the posttriDc au ails = proped <WeI" the ItWhaI Upecl of
the maxilWy sinus.
The Caldwell view provides optimal yiSUlliution of
midli"" and posterior facial J(TUcrures 5uth loS the orbiu,
the ethmoid and. frontailinl,1Jt.$, and nasal fouu (= Fig-
Uft 4-9). "IlK 1owo:r half of dle maxiIWy sinus is 001: ",,,U vi-
sualizcd. on the CaId.....n view b«a11$t of the superimpostd
pecmus ridges of the temporal bone. The orbital f100t or
roof of me sinus is represented by rwo lines: a superior line
representing the posterior roof and an inferior line repre-
senring 1M anterior roof. This projection an provide a
good 0YUVIe'N of the ...,bow lucency or opacity of Ihe en-
rire nhmoid sinus complu. H~r, individual asn"'
ment of groups of ethmoid air alIs is impossible because
of tlK supenmposirion of anterior and posterior air cdu.
Tho: brninae J»-pyncue and ethmomaxilWy pl.tte are ,.."U
demonstrated on this proj«rion. The l.trnln<IC papyn.cue
~ visuahud U two lines: a more medially located linc rep-
rescnringdw.anunor segment and a ~ laten..lly located
lme representing the postmor segment. The ethmomaxil.
bry pbte is YUualized as is the OlSCOUS septum Kpanting
the muillary andcthmoid sInuses.. The Cald_U view pro-
",des the beM ~monstratlon of tht; frontal sinlUCS, which
ofun d.emorutrau: the grUtUt degree of anatomiui yari-
arion of the pUlllasaI sinuses.
. The latcn..lvic-.; in ~ facial bone sene,; is usually an up-
. t , kft btenl ~ m case. WIth nght-.ided symprolnl,
."cht la.tcnl VIew should ~ obuined mstead (S« Figu~
~~ Crou·uble IUltral VIew$ of the facial bones (an be ob-
&aiIaaI In pallcnu .... ho a'e debIlitated, thOle In whom
- sphenOId "nU$IIISIS suspected and those in whom a
ddinlte IIr·fluld J~! unDO! ~ demonstrated on upnght
buraI VlCW$. On the Illcrall'lew the rupeclI~ sinuses are
atptnmposed 1i0000~r, the lateral y,e .... can proVIde "n.
~t mformatlon COl1(erDlng the YanOUI Sinuses. Thi s
lewl oftehn beSt demon,tratc. Ihc presence of an air.fluld
In t e nl:lJClliary smusu and s h ·d
an d' P eno, $lnuses. The
~ trnor an postcrlor ....alls of [he fron[al SmU$Lli iile ~Il
mon.trued on .he lateral view m k
, a Ing il an essctlilal
luatlon of destru'''~ lalollS [hal «P'."
yic .... It1 I ,\~ tva I -'"
~" ,'Ie SlnlIS .... alls (e.g., mucoce e, O~(<<lmilS). In ad
oreruue . ..... $ useful In d· " ' . ..... L_ •
diuon, I ,.t
teral yle I etet1!lallng ~,
n
d translucency o([he frontal SlnUKS as a Ttlul, 0(
decrease "lhlCkening or "nuSItU. ~, .
SInuS wa .'
. .. Th e "a er ... VIC ...... _
d h . ~\ • .: __ :";"0
d m;tratn
" Ihc sphenoid Sln~ an I e1r -~"-""'liJl$
t:r;;,: sella turcica and planum Iphenoidale. O~o:.ation
o r t h e 5 Phcnoid sinlU an occu r loS a. result. of sphenoid ,i.
nusitis, mucocele format.ion, ~upertor ~ttrulon ~f ~ "-_
JOpharyn~al tumor, 0' mfenor Utelllilon of a pltln~
tumor. . ' .
The SMY view can be: useful tn a$seulng mflamllla.
procellSt$ involving the midface becau$C it ~Il\On.
:~~tU [he boundarin of (he ethmoid, muilbry, and
henoid ,inuus, ethmosphenoid septa, and secondary
:~P{at berwcen individual ethmoid air uJis (set: Figure
4-10). Three lints that should be noted on the SMV view
are the antul, o.bital, and middle cranial fossa lines. The
antral line is shaped like an S or r~r.sc S and defines tht
Iaural and posterolateral ....alls of Ihe maxillary sin .....
The orbital line appears as a straighllinc superimposed
owr the orbital line and defines the lateral wall of the 0.-
bit. The Coshaped middle crUlial foua line is located
slightly posttrior to rhe antral and orbital lines and de-
fines Ihe anlerior utent of the middle crUlial fossa. The
SMY is the only sinus projection demonstrating the
sphenoid sinusts as separate strucru.cs, thereby parho-
logical conditions noted on the lateral view-can be local·
ized and defined.
Com p uted To mography ."d Magnetic RltSOnanct
Imagi ng CT is the p~fefTed imaging modw[)' for the
evaluarion of inflammatory processes of rhe pannasal si-
nUSts. CT allows ready demonstration of imporranl soft
lissue and ouwus componentS of the paranasalsinuscs
and surrounding nructuru. Images obtained using bone
windows un provide derailed anatomical information
abour the stalUs of the ostiomucal complex and underly-
ing osseous srructuru. In addition, cr studiu are rndily
performed and not subject to :utifacrs that can result from
the dessicarion of sinus secrelions that occurs in long·
standmg chronic sinusiris.
MRI IS especially useful in the tvaluation of smonual
neoplasms because direct images can be obtained in pbneS
other than the axial plane and MRJ has .upenor sofl tis-
slle resolution. Contrasl-c:nhanced MRJ cunUn.alions an
especially useful in demonstrating carly rumor extelUlOn.
CT studIes fo. the eyaluarion of infections involVIng
the paranual smuses, mid (ace, or both rcgions should be
performed In the axial and direct coronal plann Tht
coronal sectIons mUSt prOVIde opt.mal demonstration of
the ostlomUlal complex. 1),rH[ coronallmagcs art also
InlpOrtaot W-hfn ,"oluml' a~n.gmg may be occumng In
segmcnu of bon I' parallel to Ihe cr scan plane, reSUlting
In subopllmal demOnSltallOn of an arca (e.g., the noorof
the orb,t) The M:ans should include all raranasal smustS
and ad;aCellt Structurt$. All axial and dlTcct coronal ~­
tloos should rn- ",uged IIS"'& bone and soft onue WID"
 "

",...,.. "·11 Acutc ';n!ni.; •• A, Wacen' ¥iew dotl'lOnStra.inl air.

ft""" IeYds in both maDlluy "nuoa in a "",cion. with UIlfC bane-
nal .. n..,<til. ChronIC muc ..... 1 .hidtni", in tN fattn.1 upoa of
the loft fTWQbry";nu' a's.o;' ~_. 8, Contn..·.n... I'I('d alai
compu •• d 'O<noJrlphic .eellon ,h.oulh ..... maxillary .. nu"".
domon.lracinl bont ;and s.of. IIUu' changu uooei;attd ..... h
chronIC and KIM left muolluy oinu"fOJ. ChronIC c"'ng... ""Iud.
InUU>I.II .hoc!o:.n,nllnd hypttostOlic changu of.ho: .,nu. _II ..
E>cttruion of the inAa ... ma.aty pnxn. info tho: ff'trOantrJ.1 fa. pad
( _ ) .. n«ed. AcuI, changH contoS! 01 an .... ftuod ItYd In the ...
nus and mucosal cnhanc:_m: ("""-J (From Od8>.1s.o AM,
,dllar. ~ UnooJ!"S- Phlla&lph .... 1990. W8 s.undeB.)
dows. In addition,lung windows m~y be useful In evillu·
arlng thc various alr·conuinlng components of .he os·
Uoml.lt~ complex
Imponam abnormahtiu to bt nOled in .he evalua·
tion of the pau.naul sinuses Include Opa(ifi(ation, pres-
tnce of alr·flUld levels (Figure 4·! I). llIucouJ thickcnlllg
and enhancement, soft tissue masses. hyperos lotic
ch~ng(S. ~nd bone dlsp lactmefll or dUlruClion (hgurt
4·12). In Ihe evalualian afpalhoioglcal pracusu Ill'
vOlving the llIull!ary SInUSU. llwolvemcnt of adJa ctnf
strUCtures should he nOled. An Importam fat pa d 10 be
evaluated on ulal CT seCClons IS the le(roam ral ht pad.
louted adjacent to the lateral wall of Ihe SinUS (sec I'Ig
ures 4·5, (;. and 4.". B). Loss of thIS fal pad can O<:(ur .IS
a result of .he lunsmural uunSlon of an Inflammatory
Fig .." 4·12 un muillary .,,"" mUCQC:flt. A, WaUl"$' ........
d, ... on ....aunl ~iftCatlon of tho: ~f< ma.ullvy sonu, and ab-
$tl'l(e of tM la, .....1 and m,d,al_lt. ,ug'JIM of a ntOplaltl<;
process. 8. AOal CT "alon thro ..,h mlJelllary .. n.. "". domon .
...-.tu an vopanslle s.of< IlU,"" ma.s invoMnl tN left rI'lUlU.ry ...
nuS WI,h p<U",", a"""hy ofth. IInU' _lis. (From o.l8>.lso AM.
editor: M.t";~I"""'I'"Io PI,,'ad.lphia. 19-90. W8 s.unclel"J.)
Or a neoplastiC proccss involvmg the smus. The cthmo·
maxillary plate is another Important osseo"s strue,ur.
10 be Identified and evaluattd on dIrect coronal CT sec·
Clans. The ethmoll1:1Juliary platt separalfS Ihf muiJlary
sinus from the adJacrnt nhmo id all cdls (sec hg"rn
4·8 and 4·9). Destruction of thIS plale of bone O(CUTS
""Hh aggressIVe Inflammuory and ".oplastic processU
mvolving both Ihe maxilla ry and the adjacent ethmo,d
smus.
Soft IISsue abnormilllllu to be noted on cr (xamma-
I,ons of the parana5al SmustS and mldr.ce mciude orbuill

A
lnyol~m(m (F,gurc4-IJ), bone des(n1cuon (FIgure 4·\4),
.h,elcemn, and ill definition of musdu(myoslns), ,II ddi·
n;I}on or loss orr.uci.&l planes (fasciiru), edema of ~rly­
ing ,kin and subculanrou5 tilSuU (cdJuliris), rnU$ cIT«!,
fhud collt(tiol).5 with or witha"l ~nphn:l.l contrast cn·
h:anct~nt,:and adenopathy.
The evaiu.alion of the p;t.tanual sinuscs must also in-
dude a thorough ev;liu;uion of the oUiomutal complex
($« Figu ... 4-5, B). This campier is a p=icubrly irnportanr
or
:;lUll. bcU.\I5C tht dr:;un,ng oSlia of all tht paunasal "-
"uu. UCtpt for Ihe posterior ethmoid and sphenoid si-
ntUn au in dOK proximity Aru.romic,,1 abnormalities of
one or n\()fl' camponelllS of the osriomUl:aI cornplu can
unp:;ur sInus ""otibuell, drainage, Or bolh, thereby (<lelh-
taung rm ckwloplIKn( of a sinusiu.L In addnion, rhc dcs..
prOXlIlluyof,he dnuning OSUa allows (or Ihc rapId 'prud
of "'(<<lion fromo~ "nUS to :another. Abnorma.Jlflu COm-
mcmIy tneClUntt~d on mronallmages of I~ OSt,omut~J
complu .nelllcU prommtnt pnellmah2:lf[on of tht llliddle
turbinale (concha bul!osa), paradoxically cu~d turbma[~,
unW'<lte bulla, mro.<lUy culW'd uncinate process, seplal de-
"'<IliOn, and oV'(rs,zed elhmoid buUa_l'a,hologic<l] "bll
llr
mal[{.u lhat can be Sun in thIS aru .nclude chronIC mu-
cosal duchning In any 'egme", of Ihe Mlfome"!al
eomplu, n~ polyps, 2nd rarely, n:u..al nforl~'m~
PARANASAL SI NUS P,\TH O LOGY
Inflammatory Disorders Infb_mmalQry dl>or<iers rep
rf$~'" the most CQmmQn pathologlC~1 cond.tonns .n-
\
B
volving the midface and pnana»l sinuses. Inflamma-
tory disorders involVing Ihe p~unasal "lnuSts may be
dIVided 'nto three general utegorles based on the un-
derlying UU$C; infectious, noninfecrious , and granulo-
matOuS disorders. '
INFECOOUS SINUSITIS
The paranasai sinuses can be affected by a number of in-
fectious agent$, mcluding "ruses, bacteria, and funS'_ln'
fectious processes involving the paranas.aJ smuses are of-
ten clusified according 10 duration or chnical course of
rhe diseaM, with aCUte luting days or "''l:"eks, subacute lUi-
mg weeks,;md chronic wilng weeks tQ months. The radio-
graphic malllfcstalions of the~ d,vuse emlll es c~r ~ lun·
lied sp«lrum of radiographic findings
Acute Infectious Sinusitis Acute smusilis mOSt often fol-
lows an up~r ~spltato,,' tract infection' however it may
O<XUr after trauma,exces;i'~ drying, allergic edema ~';th Q(_
dUSton of dr:lllling oSlia, na~al obsuucl1on, or the mtrO '
ducl10n Qffortign bodltS_t Acu!e ,inu51115 is mos! often
viral, OCcurrmg "1 con,unClton w,th ~ ,'".. I n"s~1 infeCilon-
11,C radlOgn.phic find.ngs In aCUlt vi,J.! smu5it.~ vary, r::onS-
.ng (mrn clear smuses, 10 ~ shght mcreilStd Ih,ckness of the
mucoperiosteum, to gtnrtahud '"cre.:lsed rOldlOgraph'c
dens.ty. TIlI:5f findings are a r'-(Ie<;l'on of mucosal cdel1u
"Rcf«t""Hl,11,)S,37,4),6Q,70 101 lOllo(' 122 124 129
tRd~,tncnl,),46,'06,107.116 ' , , • ,
 • B

fi,. . . 4-H ... a .. ct B. MR. O<;U of Wonoc ........... .... n

1;0... ehn) ..,h mu,lIary .." .. Ht d~mon.truin,
· and B. Tl_,V'""" wl_.
c......"ic m"" ..... 1 Ihickeni",. On Ih.
Tl . _ightOd '.q"'''u <h. m...:o..,1 <hanlU a .... of low .ilnal intono.if)', whe'~u 0" Ih.
T2._ighted Kq ... n< .., <hr, a.. of high ,,,«,,,if)'. A ....,all .i.... fl .. id 10,....1 is noted on the T2
Kq"'''''' ""'. os nlO' ..ad ,1y 'P!'a,.nl on tho T1 wq".""u. Co Wa.ers' ¥icw demonlt""''''
chronic mucosal chanin OIl both maxol1vy ,,"uses.

ausro by vasoddauon ;md incru~d production of muclU
by tht goblCl c.11s and mUClOsal gIVld •.
In the rv.aluacion of a ~inu$ dtmonJeracing Lncr~d ra·
diographic densi.y, corrdation of the radiographic and
dirueaJ findings is important be<:ausea number of pa,ho-
logical processes can bf:gm wlIh a sImIlar radlOgn.phic ap-
pearanct. In addiuon 10 mucosal edema, mcreasW radIO-
graphic density can ruuh from chrOniC mucosal changes
caused by chron IC s",usi ri s, prev.ou. tUUma, and prtor
SUrgical proadurcs Ot hn faclors ,hat un r<'Suh.n an .p.
p.a.em IIlc.t:uo-d radIOgraphIC dtn.,ry c' l "nu. lIlelud.
hypopl~la of the sinu! wnh or wi,hoU! ~"a "ons '" .hr
th'Cknt •• of the os~ous walls ofl he sinuS
Acute b=en.al ,""us,us resuhs (, On' seclOudary ba<:.cnal
,,,ftCllon of <he ob~.ructerl ~Inus by baclf"a normally
found in the nasala,rwa)" Jnd ol al caVIl)' The r_ baueua
mosl frequ ently involved in aCutf bacterial StnUSLIIS arc
HannopbJ.f1 'nfl .....tM :llld StrtpI«om<r P"l"-- Orntr
less commonly inyol""d bacteria include SU~ q>t-
dmnu/u, Strept<xo«o<s ...nolan.<, Bn>nh..",rlla cM.:lrriWu, :llld the
diphthctoids.),I"Ol~""Ol Appl"Oxllnacd\" ICI'. <0 IS"" of maJ<.
,lIary sinus pillhologir:al rood,cions arf demal '" origin and
often arf associa{cd ..,.h absctSSHI. mOwS Vld premolars,
tht <OOlS o f wh ICh are closely relaced 10 the noo. of rhe
maxllb,y ''''(IS.· ACUlt s1l.usiu s also may OCCur after vio-
la"on of tht sinu$ and ,he mtrodu cu on of oral bacltna
d ur"'g drntal ,urs.nl p<octdures (Stt F.gure ~ · IJ). 1m·
proper closure of a (olll lllu",cat ion can result on ,." oral·
an,,)1 fisl ub and chronic s,n usiIlS. I'urulent mucosal dIS'
charge r~ul[S In purulent uudale flUId accumulating In
· R<fe •• ncu I, J. 101. 10J, ' 24, 129, 130
.h~ smus, c.a" smg an ~".f1uld k vel".J'O.' .... "I,U. (:\« Flg",e
4· 11). 11,e ndlogr~phi < findlllgs III ~c,,'. but~nal .IIIUS;·
II. vuyand nnge from a g."er..Jl~ Incrt~d denSIty Ie·
flewve of mucon edema, to an air.fluod I~I caused by a
buildup of purulent nuterial , 'o a comple.e opaclfic>uon
of.m: sinus c.aus.ed by the p~ncc of a brgc amount of pu'
rulent nlatenal and mucow edema. [n baclenal sinusius
lhe ai .... f1"id I~~ if ptuent, is Iimiled to OUe or two .inuses.
Although the a. .... fluid kvcl is n_t often the rcsultof ~C\lle
bacterial sinusitu, it also GI.tI rcsult from «<ent antw
~~ recmt trauma, or blood dyIcr2si.o. with bI...ding intO
the sinus, S1rusing the need to always corrdate ndio-
gnphic findings with dinini history. cr uanlinuions
ckmonstr.lu ai .... ftuid levels in tm: d~ent portion of in·
volvni sinusu (SC<O Figure 4-11, B). On MRl u;omination
.m: ~ppanna of an unromplico.ted acuu s!IIusin. rdlttU
Ihe undm)"ng puholog.cal condition. Inflamed, edema-
tOUS mucosa and frtt fluid Iypically demonstrate low sig-
nal intmllty on Tl·..w;ghred and incrus.ed signal intensity
on n ..."ighled 5C'I,ucnc:cs.... 'U%2 ('itt Figure .-1.).
Acute NoninfK1ious Sinusius Allergic: rhinicis and si·
nusitis an noninfcctious, inflammatory processes affecl'
ing approximarely 10'IIi. of the population. '.'),.1" These two
conditions reprcstn. the mosl commoo acute, noninfec-
Olms ptOCCliSCS Invading 1m: sinonasal uact.J"IOI The sea-
sonal conditions an .he result of immunoglobulin E
reagin-antibody reactions. In allergic sinusitis the muco-
periost",m auoo;:iated pnmanly with Ihe maxlUary sinU-"'s
becomes hypcrplanic and grossly edematous. Similar
changes often OCCur in the mucosa lining .he ethmoid,
frontal,and sphenoid sin~ nus thickening is often uni-
fonn and symmetria.l, although rhe formation oflocal-
iud polypoid mas... often oc(Urs. The ndiQgraphic find·
ingt in allergIC sinusitis m,rror these various mucosal
changcs.ln addollon to genenJiud orlocal mucosal thick·
ening, rad'ographic srud,es demonstrate edema of the
rurbinues.AI .. llwd levels an not as.sociated wi.h acute aI·
lergicsimu'llli and, when present, indicatelhe presence of
bacterial. su~nn{«:tion. ,..
Acute Slnusms, regudltu oCrhe call5t, mayevolvc into a
chrorUcSlnU$Ill.I. Factors that mayfacili.ate Ih .. evolu[ion
mdude impa.IN dr.wu.1;<' and uncion of the Involved si-
nus, pcrslltent infection, lou of cilia, and mucosal
ch&llgcs.') lnadeqlUle5lnus dtamase &Ild uration may re-
lui. from m«:h&llini factors such as a devi~l ed sep tum,
nauJ polyps, adenOId hypertrophy, nuopharyngcaltu.
mora, and edematous mucosa In thcrog1On of.hednming
O$OL lnadequate iUlUS dra.nagc can result m the accumu.
lation with,n the sums of a medium favor~b!e 10 banenal
grow,h, whutu unpaired aeralion may {acilllate Ihe
growth of Ih. parhogenic anurob..; and m'«oacroph,hc
bal::lena.lnadequace"ur"",m of an :KU,t Incteri~1 SmUS I-
(IS may ruul. in a chronic, I moldtring mf«uon .hat can
invo)"" the adjacenl bone. Mucosal changes, oflen ,rre'
"""IMe In naturt , may ... ull from chtm ical IIl)U"" or
th.ough an alltrglC mechanlJm. ChtltllCal inJUrlU m~y r.
sull In a low of ahated epl.ht!'um, ,hereby 'mpamng nOr .
mal. s,nuS tOIlet and destroymg the .e",ncrau"" capaat)'or
Ih. muCOsa. Allergies may promote the dcv(]Opmcnl Of
chronic s""l5l1is by causu'S m ucos,,1 ed. ma and hyp.,.
_<cuon; bach Impair normal smus dr-aJnage and facilll.l l t
Ihe groW'th of bactena. Grossly _and rad1ograph":ally,
chrome sonus'tu is ch.anctenztd by '~rJlblc mUCO$aj hy..
pcrpLasiaand thickening Ihal often resu!u in mucosa! foida
or pscudopolyp$"·,...",·.. t.,,,.
(sec Figure . - I 1). 1n addition
to inYOlving Iht mucosa, the inflamm.uory process ClntJI.
tend to the underlying bone, resulting in h)'P"rOStOli.c
changes, the hallmark of duonic JinusitiJ.
Acute bacterial infections may oecur in pallents Wllh
chronic ,inusiti,. RadiognphicaUy, an ai .... nuid level and
nmcow rhickening in the i.....oMd sinus maybe nDl:ed. cr
studies demonstrate contra:st enhancement of .he in.
flamed mucosa, mllCOsai thicUning, and an air·fluid level
On MRl txamirurion the thkuncd edemllous mucosa
typially demOfUtrates low signal inte .... ity on T ]·w..ighted
and incrca.scd signal. intensity on T2.~ightcd SC<juenccs
,imilar to tha. secn in acule sinusitis (Figure 4-1.). H(N).
ever, rm: appearance of entrapped secretions can vary de.
pending on the degree of hydration. On TI- ~nd T2.
~ighted SC<juences, rhe signal. intcruities decrease u rhe
secretions become more conccnmlccd. Signal. voids on TI
and n 5C<{ucnccs an nOled when Ihe secretions arc dried
and solid. l "
Complications of Sinusitis The development of chromc
sinusitis represents One complication associated with acute
Or recurrm t episodes of sinusitis. In add,tIo n, a number of
other complia.oons are ~Icd wi.h acute and chroruc
.inusitis. Thue complications can be dlYidcd into twO
main groups: those limited solely to rhe SInus and rhose
involving adjacent StruCtures. The firsl group of complica·
tiD .... includes form~tion ofhypcrtrophlC polyps, mucosal
cysts, and mucocelu. The second group results from u ·
tension of t hc inflammatory process to adjacent StrucrutCli
and includes a number ofinflammatory nuaI, orbital, and
intruraniallesions or 05tcom~liti$ of the sinus walls.
M"nHlS ReTe"Tio" Cpu Tht mOSt common IocaJ.com-
pl'Oltion of smUSltis is .he formation of mucous ...enllOO
cysu, oecurnng in apprOlUfflately l~ of the popul~·
1I0n.'·"'·'OI,"',,1I Thes( CYSIS rtsult ftom blockage of the
ducts draining seromucous gl~nds followtd by cystic u '
pansion. The luions occur most ofun III the maxiU.uy SI-
nus and ran~ f[orn less than I cm ro large lesions filling
neariyal.l.hc smULln COn tr.o.stlO mucoeeltS Ihal mold the
smus walls, mucous r."nt,on <;)'SIS ~dhere to the sinus cay.
"y without causmg any bont expansion. Rad'ognphlCally,
Ihese I(s'ons usually appcar u rounded, soft tissue densi·
tIes wuhln Ih. Involved smus (Figure 4. 15)_ A lesion or
dental ongm Ih~t at times nn have an mlllli radIographIC
appcaranct ,dentlcal to Iha( of a Ietcnllon CYSt is a pen·
aplC~J dent.allUlon invulv"'g one of th. max,llary ... olar$
The. e cyst" lesIons are fhe asul! of ... nammllory pro·
cesses occm nng I ( the apc~ o r a nOnVl{alloo,h. Thry an
elth.r d,rtClly "wol~ the miuullary $Inus o r be JOcaIC.!

f<rw ""15. Mucous 'aefltion C)'Ot$. P~,"ic~~m&.-.:I;bIt
cIemOftWJ.""I a mucous ~~'lCiofl C)"t in the Irit muilluy ....u,
r-'
"1,hin Ih~ adjacent al''«>iar bon~ and proj«ud ~r Ih~
linus, thereby sImulating pathological finding5 of sinus
origin. In thue Ca5f'S, com,lanon ... ith the vitality of adja·
{tnt tUlh is required to dIstinguish ~tWttn lesions or si·
nusmc! dental origin. On MRl uaminauoru thue lesioIU
cypKa!ly demoll.$tr.m, 10\11 to imennediat~ signal In.eJ\$ity
on T1 and high signa.! intensity on T2 sequences.
~ The moSt slgnifi("2n{ local compliation ofsi-
nusiUs is the forrrnltion of a mucocek. Mucoceles arc tNe
cystK la.ions lined by the sinus muco$.1.. Mucocdes asuh
fromobslrucrion of the draining ostia followrd by the con-
tinued $Ccrerion offluid in the obstrucTed sinus or O1.iTcell.-
Ostial obstruction is u5ua.!ly the mult ofinf\amm.awty or
~crgic proces.su, although il a.l.so can rnult from nnlplu-
II(, postsurgical, or tn.umaric factors.. 106.111.1" As a resullof
the uXllinued fluid secretIon into the obstructed smus or
;lit cell, a buildup of fluid resuits in pressure atrophy, os·
seous ~odeling, and Jx,...~ng of the s,"us w~J!s ($Ce FIg·
Ure 4-(2). Thc upamile ch:u2Cter of mucoce!t$ unduhes
threl dir.ic~1 presentarion. Mucocc1es occur mon com·
·d· II ,,,,,01
IIlQnly In [he fronu.! sinus and cthmoL 3Jr ce s. .
"-._ m~tdy twO thuds of
nvnQ] mucocelcs consuture apptOX l
all mucQCeles whereas cdunoid mucocclC$ constitU[e ap-
proxunaldy is", to 30'1r..' ,'''-'''' Ethmoid sinus rnucocelrs
I"IIort Orlen invol\/!: the amenor ethmoId all cdls, ho,,'CVt"r,
.1_. . ethmOId aIr cc!1s and
'h q""'("an origln3te III the posttnor
d s ''''.111111t~ mu·
n~ Into th.,. :leljacenc sphenol SU1I1
L. ..J.....«tbmaJ mwaKtitJ
"'OCCIQ art somtumes lefcrttd 10:U Jr'-"
Max; rIuy SInus rnucoceks arc unco ml non and conSIl'Ult
I s IQ< On rare occa·
-
~mately s't. to 10% of all mucOCt"
· .....,... ,,91, 106, 119. 129, 110
"OJ"', mucocdu OC(u< on Ih~ .ph<:nOld .'flU< and ",,,h,n
stptaeod rompa"m~rH' III Ihe max,lIary .. nu ........," '"
n'''"1 al>o mayoccu,mlM mu,llary 51nu..,. aIltr C"ld_lI.
ttl< p'OO::tdu,t<. Mtl<octlu can breomt ,nr«etd and art
d.t" Itrmrd p.}«Ju. CUta1n t1uhographi( char,o.curi<ucs
a~COmmo<110 all mucoctles On plain film and cr nud,es.
In addmon, 10m<: f3dlogDpruc find'ng> a~ relared to eht
l00::a1 tlrteU oflh~ mucoctle. Common plain film and cr
findings indudt Ihe prtstnc~ ofan vrpan.ile mo.u causing
dispbu .... nt <lr bowing orlhe sinlU or a1. (til walls.. Ax,al
cr II«rions through all noninfc<ud mucoc.~lu typically
demorutn.1t:o ....dl<ircunucribcd, nonenhancing soft Us'
sue mass. ""n""h....a] macro$COpic calcification u "",dent In
approximately S'of mucocelcs. "'Tht ~nce of rim n>-
Ioanctrn¢ne 01" incuased density of tht soft tiS$ut rna» sug·
gflts lilt prtstnct of inftenon and are mo", accut2ttly di-
:lgnORd as a pyocelt.
Pla.in film findings associaeed ""ieh frontal mucoctles
indudo: clouding of the involvro smus, tmSlOn of Ihe in-
tra$inu. stpra., tht p~nce ofasmoo<h wall sinusc::ovity,
and iU d~fuoition or loss of the mucopviost~a11ine.1Q< Ax-
ial cr ..·nions through rroneal sinus mucoctlu also ma.y
d~mO~f2{t incracranial and tntraorbieal vrtension. prop-
tosis, surural diutuis, and supraorbital soft twue masses.
Ethmoid mucocelcs are best diagnosed on cr srudies
and dtmonltrate a nontnhancing, apansile, soft ril.Su~
mus causing bowing of th~ walls of air ctll$. Ethmoid
mucoctlu originating in the posterior tthmoid sinuses
(spheno~rhmOld mucoctlu) may demonstrate siSnlfi-
cant involvem~nt and npansion of the adjacent sphe-
noid ,inu... ]n addition, unl cr scans also demonstrate
orbital and nasal involvtm~nt. Maxillary SInus muco~
eelts often initially display plaJn film findings suggestive
of a malignancy. Thest findings include op.acification of
tht involwd sinus and ofltn 10"-' or apparent destruction
or Ihe sinus walls (set Figure 4-12). CT studirs show a
_Il-<ircumscri~d mass filling the sinus with bowing or
;ttrophy of the sinus. On MRl examination the appur·
anet of mucoctlts Can vary depending on the degree of
hydration o f mUCOId malerial present. Uncomphcued
mucocelu demonstrate 10"" .ignal intensLty on TI and
high signal intensity on T2 stquencu. HowevCt, dt-
pending on tht degree of hydration present, mucaedes
also may demonstrate incrcased Signal intensity on T]
and 1'2 scqUenCfS o r an absence of signal intensiq on the
sequmees.'"
SphenOid sinus mucoceles on plam film and CT ,ruwes
demonSiralc opacification of the sinus and vrpansion and
chinning of tht sinus waHs" IntracranIal vrteJ\$ion and
anterior nrensi!)n also can occur. Jmracramal eXlension
,
can result in sdlaror parascllu mas5CS on cr <{udiu .... '"
Amenor extenSIon LIltO the PO<ltnorffhmOld airuUs also
can occur, oflen rnulnng in bont deSHl" lion indLstin-
gUlshable from Ihar caused by a malignancy.'Q<
OrilitDi t",d &11"<11;""$ Comp/iell/ioM o(Si"",,;/i$ If Lm-
properly treated or unrtlOponSl\ft to ;tpproprialc therapy,
acute $.nu.il1s and, mOrt rardy, chrome SinUSitiS can
 '0
IIw"lw I',. adJutn. (If 1m an,I.It"e!u,,_'." .... {"t~ o.-b,ul
",,,,),1"""0"5 ",d"d~ ,-.lIul"" '" .b~ •• fo,m",o" .• ul>
1~",oSle.1 .bsceu 10,.,"'''011 a"d 5"1"><'''0' orb".1 (".ur,
.yndrom., and o.«:orn)",Io[l$ oflht OSSffiO. w.lls (se'!-oR
" •• ~·IJ). Orbual comrh<."oru usually ..... h. , •• ult of
Ml,wla,ed nhmotd,m .•• hmo,d"lJ and .",,,.n ..
II'VOI\'
mg ,h. adJ:ocml (ron ••1 or ",.,unary .",uses, or both. 1m·
prol"',ly '.ta,...!
m,.xnomal tx{(nsion of an aculr "nus.
us ,. a.uocUl..d ",,,h ."n,fican( ItIOI'btdny and mortality
r.ua. Intracranial ulcnJ,on tan OCCur along anatomICal
palhways ",eluding poenntunl by mun. of ... retrogradr
.hrombophltb" .. or Ihrough dirKI spread from an in
""lwd Jinus bordering ,h. (ramal fossa or hematogenous
.oulu_ Inlraer... ,,;.] complications includ. purulent
m(ning'.;s, acu.t subdural 0. epidural rmpytmu, brIm
ah$cURS, and u","moUl smlU Ihrombo..... Os{wm),d,us
of me wall of an invoI.-ed S,nW also an occur Th;s wually
;s found (n .ht fmn ....1 sinus, although it abonn occur in
{II<: nw<Illary sinus, wual~· J,tT den.al c:xrracnoru. An un·
usual complication of <)5{wm)""I,,,s of tht frontal .,nUS on
{he p«hunc age group IS urension of the inOammatory
p,ocU! onto tll<:cranlUm and .he dtvC]opm~n' of a su~r·
ficial subgilltill abSCUJ ,,~thout evidell« ofbon~ destruc·
t;on, rnulung in adin.ul entiry known as a f>rJtt', /'Nib No-
....". ' -".11,1001 Rad.ograph., findings associated with
ostwmydms:are evtdtnt 7 ro 14 da)'S and include Ios.s of
rll<: slwp oudine of til<: stnw ~n and a patchy "moo:h·
falen" apparan« of invo]""d bon" ruulting from local·
t~ed decalCIfication," Thnt areas subsequcntly may dc·
wlop sclerocic chwges, focal "'quutrarion, or bo,h. CT
provid~s oplima] demonstration of uquesrr.>t that may
not be rudily seen on plain film$ (sec Chapter 14).
Fw"v'SillwJitis The tWO major fungal infections on'
voMng the puanasaJ sinuSl's are as~rgill05is (cauS«! by
genus Nf>tr1.iJbtJ) and mucolmy.:osis (caused by genera
Rh,uptu, M"cor, and Ab"'~/jI), As~rgiJ!osis is the mon
common fungal inf«toon of the pannasal sinU$CS-n'J As.
pergtlli:are ubiqullou. uprophyuc molds Ihat occll$ion.
ally become pathogenic in humans. Aspugillos.s of Iht
~ sinuses an occur In a number of distiner forms.
In the otherwise huJrhr person, II may be found as a
chronIC, noninvasiw (orm of .mum.s, usually lim'rtd to a
.. ngk muiIlary&inW, ... · ~l "'.Il, The r,od,ograpluc findongs
MIOaalN wllh thlS form of aspergdloSls ate nonspe:"fi,.
III tht urly phaMS a soft "Slue mass rtpresenting a mas,
oIR1)'Ceha maybe nOltd, whereas m lar.. phasts, a homo-
p n eous opacification of the involl'td sinus may be
(au nd""~.J>l In ~pproxtmately half (he ~dvanc~d casts,
d~nstconc~{ion~ accumulau wlrhm (h. sinus; such find.
mgs arc conSIder«! pathognomonIC of asperg.llos,s, Thn~
radtodensllln a~ rompo>~d pnmanly of ttr.iary calcoum
phosphate (apal"e) and smalinquanm'ts ofcaklum snl
fidt and heavy mClal ul ... ',1" Th.~t matenal~ art dt.
POSlltd In necrO[ic arus or the my.:elium, usually In rhe
umtr ofth. mus fi1hnS rht SInus, and art rudily d.
(tned On plain film and C,.~",d,e.·' CT Stc!{ons al so
' Rt(tftn<n 1.3.39 .•0. 9~ )06, 111, 128. 119
demon'''''' •• hl('k~nlng of ,ht osseouS ""Us walls and
lnw d.n~"y artU w,dnn .he sort "nue ",ass hlhng rhe SI·
n", ' " M,-pllws ,nf."oon also may ~ round """ally as a
{"ngus ball (uptrglllom") in ,ht Involved SInUS, whIch
'''.n radloglaphically 5nnulau a nwpl~5m In pa"enr..< .... ho
are deb,llfatN or ,mmunocomprom.std, NP"t;l/us mfec-
.ion n,ay ~ firu sten as a fulmina"ng ,nf.cllon with
rapid dUlrucuon o f ,ht nasal uv.ry and ,"volved
paranasal s;nus(J, ".16.17 Ea-1,enSlve and rapId bone d~·
.(rucuon suggtsu.... of a malIgnancy can be sten;n such
casts.
Mucormyco5l' represents the mos! falal, acute: op-
portunist;C fungal inftction_ It is ""sed by fung' bt-
longong to .he Muc oracut famIly, which incJudu
s~c;es of the gentra Rh,u/",', M",o" and Ab.uJ .... • The
I
fungi ;n mucormy.:-olls ,"vade Ihe arlenal """II and pro·
duce an anenUS follOlWd byvucular .hmmbosis and in-
farction of rh. surrounding tissue. Rhinocuebral mu-
cormycosis lrarrs with na ....1 involvemtnt, followed by
cxlension mtO {he paran:ual ,inusts and orb.ts and in-
Iracran;al eff~eu. Fungal disseminallon usually oceu",
through vascular ehannds." [ntracranial exttns;on can
result in ~ither infarction or abscess (ormation,,··H •JJ
Plain film and CT findings associa{ed with mucormyco-
sis include nodular rhick~ning of Iht muco~riosuum
lining ,he maxillary smus, usually "-;thout a,r·flu;d lev-
els; clouding of the tthmoid sinuses; and mulnrle foul
ueas of bone dcslrucnon. I•.'1.lJ
CTplays an 'mponam role in kno....n or suspected Muuw
infections. Gamba et ill." d.scriW a number ofCT find-
ings in palients with mucormycosis. The initial clinical
findings of cr.u1iofacia.\ mucorm)"'osis tdlecr the Structures
involved. lo Initiallnvolvtment of tht sinonauJ tract is r~'
O«IN by a nonspecific mucosal thickentng, ofren without
alr·fluid I~ls. Invol""mtnl of tht d.ep soft tissu~ o( the
mfratemporal and pterygopalatine fouu rtsults in tht loss
of rh~ retroanual fat pad and tht vanow fat plants sepa-
raung rht musclu of muncuion. Orbital mvol .... mtnl can
rtsult in presepral ed.ma, ptosis, infiltration of far in the
orbital a~x, subpenosteaj abscess form~tion, and changu
m tht OrbItal musculatu~. Intracranial txttnsion usually
.nvolves Ih. ctrebellum and brain parench),ma at th. base
of tht bram, resultmg in t]thu focal abscessts, arcu onn-
farenon , or boIh ftatures. Bone destrucuon, when pr.sent,
occurs bit tn the dtsease pf'OCtU (ste Chapt.. II).
GrarluiOm"tDws Oistost Th. granulomatous diseasts
.. ffec11ng the noSl' and paranasal sInuses represe"t a hel'
erosenous group of pathological tntit;u characterized by
the formation of soft tIssue granulomata {har Often txhibit
slm,I~ , cl,nICal and radIographIC fi d U Th
n mg~, • gross de-
SUUCllon noted on chmeal exam' .-
h bl .. manon .s Otten mdisrin-
gUls a • rrom {hat of neopiasllC prOCtsSt~ Th
r granulo-
matOu~ dIS~ase~ Involvmg tht nos d
I d ean patanualsin uses
mc u e a nom brr of 'nfe",o us d .stasn: tub I
l.prosy, syph!ltl, yaws, UtlOlmmune dost 'rcu OStS,
W,senu'sgr .. nulorn310Sls .dlOpJ1h II ases s\lch as
, I( nlt( "Ie granuloma,
• R,ftf.n(f·, 10. 14, (1. 31,33. 10]
 urco,d<>SlS ~"d f<>r~'&" b<>dy-",duc~d !:r~"ul"",a.a u-
."l,, "!: from l<>ng· .. r'" ~xp<>sure to I>f:ryll;u", and chro-
·I1·
",a" sahs·,·, .. The tadiogt:tphic and CT findings In
,he'" different ~nmiu ace sim,l:u. Ini.i al CT uamination
de",onstrates nas:ol soft tinue nodules and .hickentng,
Sub..... u.n. invol""'ment of the pa..na.ul sinuses can oc-
cu r. In the later phases of the d... eas~ process, bone de-
struction and roft ti$$u~ mass ... suggesti"" of a neoplasric
process an: pr~nt.
fASCIAL SPACES
11t.e fascial spaces of [he head and neck represent major
pathw.l.YS for the spuad of deql infections. Failure to <C<:-
0sniu and appropri.ately nut a fuciill space infection Un
1'd"lr in duth from airway obstruction or mediastiniti •.
Diagnostic "naging is imp<>n:ant in th~ evaluation ofras.
,ialsP"'C( infKoons.
ANATOMY
11t.e soft tissues of the head and necK can be divided intO a
series of spaus. Some spaces are normal anuomic:al spaces
containing various structure. (e.g., mauintor space),
..nereas others are potential.paces, idencifiable only when
invol""d by a pamologic:ol pnxess (e.g., retropharyngeal
space). Important anatomicill conn~ctions uist bet\Wen
thue. wrious acrua.! and porenciill spaces that can allow for
the rapid dissemination of infeccions throughout me head
~ neck and .... en into the mediastinum.
Conceptually, the f1.Scial pLmu of the head and nrcl<
may be visualized 1.S a ..rics of-conduits."- The ourer en-
""lope, ",hich surrounds .he neck and head, is composed
of ,he SKin and superficial fascia (subcutaneous tissues).
Two fururrs of the supuficial fil-Sci;l are thu (1) it conrains
the muscles of facial expression, including the pia [)'Sma,
and (2) by virtue ofits superficialloca.oon, it is readilyeval-
uated on clinical examination and usually doa nOt neces-
si,a{e diagnostic imaging of pathological pnx~sses.
Anatomically the d~ep neck Can be divid~d into a su-
ptrficial investing layer, middle or pretracheallayer, and
deep or prevertebrallayer. These spaces ue major pathw:l.)'S
for the spread of innammatory procencs and .m ust. be
thoroughly ....a1uared in any imaging study. The Iflvt.m~g
li~r is the most superfidallayer and surrounds the ennre
neck. It is a[.ached posteriorly to ,he spinous processes
:ond ligamentum nuchae and anteriorly,~ the c~in, body
of the hyoid bone, and ma.nubrium sternl. Su~.nor!y, ,he
mperficialla.yer is attached to {he external OCClpttal protU-
berince and nucha! line, up of the ma5{OId pro<:~ss, lower
border of ,he zygomatic arch, and lower bo~der o.f ~an·
dlble between .he angle and ,he chIn. Infeno~ly, It IS al-
{iched to .he sternum, clavicle, and acr0I1110 n or the
scapula.' In the neck rhe uwes,ing fa5cia sph{s to .endose
, trapezius sternoc JeJ d oma5wi d ,a nd ",frahYOld mus-
t".
cula{ure (om~hyoid, sternohyoid, sternothyroid, .and thy.
rOhyoid)_ In the maxillofacial region ,he ",vemng layer
· Rc("~nc .. 46, 50, 51. 69. 96, 118
5pht.< 10 form ,h. submaml,hulu ."blillgual mas"c~,o,
alt d paro.id .pac~. (F'gu[l:4-16), ' , ,
The mid!lle lay" o(,h. !leep cervical f... cia cxtend.
from Ihe .kuU bas.!O .he pericardium .hrough .he ca.t"'id
.hea.h I ... dwid.d i",o a ",uscular and vUc..al division.
The mU$CUlar dIVision sunounds .. rap muxl ... and the
adventltta of the great veuds; Ihe visceral division SUr.
rounds th~ COns{nctor mu.scl~s of .he pharynx md t.SOph_
agw, and forms th. buccophuyngeill fascia. and anterior
wallofthe rettopharyngeal spact. The Ja..ryru-. trachea, and
thyroid gland alw are enveloped by the middle layer of
deep ce.-vical fascia.
The deep layer of me deep cervical fascia is composed
of the p .. wrtebral and alar divisions. The alar division
form. the posterior border of the renopharyngealspa«
and surrounds the deep neck muscles. Th~ abr division
also contributes (0 the c,,-,otid shea.h and fuses with .he
middle laye.ofme deep cervical fascia at th~ appr<»<inute
level ofT! to 1"2. The preven~bral division is attached tQ
the an'enor aspects of me wnebral bodies and extends lat·
erally ,0 the tnnSVe ... processes of the ""'rtebrae. An im-
polUtlt potential space forthe spread ofhea.d and neck in-
fections to the mediastinum is the potencial space becwun
the alar and prevenebral divisic<l. of the deqlla)'Cr of the
deep u.-vical fascia known as the -danger space. -This p0.-
tential .pace is bounded laterally by the fusion of me alu
and prevcrt~bral divisions of the deep cervical fascia with
the tt2ltSV1:rse processes of me ""rtebrae. The danger space
extends from the base of the skull to the level of the di-
aphragm (see Chapter 8).
DIAGNOSTIC IMAGING
Plain Film Diagnostic imaging of a. patient with a known
Or suspected fascial 'pace infection often st:artS with a
plain film srudy of ,he pharyngea.J and cervical airway. This
srudy usually consistS of anteroposterior and Lateral views
of me airw~y taken wi,h a lesser degree of penetration man
comparable views of the cervic:a1spine (Figute 4-17, sec Fig-
ure 14·1). Plain film findings associated with aCUte fascial
sp"'cc infections include thickening of the tetrOpharyngeal
soft tissues, distonion with Or withou, displacrmenr of .he
pharyngeal air column caused by soft tissue ro~ma or ab-
scess formation, .oft tissue g1.S, and radiodense foreign
bodies. In addition, plain films obtained using standard
techniques for osseous tissues may demonstr;lte os-
[Comydicis of ,he mandible or cervical spine and radio-
dense sialoliths. The laceral view of the cervical. airway is
especially imp<>nant in the evaluation of ret<opharyngeal,
par~pha<yngeal, and submandibular space infec,ions. In
such studies, evalu:uion of nOt only the gross p~tfnCY of
the airway but also the width ofth. ptevenebral soft tis-
sues i. important. In the ~dult with the n"k in the nCt"
nal posuion, the thICkne .. of prevntcbral soft tissues
should not Utero 10 mm at the ClI ....d, 7 mm a. the C3
I.... el, aud 20 mm at th~ C71.... d, " In s<:hool-aged cluldrcn
the nonnal m.lXi",um width of the rctropharyngeal ussues
at C2 should not exceed 6 mm and 15 mm at C6 These
41
mea5urem~nts represent ,he maximum w,dth of normal
" .-
...--
-- •

HgutW 4-16 A, Cros.-s.«t1On ofCeMC*1 f'5(;~. pot~nti,,1 a.n~tomiul 5paces, and p"oxima,~
VI,al """"un> at ,htlevtl of.he orop~a.ryno:. Th. pacapha..,.,gnllpaco i. referred to as
,"'J"~,,.lpM'Y"P"Isp.a. (From H.tI..., MH. Hall RE. 0.18,,1.., AM: R.adtologyofhoad and
n«k dup "1"''''' '"rK"O."' .... d,,,;':o&,,', p<rSp"nivo:. In DeIBal ... AM, editor: M.uu/~1
"""'"' Phi~.Ip!'Ka, 19'90, W8»,,~) Th • ..,latiOl'l"';p o(.ht v;triou. '''Kial spaces '"'
d>e Ievd of the midol'll c."'ty in tho .... 1 plano (8 ) and coronal pia ... at the lewl of ,ho
P""'"""" on.l "''''ty (q.
I A B

~ -"'7 A. Yecn.1 Ww 01 n«l< ... th ... re .issue dua~ demoMua.ing a ~al

aboe ...1 afUr ~otion 01 a ~"n body S days .arl~. Marlord thiclwling 01 ct... ~e·
IInI ..m tISWn _th an.fl>(IO" dosplacc .... nt 01 .... ~I. lat)"ICOal. and UKh..J
c

...om
a.n...ys 01 p<ur<lt.. ,.." is "..-urn< the •...-obtyngu.l and ~""al ooh ouua (_
~). A pl.... ic fo... ign body(Lo,.. _)was rvnowd ~Ily. AnI~

I
and lalerlOl ....... of airway drrnonwa,ing airway displace ....... <;auMd by diffus.r raKHt>S
and ab,USI formation in .... left Iubma<><libular. pa""pharyng..l, a<><l •• tropharyngal
spKH. B. Arn.roposc ........ .-icw of the neck drmonstrales a marbO displaco"""" of ct... ~u­
.oal airway.o 'hold1.. C. YI.""I view of the ~ero-ia.l airway demOflstraU's a ma.ked in·
Cf"!'a .. d in .... width of the preYM..bral ... ft C<SSUH in the middle a<><llowior n«1c. (CaM
~t$)'V. Baroda_la. Buffalo, NrwYork.)

IlSSUes; It.., :awrage v.al.uu for the population from which
,hu.: v:aiues ..~u deriwd:arr Jess.lka.u.w utropharyngeal
or puapharynge:al space infea:'oru may occur with mta-
suremencs within normallunits, eliniciaru should illw;c.ys
look for <.>Ihn signs o(inf«tion on ,he lalerill view liu<;h as
(ocal increues In soft tissu<; Ihi<;kness, soft tiuue emphy-
sema, foreign bodies. and localized d<;Yi:ation$ oflhe air-
way. In addition, the anlcroponerior vicw of Ihe airway
should bot, uammed fOf signs of pathological <;on.dmons.
On rhe nonnal, properly position.d ameroposterior view
of Ihe aIrway, the air (olumn Ihould appear symmetrical
ow. the middle third of the <;crvical spine (see Figure 4-1,
A). DispiacemCl11 o( the pharyngeal or tracheal airway re-
fl«ts in\o'Olwment of Ihe paraphar~"geal, renopharyngeal,
Or prelrxhcal spxes. An Imponam area to evaluate is the
subglolUc region of the rrachea; a di$rinct shoulder mould
~ tvldem in the lubgloClK: stgmenL A concentric narrow-
Ing or rhis area rnulung In an invened 1/ appearance is
seen 10 patIents with croup
Compuud Tomography CT 15 probably Ihe most
Widely u~d advanced imaging modality in the cV3luauon
of deep fasCLal mfecllon s. · It can provide "nponanr m·
(O""al,on concerning the UIen! o( sofr ussue Involve·
nlttlt. ",eluding demonstratIOn o( the full urent of Ihe
Inflammalory process and JlS probable epoce/ll,r, d,ffer
emlallon berween myosllis-fascmls and absctss forma
·R~r.'.nH> 4. 29. 49, 52, 81. 99.
lion, accurate demonsnuion of the staws of the airway,
:and in\o'Olvement of var\OUli groUP'S o(lymph nodes. The
diffeuntiation between myositis·fasciiru and abKess i. es-
pecially important clinically because abscesses require
prompt surgial imervention to ulabluh good drainage,
whereas cellulitis may respond solely to approprialc an-
tibiotics. cr :also an provide imponant inform arion con-
ceming the StaWS of adjacenl QSstOUS structures and may
demonstrlle early petiosteal ructions associated wilh
osuomyditis.
COntrut~nhanctd :u:'al cr Stcrions should be per-
formed in the :u:ial plane in S-mm increments rhrough all
the involved fudal spacC$ and the major lymph node
chains receiving drainage from involved regions of the
head and n«k.ln ~ of mediastinal in\o'Olwmem Ihe full
utem of mediastinal in\o'Olwment mUSt be demorulrated.
cr findings associated with Euc:ia1 space ,n\o'O)wment
include myosilU and hsciilis (Figure .... 18), aU"way defor-
mity, inflammatory mUStS, flUId coll~rions and abscesses,
and osteomyelitis of m\o'Olved bone. A v;t.nuy of mte"..,n·
lIon3) procedures can be performed usmg cr g"idance
Fine·needle asplrarion of fluid collections ro obram
marenal for nucrobial analys's is rouuntly performed In
add ilion, abscess dra,nage and d.am rlaccmen, can be
readdy pc.formed undn cr gUIdance
Alrhough MRl has been u~d ,XIcn$"..,ly 10 the cv3lua·
!tOn o f conditIons in rhe hud and neck. " has nO' bctn
u~d u[ens,wly m rhe r:va.Iuauon of d~V t~xlal ~pa« NI-
ftenons. Major advamages of MRl ",elude th~ abibcy 10
 I)'-~I~...J M "",lIofd"dl l"Jmlo~'
" 0'
,h
,0
\ "',h
,b

"
• ",h
A 0'
"
jo
f,
'I

c o

Fig"n 4·16 Submandibular space absc •••. Myo.i,i. and fueii,i. ofn,l>t submandibular
.~. cau«,d byoun,ion oh de"t.I.t>sc ... in"""""g th. right >«ond molar. A. Con.....'·
enh."""d &><ial c.T 5«lion ,"'rough floor of mouth demonstrating a diffu", myositis and
fascii,i. in""l,,;ng th. right submandibular and JOWl" portion of right m ....'ica.Qr .pace.
low-densitya.ea, "p'... n,ing early .b",... formnion a~ noted ("""I/CIIrm/ Q~). B, A1<.
ial CT Halon ofmandibl. with bom windows demon>,'a'" a periapical abKesoarou<>d .h.
ap"'e. of mv>dil>ul. ",e"ond molar (aJrwJ Q"""J Thi, usc demonstratH me ned. to alw.o)'$
obtain appropn.o.t. bone window> ""'en ev.oluaung fueial opue ,nfections of possiblfc odon-
'o,<nic ong,n. C and D, Contra"-enh",n,.d ;ox;.1 CT .eCUe", through the deep and <up.'.
fic,al ..gmen« oftil. right submandIbular .pace demon"""'ng an absc.ss ;"""M~g tho
d •• p and "'po,foclal portIon, of,h. ng~' submandIbular .pa... Th. normal·af>P"aring su .
,h.
p..f""al so,,,,,,,,, of submandIbular ,land (o~~ n.,,~d ~rruw) i1. d'splaud anwiorfy by ,h.
ab><:u. (.w'Jlt, ~,,_). O. fofTmty of ,h. right half ofth. alfWay i. p'... nt.
 I"'w-'" 1,"4~"'~D' M4"'~·I"""'4.,;114"wI ~,..., 1-1...,-.
,.b<~'" dnt" ",ug.. In nO( only ,I,.. ",-",.ll'bn,. bUI alw
~. ">ro,,~1 ~nd .ugHt.! pl~"t"'lr"a"ts" , ,
,,~c . ~ ~ t tIISU$(tl'.. b~
,,, .,,,r,,e,! UU5td b) donul 'Ul t'ta"on., and 'ht "'".
... ,,<>u seo ,,"." """,,,,,.1u~d In MIU IInd'e, IS Ins IOXK
(ha" ,he ,odmu«i com'~l u.sed In cr icannong .. The
.!>Iluy 10 .mage In 'he USLI,aj and paru:.g"ral planu OJ
opt<"aUy uStful on th" dcn,onslra"Qn of re,ropharyngul
.r>d I"!,,,nor n.ed':all"nai '"'101"""'''1>1 LI' I he reS'on of iI'e
II><'U'"' ,nlet,:an atca that is SOrntr,m"l ddlicuh ' 0 ,,,,aSe
cr
.,.., roun nc a......J uarn;natiol\S ~aU$<l of arufacu from
.d;Ju"t bonts. lio"",,,,,,, MRI d~s h""", a numbcrofma_
"'( dlJad".m agcs 1!l the evalu.ation ofhud and neck in-
~10n., IneludIng length of .magLng time and the ',mii:u-
.ppfarancts of abscuses and cdluli.i. On n."",ighlw ,m-
"
... gu, m"klng d,fte'~nuauon b..t\W:en .h. lWO d,ffin,h .01
",nes"" In add,"on, mur... lenhancemenl by an ahKen
wall may Ix ,,"o,nl.n<e ",,,h '''pe<''o SU,"OUMong fn.of
... gadolinIum .d,nllll$"."on, r~ul"ng In t.mutd d.,u_
Uon 01 del",uI1on of d'e abkus_ Thcculaneouo m.o",(~-s­
lallon. abo may no. br obv,ou! on MRJ 'f Imag,ng
p"""IlIe'cn .,. no. ",on"oled" In addlUOTI, MRJ ""aml-
nall ons arc more upenll"'" .h:lll standard cr exam,n ..
{Ions and may no, br ava,labl. In anemCfgtncy_
MRJ findmg. associ •• ed wuh m)"OSi,,":lIld fue"", in-
dude an app at.'" in"ca,. in the siu of ,he 'nvol .... d
musdes Or lIuue plants associated with ... vanable low
signal Intensity on T I-we,ghted and Increucd olgnal on
tensity On Tl-wclghted seGucnccs (FIgure "-19. Sct

c

h&"'~. 1). t,nh"n'tn~"t of [h~ ,ofbmmarory r'(Kt~S
<'.(U<$ on TI-wr'j:h"d s.tqllcncu afcrr gild .. lo".un. a
"",lI'•• ,. ~"' '. ,1'0.'" A{,.«ucs demonsnUt "",lIa,
II
"S'
be
naI chara".,.. "n and n,U$ dl",,' Absct» "';1 S n"'·r
JlSnns,ushlblt On T2·"'c' ghtcd or TI_"'.,ghud .t-
qucncU afln gadolinIUm admmucranon Dtmans".
non ofll1. "biens wall may not« al-ny. possIble be-
,aust Ih. IOcrused Signal intensity of Iht edlullru
... <round,ng an absct$5 may be sim.lar [0 thar oflhe ab·
• cen waH on n ....·clghlcd stqutnca. SimIlarly, mUr31.n ·
haneomcnl "frr< gadohn,um (nhill,.,.m."t nuy r.sulf In
tht munl nng mom.ng ,sointtnK Wllh the ,,,,round·
mg fu. M&l'T'OW spact Invol~m.nl by Oln mnammato!,)
procus mulLS Ifl "d«,..,au in th. normatly hrgh SIgnal
,nlc"s,ty of,h. muro ... sten on Tl ....~lghtt'd s.tqutn<eu
""d an mcfC"", mthe 5lgna! lnCelUlcyorthe marrow on
T2-""'lghttd ~uencu.
FASCIAL SPACES
Submandibula.r F&.5Ciai Spue The submandibular ras·
oa!.fpa« II ronned by the il1\'eSting layer splitcing ~ the
hyoid bone to encloar: the submandibular gland; 5uIXrioriy,
thlS layer orrW.>. lS alcached to me memum and ,UUUlor
body or the mandibk. .....,... The imtiting Ia)"'r uunds to
cOW\" W supufiOal surfaas or rhc musda comriruting the
t100r orthe mouth (mylohyoid and digastrics), The sub-
mand.ibular fasoal spa<:H an: consi<:kred. anlmor el<tensioru
of dw: panptwyngalspac:e and an: divided inro tl'M: upper
lublmgual and ~ submandibular spal'" by 1M mylo-
h)otd muscle (Figutl' "20, Oft: Figun 4-16); dv.$t; twO Ipaas
commUJUCa[( fittly around rhc posttrior border or rhc my.
lohyo>d muscle:. TIx sublingual space is Locactd between the
mylohyoid muscle inferiorly and laccwly, and the genio·
glossus and hroglo»llS-StylogIossus muscle complexel me·
dially_,·'''',los Major components of ,he sublingual space
Include ,he geniohyoid and gcnioglonus musde, the
hyoglouus.scylogl05sus muscle eomplu, the sublingual
gWld, dttp portion of the submandibular gland and duct,
,ht Irngual r\ft'\'e and arwy, and tht [WfLfth (hypoglossal)
nerve. TIxscyklglossus musdt zriwsfrom the rip oftI'M: sty-
lOKI process and pass8 dov.=-=<I and folWilrd betwun the
m,ddle and supmor ptwynguJ cons«ictot musda_ As the
scyloglouus musdt pa»Q ~ u,., consmclor muscles,
" creates a potential communication bcrwctn ,he sub-
mandIbular and panphuynguJ spat'" known as Iht bw-
roplury"vAi VP. Th.s gap is a potential pathway for ,he
spread ofmfwlon betw«n these twO raIXct ....e 'paces. The
subma!nUary space IS located below the le~1 oflhe mylohy-
OId nluscle and con tams the 5uf'('.ficlal lobe ortht sub-
mandIbular gland, submandIbular and 5ubmfntallymph
nodes, and lnttrlOr belly of thtdiga.mlc mu«k n,t fOlSC,~1
lt1~chm~"t5 to Iht ame.ior b-clly of rht dlgutn( mu~clt
u,bd'Vldt tht sllbm ~nd,buJar sp~ct mro .h t {e'\tIl1 ~ub
mt mal and Lactral submandIbular .paa. '''' No m~Jor ~nl­
~omlCai harncrs tXISt be~n the twO submtntallnd ~ub
llinJ,bull' spJ.ct, proIXr. consequmdy. mfu!lons ( 1n
·\trnd rud.l y ..... ro" rhe m,dllne (set Chapttr~ 8 and 9)
An undtr •• andln): 01 .h. loulC IXI11 and coronal cr.....
o«tlonal .... a."rny 1$ tutllual '" .h. evaluation of Ina...".
matory procr_' """.lvUlg .h. submandIbular sp>.et ""'1
liS "",rious d,Vls,on. Tht submand,bular gland IS lota.t<j
wuh;n rht submand,bular spact. cr o«lIons show ,hat It
normally has a cr dcnmy com parable wlrh that of ~~.
eem muscle. On ..... ,,1 CT , t CtlOnS rhrough tht sub.
mand,bular SpOle' proper, the superfic,allobe of the sub.
mandibular gland appears as a _1I ·defintd, soft flSsue
dmsicy usuaily sutTounded by a rat plant (sec Figure 4-20) .
Lo&softhis wfl tissue plane 1$ associated WIth UttOS;on of
a nroplastic or all mnammatory procus ,n""lving eilhe.
,he glandot Ihe unJclurcs bordenng rhe gland.. Although
,I docs nOC conum any Intraglandulu lymph nod~, the
submandIbular gland " closely rdaled to a number of
small submandibular lymph nodes. These lymph nodu
should hne a homogtnous, noncnhancing apIXarance
and newr ucud 1.5 em m d,amcrcr.oo .n .lI-1ltc d«p lobe
of the submandibular gland .s mx wtU demonscr;t.[td On
axial cr s«rions because ' Ill cr duu;icy is dose to ,h,u of
Ihe adjOlecnt wft rissues of the floor of the moulh ; h""".
ewr, icean be identified on direct coronal cr SCctions.
OnMRI stetions through tMsubmandibuiar Spa.ce, tht
m~ all: onow signal imtnsicy on Tl and 1'2 ~uenca,
whUU$ fat: within tM fascial spaces demonstr.ues high lig·
na! inwuicy on TI."'~ighttd $t<juen«5. Thc: submandibu·
lar and sublingual glands demoosu:u:e int<'IIJWdi.a1l: signal
imcnsicy on n·"",ighttd ~nd Il:lariv"]y high signailOltn·
sicy on n .....,ghltd scqucncu. The sUIXrficiallobcs of the
submandibular gland art r~ly Kientified because they art
sutTQWIdtd by high SIgnal inttnsicy rat immediately an~·
<iorly. The d«p lobe of the submandibular gland can be
identified bctwttn ,he mylohyoid and styloglossus and hyo-
g!05SUS musc1u.
In addition to the submandibulu gtands, several mus·
cles should bt idmtified in the evalu31;on of the sub·
mandibular region on CT and MRl sNdies because thest
define nOt only tht Ipact but also tht ma.jor subdiVIsions
o~ tht Sp~".»M.,t1l Thest musclu includt the mylohy-
o~d and. gemogl05sus mU$oClcs, and the anTerior belly of the
digastnc mU$oCle (5« F'gull: 4-20). The mylohyo,d is a fan·
shaped muscle ansmg from the mylohyoid ndge on the
medial ilSpta of the ItUIndlble and, along with the pairtd
geflloglossus muscles, IS readIly idtmifi.ble on :unl and
dtrKt coronal $oC~ns. On aJuai cr sections through illl 00'
gm rM mylohyoid apIXars ilS a baod of soft Tissue denStty
adJOleent to the med,al uptct of the mandibk on direct
coronal scan~, 11lppcars as a nlUscular s],ng ext~ndmg be·
twun tht med'al aspect s OrbOlh htmirnandibles. The ge.
nlOglossus musel, •• ppeal' a~ IWo plflmroian muscular
bands st"ara!td I",.
,. -, I01, .-d e"sny \>trrical deft or midhne
hngu1l :>C"Hlm Th t<t ",u,.- Itl on glnatc from th. gtmal
,. .
tubercles On tht If}! trna I lSptct of th. anttrior mandibular
mldlme and ,- na 55 SUperior Iy mto tht substance of (h.
longue The subl I
'- _ . InS"a spare apf'('ars as a low-densl'Y area
"""'een Ihe para dl
and h I h ml 'ne genIoglossus mu~dt medIally
tem)"oyo,dn I
mandIble I 11 'usc. and nltd'1l surfac. of the
attra y h s roof 'S formtd by the mucosa or tht
•

Figure 04-20 A. Concrut-c"harK,d ~al CT S«(io<1 dIrough submandibular spa,e. Tht

pa,,~d midline g''''oSlonu. mu~~S (G), cu",,~nur hyogIOSSOJs-.cyIogionus musde com-
plu (..,.-oJ, mylot.yo;d muscle (M) arising from rM rnyIobyoid ridge, and .uperfic,allobe.
"fthe wbml.nd,bular glar>d (S) in the wbmandiboJlv ~ce " .... indicated. The Iow-dtftJ<t)'
.ublinsual space wich Its enha"",ng. ~ngual vt'Ws (~,,-). urotid .n..-,(C). and jucu-
la' vein UJ art indoCatfd. 8, Tl ......'ghttd ;lXIal sKUOfI rlvough $Ub",,.,,,j,t,,,lv .pact. 1M
normal.ubm:andibul.ar ,land (sMrl WIIif./tl i ffCW). fat anttnor to gland (cwrwd.now), mylo-
hyoid muscle (s1torl rurwJ .."""'), ~Iossu. and hyp<>sIoual musdes (opttt .~), sub-
lingual gland (~n cwrvd IIm1"'1), g,,,ioglonu. """.clt.fG), and longual ..,plum (soIiJ_
bud) are ,ndiclttd. Tht dup lobe of tht submand,bull" gland I.
located bHWtcn dlt
ylohyoid ilnd .tylogloHU./hypoglossal ",u.du. C, Tl·wt'gh,ed coronal MRI st",,,n
~rough anterior maJ(lllofacial region demonstrat,ng t,he high s'gnal ,"'ens,t)' of fal .n the
left submandibular space (sMrt jtl1l;g.t ~,rt1W) and sublongualspacts (Jto.t nlro;U ..,row) and
midline eniogloSSUS mUlelts (n;rwd~ltf.r",,~) at~ no,td. The balld oflow s'gnal ,ntellS't)'
b
t~e~ t t S,.
g h ubmalld,bular and subl,ngual spacts 's ,ke mylokyo,d mu...,le , H'gh ·,snal ," -
the normal marrowofl ht left htmimandiblt. All odontogenIC ktratoeyst
tens't)' 's not e ,n,he rigk' m~,lIary .,nUS (",/HIt gm>"'"'""'"
......... -..) 0 • A>:" 'CT S.CUOII through hy·
also ,s prtseThnt ,n n t"or belly of tht d'gUlflC musclt (0) and sup.,r",,1 lob. of \h. sub ·
opkaryruc . • I \ , C
mandibular gllnd (S) are ,den"f,e '
P ""1Jn,,fd
"
, F
noor of the mouth. Important landmarks uuful in the
,dmtlficalion of chis spau :l«' the lingu~l blood vessds,
",h.ch tn~t after ;ntuvenous con(n$[ injection, and
tht hyogloJSus·sryloglossus mU$Cle complex, which "p-
pun:a.t: a thill, C'Urvili"",u museu complu medially. On
succuslYely I~r will KOUlS a low..dtnsity &«a is nouod
Ixc""ftn the mandIble and mylohyoid musde, ~prestm­
Ing me Jubm;rnd.,buiar space. low,," scans demonstrate
tht supuficiallobf: of the submandibular gland and sub-
mandibular nodu. On diree[ coronal scaM, dlt sub-
mandibular space IS ru(hly apparem berween the medial
asp«t Or lM Im./ldiblc:lfld mylohyoid muscle. The ame-
rior bt.lly of thc d'ga5u'ic utends downwud ;lrId backward
from the dIgastric (ossa on {he mferior border of the chin
[0 ,he gTU-Iet horn of the hyoid bone illld dividu the sub-
manwbular I~ IIlto the ccmn} submenu.l and lateral
submand,bular space propu. On ax,al CT secllons
through the inferior mandible the anterior NlIy orthe di-
gutrie muscle un be Identified in the dIgastric fO$$a lo-
uted on the undel"lurfaccofthc antenOr mandIble. On ax-
,:0.1 CT sections below the level of the mamilble the paJred
Intenor belli~ of the digulTic are noted below tht subcu·
taneOuS tmiues of the neck, extend"'g bet~tn the anrc-
nor mandIble and gruter horn of hy<:>ld bone. lnftttions
Involvmg tht submandIbular spaa often art the result of
dental mfullons, adenins 10 ,he sublingual or sub.
mandIbular lymph nodes, pcnetUrHlS tr~uma, or slaload·
enltls"·" Odontogenic ",ftc lions ""ually 1IIvo]vmg the
$ublmgu:o.l spa<:c usw.lly a«c :l5.SOClattd wllh Ihe p~molars,
whereas ",frellont ",volvmg Ihe subma.ndlbul;l.' space are
usoclaltd WIth Ihe molars (sec FIgure 4·18)
One potenually fatal infecnon involving the sub-
mandibular space is Ludwig's angm;!... 37 .....7'-'11 Ludwig's
angina is a brawny. hard cellulitis of [he enure sub-
mandibular fascial sp:aa: biluerally.lt uswJ.Iy resulrl from
a dental infection or suppurative nodes in the sub-
mandibular space; how~r, it also may occur u a result of
acute sialo:ldenills. This cellulilis, often associated with
phlegmon formation, can extend into the mediastinum by
wayofthe parapharyngul and retropharyngeal spaces. In.
volvement of these spaces can result in airway embarra.u-
ment and duth, whereas involvement of the superior me-
diutinum can result in medlasrinitis.14,s2.t6.117 Plam film
findings include sof, tissue s~llmg of the noor of the
mouth and suprahyoid nrek and~rwaydefonnity(ste Fig-
ure 4-17). cr fmdlngs Include cellulitis of the soft tissues
ofth~ submand..bular and sublingual spaces (Figure 4-21.
Stt Flgurt 4-18), absces$ formation, and fluid co!l«:tions.
~nslOn 11110 Ihe parapharyngeal, relropharyngeal, Or
.spaces or the mechunnum an result In nUuhns with
Or WIthout abscess formation In these spac~$. Airway dis-
placement or deformllY IllYanably accomp:r.lli~ involv~­
mtnt of rhes~ anaconl1c:o.I spans.
Sp:r.ce of the Body of the Mandible and Osteom e litis
of the Jaws The spICe ofth~ body of the mand~ble 1$
formed by the upward exlfnslon of the superficl:o.Ilayu of
tm d«p celVlc~1 fUCla as It SP],IS 10 endose the bucc:o.l and
hngu:r.J aspect of the mand,ble ....,DI The 'P"
_e 15 conllnu.
ous "'''h the mandIbular pen~teum. Infections of the
space of {he body of thr mandIble are prim I
chronIC o"eom~llfls ofth~ mand'ble. A .o.n y acute or
Cute OSteom~htlS
 Fig.... 4-22 Acu,. osteomyelitis ari"",in a p"......i"ltpon..,piu.\
I..io". Convu(·.nhanud uial CT _ ..on (hrolllth ",&>rill.
dc,,->S(r.ItHI, • I.". intnos........ f>«'llpocal .bKess wiI.h con ..
c;tl bruhl'OIIgh and _,.,.,.,..,., iNo ~ soh Ossues.. 1M
wals oft .... abK«sdemorutn,. ~I tn""A«mtn< (cwoetl
~ ~J. ~ ;",ti.a! !«ion in eM "",'M was • ionf:-suJLdi",
ptnapoc.1 I«Oon t"", b.n .... acutely infected.

of both the mandible and the m;uillary :liveob.r ridges

most often occurs :lS a result of the contiguous spread of
an odontog=ic:.inftcrion .ongin:lfing in the tooth-~~ring
regIons of the mvolved J;1.W to the ~djacent spongiosa.
Other Jess common QU5eS of acute QSteQm)'"'litiJ include a
surgical procedure (e.g., exrraaion, apical curettage), pas-
uge of bacten;t through the p¢riodont;t[ [ig;tment, the
hematogenoU$ disscminadon ofb;tctuia from a distant
site, or osseous involvement by a soft tissue infection.
Acute osteomyelitis of odontogenic origin resu[t$ from ei-
ther the direa: extension of an acute pulpal inf«rion with·
OUt me fonnation of;t gnnulom.a Of me ac:ute aacerba·
rion of a chronic: peri;tpicallesion (Figure 4-22). Extension
of the in&mmarory process throughout the marrow cav-
Ity can result in ;t fulminating acute osteomyelitis involv-
inga latge segment of the involved bone. TttnSCortic:li ex-
tension of the inflammuory proccss can result in corrical
destruction, fisrub fo rmatio n,;trld perios[e;r.] re;tclion. Ex- Figul't 4-23 A ~apical ~bscen (........). This is tho ....... cast u
tension into the soft tissues bordering the bone may result in Figur. 4-2.
in myositis, fa.sciitis, cellulins, and abscess fonnarion (see
Figures 4-2, 4-18, and 4-22).
Initi.al r.adiognaphic findings in acute ostCOl11yelitis ans·
mgde novo are typically abSCnt forthe first 7 to 14 d~}'$ ex· on pl;tin films, foll~ by loss of fn.becubrion in the ad-
(Cpt for a possible widening of the p¢rio<iontai sp~ce Jaceor bone as Ihe procC5S utends into Ihe uu. ExlCnsion
around me root apex or gener:liiud osteoporosis around ofehe ",fe(ti on mto adJ'lCcnt soft tissues and fasci..J $pacu
the apa of an involved ('OOI.h (Figure 4-23). Definitive plain I~ common and often the initi..Jclinical sympmm for .... hid'l
film findings usually bec:ome evident between 7 and 14 ~ CT ~Iudy IS ",d1C~led, and .hould be ordered ;mmecli·
dt)'$. Findings include poorddinirion ofrrabecube, smgle ~tely IT studlcs of ,hue p~tienu should be p¢rformed
or multiple ill...:lefined r.idiolucent areu, and loss of the
lamllU du ra between the lucent lesion ;tnd tooth ~pex.
"'ith "'tr~VenOUli c:ontrut unlus Olhe rw;se con traindi-
catro. cr sections should be imaged using soh
bone ...,ndo,,'!, Information gained can haw I dl:6niletf.
u.ue_
".:UIC osteomyelitis ;tlso may develop in ;t pnulstmg
(hronic periapicallesion_'n these Ca5C'S the progreS51YC loss f«1 on p~ILCor management Im;tgcs obcl.lned .........
ti~$ue wlndow$ wnh contrast aR Ultful.n ..............
of d'screte margln~,ion of thc lesIon miu..Jly m~y be noted
" tX~(nI
,h<: of wf. tissue abs.:csses, whuu.l mugn ob{~Jned
",;USetct, latcral. and mfd,al pluygoJds and tn S~fnOn <If
the tempo rah~ mu sde (F'guI U 4· 25 and 4 · 16; n t FIg.
"s;ng bone WindOWS m;aydcmons{ra.e;a ptn;apKal aN.o:us urCS 4· 5. 4_16, and 4 .20).JG ..·H If also cOnt a ,ns Iht fa .... '"
, luI may IW)( M appann. on plain fil",s o r cr UI.ages 00' and po ~leflo r potllo n o f .he body of the mandIble an<:l
UUlW ..."h~' [issue ..~ndOW5 (~F'gure 4 18, 8). Surg. btanchu of the mandIbular diVISion of Ih~ tngun'nat
u.l dr:lUu.gt of oueous and fOf' IIssue ,WSC6SCS o f,cn IS Mtv1:. These bDnches mclude the m;uncatOr, buccal, lin.
central 10 cITrcuw (fUlmen! of such pancnts.
CT findings in .hue patienu may include penoslul re-
actions, myositis, f:MC.iris,ceUulitis, abscess (O""atlon, iln d
smus ,.acu- Oss~us changes may indude loc.lliud os·
$fi>US bru.kdown resulting from u,sens formation, $C-
ques,rac, and ptriO$tc;a] ON' boot fonn.ltion. MRi IS u~ful
In ~lin, puitnU wi,h lCute O$[~mY"h'is. On Mill (X-
am.narion, inflammatory changes inllOtving the marrow
and 50fl u.,uuu dcmolUtralt d«te~d signal on TI -
,••,,,ghtw Kquencu, mtcl1l'lftiiatt Jignal ;n(roslty on pro-
ton denJlIY Kquences, and hiSh signal intensiry on T2-
wvghrw Jorquen(t.S (5« figu~ ..1)'
Chrome O$ltomY"iiris may result from an aCUle os-
teomydnis Wt was inado:qw.tdy tIU.trd or a low-gndt in-
flammatory pro(tll that n~r n'Oktd an acutc ph;uc.
Chronic oltwmyditi5 il ts5<'ntially a ~rsistcn[ in(<<lion
of bone, often with abscess formation. Tht radiographic
appunncts :an. variable, ranging from a liingle radiolucent
uta n:pl'6tfltinS an ab«tsS loa "moth-uten" apptarance
coruimng o( multiple utas of bone dunucrion separatrd
by nomuJ-appurins bont. lJP,\ Often IiCI.. rocic changes Figu.. 4-25 ....... In __ .'hltd magneoio< ~nct imagt ><ction
arc f"idtm around th~ absceu. Scquesttac, foci of in- .Iflevd of zygomas dtmonwati"g .ht t.t .....1 puryzotd ......sdt
(IPF "'''" fI(tOW), mas.M"ltl" mUi<:lt (M), condylar nKk of man-
crUKd dtrui<y rtprucnnng dud bone, become mort ap- d iblt (Jlo<,rl "'fWd .,..-). and parotid gland ( ...I"u fI~
parent a$ tht liurrounding bont becomes osteoporotic. Thnt mU>deJ~..-td to be oflow Ioig"at inlttHJty. Tht normal-
TIw:st changes azt bul dtmo~trd on cr uammauon appearing parotid gland i, of ;ntt<m~d,att signal inttn~ty,
(Figure 4-l4). cr SKtions may demorutntc:o prominent wII ... eal <lIt rttroantral rat pads (_II ",.. ig#tt flrrvw) and para·
involucrum or fistulous communicarion, which might not pha'Y"val 'Pun (10'1" WIIitJtl • ..-) d.tmonStntt h~ .. gnal ....
,.n.iLy rtllecting Ihti, h;gh fal (ontCnL
be appaztnr on plain films.

Muticator Space Tht mtnticllf"," spau, ;u it name im-

plics, conu.inli tht muscles of masrication; thest 1ft the

F"T'" ' -1' (lvonoc ..... ~~ .. '" ....... ICT on.oon .1v0Ult. m~
,na o.monlol,a""gd...onoc ""~orny<I" ... ft .. rhon:! molar ......c.
"on "" .rwotUCI\Jm IS dtm<>nlolrattd ~'n th~ bof\Ot ("""<II ...
~) Cor",.! brf.~'hro"gh and .... " .. on of ,h~ ."namm.,OfY
p<oc .... '''.0 .d)llco", ma ... t ... m~.d~ h.u ",suited ,n m),,»"" o(
,h. musclt (Il"''f!of or.-)
 I)"'J""'''< I'"~l'" Pj M.",U~/.w ",I~ ..J I ~""..J Sp.-, '"1«'-'
1 ~"d " ,fen or 3 1 ~~",I~r IlUVU. Th ~ Ol,"
IU~ ' " ,u,," I p~c.,S
d'....:I.J "''0 a lucr"l and m ed ,a1 COm p a""'tm h, 'h • • ~
of ma"d,bk Th. mastlCa'or 'po<, " , d '
m
" "ung oft t.t ",,,.,s II "8 f~ua "'to .... ,"" ,,
0"'" uy:a
Ip f I_ a,\ d .tV
' d
I' yt"
' ,ha, d. on. t h. lntra! and mtd lal nu n. o f , h.
lpi'£. The .u ~rr.c,allar·r lin along t helueral tu rfacn
of fht rnasulu and 10"-~r half of ,h. 't'nponJ,. n,u sclu
Su pf"o,ly, , h. lupufic,allayn fU l t l wuh the PUl OS-
[tUm Of lh. t )'go ma and temporallS fUda . Th. d •• p
lart' passn al ong th. medial surfact of ,h. P,uY8 md
",,,"Iu ""(ort a!laching to ,h. but of ,h. skulllupt;".
or1y- Th. mUU CatOr spact bordtrs on:o. number of other
I~n. Posurlo .ly, Jl borders on ,h. parOlld space, m._
d.al!y on th. "", raphar)'nguJ. spact , and ,,,fu.o.I>' On the
submandibular and Subhngual spuu. POltnl1al COm -
municanOrU exlSI among Iha( rtspecm\' spacu , .hfl'~ by
a1,.,.., ng fottht sprud of Infecnons and n«oplasms_Th,
ramus o( the mandible and th, O\\'d)'lng muwltI' mu. -
de are 1\'~lly Idcntified on fton,,1 vitW$ oftke "'.ull and
fxu.) bonn. HOW~t, tht medlll ponlon o[lh, mUli-
U lor spact is not ",til demonur:lttd On . out;ne plain
film u;un;natio n.
cr
Axial and dIl\'Ct coronal cr
~ons through .he mas-
Ua.tOt ~ dcmonsmltt tht =us o[ tht mandible divid-
Ing d>t mastiaror space inco iu lun-al and me<!i.lI ugtmnu
(Figure 4-27; s.ee Figur(;5 4-5, 4-20. and 4-26). Tht m:l.liStttr
mlddt is n<:oUd throughout tht b.tn.I. comp:utmtnL In .he
upprr IuJ( of lht mniial comFtmtnr, .he horizontally On-
mIt<! luen! pttl'}'gO'd mUKlt is rudily identified u .. tnd-
mg ~n Iht \.artral pltry)';old plaIt and .tmporo-
onMld,bulu p ", t In the Iowa h'll f of.he nled,..! compa"
"
mtnt .ht ubhq ud y o.,cRl ,d mMIII pl'trYX"'ld musdt, u.
,tnd",S Ixotwttn t ht rmd,al pttf}'g<>lod pl." and anglt ohhe
mand,ble, II _ U demons" " .... ",., k>wtr half of the .tm
pot..! .. muscle alld lUI a" ach ment to.he a>tono.d proc ....
IJ dtmonsm"nI on ..ull and coron..alsecuons . hrough tht
lown po ruo n oflh .. Infratemporal f....... and coronoId
proce ...
Pnmaf)' ",f.cuonl o{ Ih .. masticator Ipa.:t art usually
of odontogeniC ongin.'J." Uncommon pnmMY causa of
mastiCatOr spac .. infections inclu,u iUfog .. nic Introduc-
tion ofbacttna dunng local anuthtsoa admuus.Iru>on a.nd
ptnttruing .. auma_ Mo ... commonly, .he masllcatOr IS
w condully myol~d by .nfcellons affecting the adJaCent
pa.a pharyngeal or paroud spacts.
Pl;l.]n film findings U5QC .... tcd .... th mutic.;uor space In-
fecnons include fOfl t1SS~ swt1hnS owr .ht bunl Uptcl
oCthe =us and, ra«ly, osu,o...,...htiJ of tht ramus of Iht
mandIble. cr findings ~cd wi<b rrusticau>r spaGe in-
fections indudt myosltl' and {IKutis ofim"OMd musda
and f;o.s<:w planes (Figure 4-28), nuid eoLlerooru, ~
formation. puioSltal ructions, and rutly, osteomyelitis
of the ramus. MRJ findings indudt dccreaud sizn.al In-
'~l1$i<)' on T l -wcighled and incrtaW<! ligna! intensIty on
n-,,·cightcd ~uencu ohhe invoMd bone matTOW and
$urroundingsoft tUsuc ..
Parotid Spaao Posterior to Iht mastiCUOf spac.. dtt su-
ptrfiCllllaycr of (he deep cervical fasc12 .pb~ 10 form the
parotid sp:ace_ The parotid space contains tht parol1d
Sluod and lymph nodes (s.ee Figuru 4-5, 4-Hi, and 4-lS).
lnfenoo-Ly, it is ... panted [rom tht submandibubr space by
.. ~II('On.tI" u,"
tI, ,,·L,'m.;m,ilbul~r "f;anl~"1. COl1lm""'~ I,. ,] ,h~
....'''.... n ,h~ ,....0 'racu . hrough ~ ",~n'" 'Ia'" , "
f","~"or !.aual ,..-,n fIt<! " n ax,a l and tI,
rh, raloud gbnd ,~ rudLly ,d~n" I parapha,,"gu.J
, he massr.er muS(" . ,
"(lroron al (T ~"onspo<{.norlO I .h,-
On u,aJ _ !lon. ,h , paro" d g:on I d h.u am:onguard ,.-,
'- _ n no" , ,,h,ncf SH I\ .
"" ,h a rd a,,~ly low CT nu," ".oro d
(-- 10 1010 flU) rtf1t wng ,Is juSh fat and nUl (o n-
Itn f,
,1.1 ...." In "dd;[;o o 10 the gb.n dular lIIiJ Uts ,
f
,h.,d
parotid gland also conlaln. a numbu 0 "'Hararo"
lymph noda , .he facial n. ~, the "=,romand,bular "''''',
and .hf;UIUn.al caroc id antry The fX!al n.~dl .... dts ,h,
parotId ''''0 su~rfLOal (l atcral) and dup (..mbal ) 10bO'$
and can bot bttnlly displaced by puholOS'cal ptocrssn Ill '
,..,lvLng tN oop lobo: or adpctnt PM"pn..rynVai liput AI·
.hough the f:lOil "trw annO{ bot idt nnfied on direct ."",a1
aatU,HJ Iocanon Qn bt aPP!'QX]mattd bylM rcad,ly .dtn -
,ifiablt Il'tmmandibular V~tn. The facU.l nerve lies la, ~ral
to tm retromandlbular Win, and latenl diSp1u(nl~m of
the ruromandlbular win IS indicauw of a puhologiul
condJ{Jon allStng in <he dup l~.
On MRI examinuions the signal mtensl<y of the nor·
mal puotid gland IS gual~r ,nan that of musde bUI1Cl""¢r
than that offal in tht subcu.antOUs tissues or ~rapha­
ryngtal spaa On T1 -and TZ-wtighted sequenc:~ (set Fig-
urt. 4-25). On TZ'WI:'igh<td ,mages t~ p~rot:ld gland's lug-
n.a.llnttnmy is gruttr than that of ad?Cent musel~ but
I..-r tban that of fat. Anu dtvOid of signa l art noted
.." h,n <t.. parotid gland rtpteen"ng tt.. rttromandioolar
""In and Uttrnll carotid :>rtef")'. The facial nerve is an im·
portant strucrutt thoU can'" identifitd on TI _wt;ghtffl
imagts, ;tp~aring:as a curvilinear density of rdat;""ly low
slgnallnttnsl<y. Tht high signal in'ensl<y offarwi'hin the
parapharyngoal space adjacent '0 lht deep lobe of ,he
~tond and III th. subcutaneous tissut around the super-
fiw.! loboe IS icitmified ccadilyon T1-WI:'ighred images.
The parotid gland is surround.d by an d comains a
numboer oflymph nodes_ Th6e nodes normally appnr as
fOQ] UtU of incrtUtd densi<y on non-<on u;l.n-tn!Jamed
CT !'CeUON arid filling def...,,,, on eonu ;l.u-enhanctd CT
stu!Les'1.l ....... (su Chapter 12).
~
_I
f Ihe ",rdl;o> r , rry):OI'
j m11...-I. and u,tdlal surfu( of t'
_. ~
1'1'0< Ihe l'a toud lu ",.d.al wall" ormed by II,.
...
~e;'at'm",du at .ht 1....... 1~,f rl\( ,usopharyruc and the ph...
r,yngu I co..."",lorS at Ihe Irvtl of the oroph arynx."l"\.
d I h
'.paca co m m u ",ca rl: ..eet yWl( [he IUb..
·"
h
mand,buiar space anterolOftn orly and t e "'t romand,boulv
space posren orly
On MRI slUcll U ,he parap h aryngul space edllbiu l
high Signal m.enSlty on T I nquence:<, rdle<:tmg Its hlgll fat
conttnt. On axial sections thro ugh the SUp<"nor nOUOphar.
Iht parapharYllgealSpaCt appears as a deft "'~en the
~arynval and pttrygo,d umscla. At the k ....1of t he mld_
p tunTl.ll throu gh Iowtr o ropharynx, rhe puaphu yn.
;:~pac~ assumes a t,uuguiar stupe. Inferiorly, the I~
IS Ilmittd by the . healh o r the submand,bular gland and
app"an u a fat I~ce mt:dlall o the submand,bul.ar gland
and anterior [0 the cam ud arnry and Jugular ...."'.
puapharyngeal s~e infe<:lio ns rep",nm ulens,ons o(
infections thar occur in structu res bo rdenng On It o.
through anatomical pathways commu~icating with til t
space. [nfections thar most commonl)" Involve the pna-
pharyngeal. spUt include those of demal, tonsil, mastOId,
and salivary otigin.
Plain film findings associated with puaphuyngeal
s~ce infections consist primarily of soft tissue swellmg
and ai",'~~ dlsplaeemtm ..,)[h or wimout distortill n (_
Figure 4-17) . cr findings ;w.ociatt:d with par.opharyngeal
infcClions ",elude rasciitis of the spact and t:d~ma (m )"Oll-
tis) of mu sdu bordenng II , flu id collt(:rions, a nd abseess
formation (Figu'" "-29).
Thc mrophuyngeal space is a potential mldhne spa.ct
"'~n the phuyngobuibr fascia, which attaches to tilt
pharyngu! constriCtors to the base of the skull, and pre·
vertebral fascia.U,llIlt;s bounded laterally by the alar fascia
of the deop la)"¢r of deep cervical fascia.. The reuopharyn-
geal .pact exttnd$ fmm the skull bast to the approxi mate

Panphuyngul and Ro.rroplwyngeal Spaces Two ma_

JOr p'-,hWllysforlhe sprudof t..ad arid n...,k int«tions Ue
1m: paraphuyngul and "'tropharynguilpillCtS.U.IOJ.,I."u
TheH IpUtl form a -.,ng" around the p harynx and to_
geth.r form a pathway for tht sp",ad or mu, l1ofulal in.
f«llon~ IIIto the neck and mediastinum. TI,e par:lpha<yn_
gul space" a far· filled spact txtendlng from the bast of
skull to the h)"md bont ' stp •.nll~g
., ,h. muse Iell 0 f mUlica-
lion from ,h. muscles of deglulllion; Iht space is " 'fl1
d.mon"r;I{'~. on 'OU'lOt ulal and coronal CT and MRI
stellons (~e hgures 4-$' 4-20 F 4·2S a-~' ,~ T1
h ' " . 11U 'J' .epara_
p __ .... 1 sp",e IS bounded antenorl, by 'h t pttrygo_
arynSul
m...... lvu U .aph., blttally by
_ _" _'I
,h.parQt... __ .... .
"' ...... ma."taIOt"
spa't'. "on<l.., y by lhe ph.nm""al ""all _"
h ""0' ,a..... p05tfnOfI)" by
t e sl)"lold muscle and caroud shuth. I I I
,
n,mf
d by
dlt uund,ng ramus oflhe
'sd artra
II
""all ..
man ') t, ,n5('rllon
 J<,'tI,,1 I'l No mldh" . ~ t<ad'm~"" a,. !, ...(n f 'n Ih.
.... cwrharyu!:.a.! spac., , hn eby p"n"" "'1; unlm~lcd In
ron,'r • .ern"on of ,n n.. mnu le,ry ~"d "f<'ria_,,,c p,-o.:rss."
111'0 ,hr mtJ, .. ~"num In("'""ns of ,he rfu<.>pharyngul
lpo"U u,", .. Uy ff pl<M'" U """On of I"fcn,on' III .pUU
commu,,,ca n ng with .he . «roplurYIl!:<'a.! s~. ~ h""~ r,
pnm.. ry ,nf.cu o" . _m..,. occur ,.f. u pt:ne"'~Clll g Iraun, ..
OatiS" space ",f.cu ons .....11 from"~ UC,'IS.on of ",ftc-
"on.! nlvolvms :odJac.nc regIo n. "ueh u cht r<cropharyn.
gcaI, p~npharyngcaJ , md prevocrccbn! sp<>.<u
The norma.! rClroph:oryngea.! sp~e IS a potenCIal ~p&Ce
and, In . he all"n« of pathologica.! condItions,,, ,,0, usu-
ally iden Clfiable on pl.. in films Or cr slUd,es. Pia", film
findmgs ll$Soc,aled wilh retroph.. ryngul space ", fceci ons
"."luJc ....denmg of tho p~fld<ral wfl IISSUes, aIr wllhin
Ihf rclropharyn!:<,al. sofl tissues, ilIlWlIy d1510rUOn ....,h or
.."houl d lSplac.men t, and .he preseocc of rad ,odcnsc for-
flgn bodIes. cr findings may dcmon$tr.. te Ihe find'ngs
noted for pwn fi lms ;md cd lu l"" of the tiSSue bordering
the lpace, fl uid collection in the space, and ab5c:us forma-
"on (FI gure 4·30). MRl is pamcularly uKful for the as-
{oroph:uyru and nuop uynx,jrid the mlddl. ul. Effe..
....OSmt'" of tt Llopharyngea.! . pue '"vol....,m.''' ~ ~u.r "
perm". d lf.el ug". al and paruagltu ! """"', Ih.reby a!
lowmg rndy Ide ntification of.he In fe"or u •• ", " f. ht ,n-
(bmma"..,), p. OCt" (Kt hgur~ 4. 19).
P~e .....:oche:ol Space Th. p.etra.ch.al spa.cr IS ~ po.tntlal
~p~Ct loca.~ betwetn tht prcua.ch.a.! f:;UCla..,d uopha-
gU5. n,e prttrachcaJ s p~c. rt prCK"<S an ImPOfl~nt path-
way (0 ' Ihe spread ofhead and n«k InffCIIOnSIntO.ht lu
p."or med,astinum. In Ihe ~bs.nee of a palholog,ea!
process Ih ... potenlJal spact is "0' id.n.ifiabl. on routine
plain film Or cr l rud,ea. In fhe presence of inf.cuon, cr
find"'gl limllar to .hose nOI~ for inftc"onl invo lv,ng
olher fascial. ' pa«S may be evtd.nl.
LYMPH NODE EVALUATION
Ev~luauon of any ,nn.amm.u ory process InvolVIng .h.
maxillofaCIal regIon al.so musl mclud. rva!u .. uon fo r
dr""mng lymphatI CS, thtK mclude Ih. pilfoc,d, I Ub-
mandibula.-, lubmcma!, in<cnuJ Jugular, ruropharyngu1,
$pinal KCt"soty, trans....,rst cel'VlCai, md ""unor c.rvi.al
noda (Figure 4.31).>OOJ>UOJ,.,. Thcst CCI'VJCO>l lymph I>Oda
have b«n org:lniud imo scvc:n kvels for Ihe purpau ot
describing tht spread of neopiauic processes. ~ll in-
cludes Ihe lubm:lndibul.. and lubmc:mallymph nodes;
l~( includes tht upper ctrvical chain nodn; I~l
consi.5ts of the middle dcrp cervical chain; ~ con$isu
of the lower deep CfNICa! nodes; l~ consists of thl:
spmal ucessory and lran ..... rx cc.v;caJ cham nodu; I~l
VI nodu (oruilts o f thf pr.uacheal, paratra cheal, and
P;;luyn~al. nodrs; and lcYc.,!!!1 consists of the uppc:r me-
diulina1 nodes (5« Chapta- 9).
The paroc:id lymph node. att divi.d~ ",to CWO groups.
5upcrficial and detp. Th. superficial, o r extraglandulu,
group receives drainage from the scalp above the parond,
thelarual portion oflht eyelid, auriele, and external audi·
lOry canal; and the posterior ponion of the cheek, buca.I
mucosa, and pa.-otid gla"d.~'·The deep lym ph nod..,; an
located within th. subseanc. 'tf Ihe ~nd and reCelV(
drainage from the dtepJ!UrIloc;< of ,h.-race, meludmg the
tnl dr.unage il to the mttrnal. jugular chain J
The ",bmandibul~r gland, although noc cont;urung any
mtragl.andular Iymphanes, IS doMly relalrd to a number
of smail lymph nodes locu~ on ,he anterior upect ofthc
submandibulat gland and Ihf Iattn! upcct ofeM antcOor
bcUyofth. d iga.stn( muscl. bctwttn Its ",serllon and the
angle ofth. mand,ble (s-:. FIgure 4·31, Bl_ Thes-: nodu afe
collectwcly rtferred to a$ Ihe ,ubm"nd"",t..~ rKIIhs and re·
ceive dr.. inagt (rom Iht submental and 5ubh"guaJ lymph
nodts, laltral ..egmcnt or Ihe lowcr hI', a11lht uppcr hI' alld
CJ(1~mal "OM, the iiubmand,bular and ~ubhngual gl;ll1ds,
and Iht antfllOr fWO Ihmh of , h. tongue Effttent dram-
age is to Ih. mlnnat Jugular chill" through lymphauCl kI-
ultd along ,l~ anttnOr fac,al WIn and ..ltry
Thf sub",.m.. l lymph nodts ~rt .. group of noda 10-
Uled ocrwte" II~ anunor btlbcsofdw d.sumc mu.dIe.

A
-
Jo-ogookKJ9'$IOC lymph
supuficial (0 dIe myloh~'O,d mU>clc_ COOSIJung of up '0
tight nodes, the submenr~llymph nodes rc,,,'''' dram~sc
from the: chm, ~r lip, ch«n, ;omenO. S"ng"'a, floor of
mO\llh, ilIld Ilpoftongue. Erronn. dramage" to the 'ps,·
lateral or conrnJa.tral subnundibular lymph nodes u,d
.ardydir«dy.o [he ;nltrnal jugular chain.
The anterior Jugular chain is l<xued in .he supnficial
rue;& of the nr<;k and rCct"~S affcrtn[ drainage from ,he
skin and anterior portion of,he ned, Efferem drainage on
the right is to the 10_5. ",{emI.l jugular chain or hightst
mtratho=oc node and on .he left.s 10,0 ,he .hora(1C duct
or anImo. mro. .... unallymph nodu." The supt'rfiCl;;a.l ccr·
",cal nodes are SUp"mcial [0 the stemodeidolTlUloid mU$-
ck along the COlI"" of [he utenul Jugular "'>n.AfTell'n,
drainage IS from [he suptrnctal ussues of the preauricular
and postauncular """]p and 0>1:rl~1ng s:em." effrrrm
dr... ru.~ '$ to .hr dup imtrnal Jugular or (nnSVCI'K cervi-
cal cham_
The rr(roph~ryngrall)'mph nOOrs cons.st of a blla.eral
med.an and b.eral group. In adults the$( nOOts are often
nOi idcnufi;ilile txCtpt ",hen inV'OI""d by patholog,cal COn-
dltlons,IOj The mW.an group;s loca.ed :tIong .h~ mldl"'e;
the latenl group 1$ located along the lateral border of th~
longus Upl!lS mUKI., med,al to <he carotid a,{uy. Thue
lymph nOOts recei ... afferrnt dr~m~g. f.om the n;os~l fos.
<~', S,nU$(S, nnopharyn~ ~nd orophuyn .. , p~b'f, and
m,ddle Ur. Effue'" dra,nage'5'0 .he ,mernal Jugubr
cham
The deep lymrh~tlcs of <he nrcl<. tan be d"nded ,nl0
thre. maJOr group" .h. imernal Jugubt, .pmal atcesrory.
and LranscetvlCallymph node •. Th. ,n'.rnal Jugular "odt~
B
he anterolatetal to the inurnal Jugular vein, ~no:ath the
stemoclt,domu.oid muscle ($ee Figure 4-31, B). Tho:y ro:·
C(,ve efferen. draLn.. ge from the parotid, subment:tl, sub-
mandibulu, retTOpharyngeal, .. nd anro:rior cervical lymph
nodts." Two impotrant nodrs in Ihis chain are .he jugu-
lodigutric and juguloomohyoid lymph nodes. That lWO
lymph nodo:s an: larger Ihan tho: other nod(S in Ihe chain
and Ofltn tnlarge in response 10 infrelion or neoplasms in
one of the regions from which rho:y r«'o:ive drainage. The
jugulodig.... tric lymph node is located below the posterior
b.,Uy of the dig .... tnc muscle .. t the level of tho: hyoid bone
and r.eei~s du.inage from tho: post(rior third of the
longue and pal.. rint (onsils. The juguloomohyoid lymph
nod. is localed eilher at Or .. boo.-e thr level at which the
middle ~ndon of the omohyoid CroMts tho: into:mal Jugu·
l.u~'n.lt ~i""'$ dm~ct or indirect arr.1"(01 drainagt from
'ho: entLrt rongu~ Indlcect dumago: occur$ through the
subm<:ntal, submandibular, and upper deep (e!Vical nodes.
Th. spmal ..ccusory lymph nod.. ate located in .he
pOSlenOt rrianglo: of the neck, along tho: course of the
sponal ac(o:nory nerve. Thesr nodes r((eivo: afferent
dramage from various lymphatics loc ...ed in the occipir.. l
'·s'on .. nd larnal neek; efferent dr;oinage is primanly to
<he tf;l""....,rw e([v,e.. l nodtS. Thc tran.~rse cCrvLcallymph
nod •• ~rtlOCatcd along tho: courSt of ,he .r~ns""rsc etn-l'
ul artt"' .,. They rece,~ d r.. ,nagt 'Itom .he spmal ..ccessory
lymph nodes and the skm of .he anttrol ...er.. l neck and
upper an'ttob.tcral che~1 wall Effrrem dr .. m~g. 's .. m,]ar
.0 that descnbed for ,h. Imt'n .. l Jusul .. , nodo:s
Th. cr fill(hngs m ,nfbmmalory .. nd neopla5tLC d,!oU!ot
eowraWLdc$pectruonof L r
("angu. ('I ten of Slm,lar appear·

.'" ft . ",~UI"!,: , h~ nud ro ~ondalc d'n.ul and 'm~Il"'f
jind,n!t" " " .. ",\..t , of dl a ~nM"< ("'''tI" h .. v.. \..t." n.ab '
I.,h.d '" ,valuate .h.. lymph",,€> ofth .. hud anrl nu k
f"~U (",,, ella cOJu,de r SIU, "urnbn . "I'!><'uancc, and en'
hancrmcn. pall""'!. W"h the uccpw,I ns of ,he sub -
",an d ,bubr and Jugulod,gastnc nodes, any node lu u
,han I cm ,scons,dcr«l abnomw """"Jotn, t "pprr I,mn
o( notm,,1 fO,' the subm.nd,bulat and J"gulod'gumc
lymph nodel 's LS Cm. The pnKncc of a low-dcns"y uu
(10 ,0 18 HU) rcpruennng«ntl'1ll n~ros;s is aboom,a! r~
gardlu.s ofs'>:f' or pattern ofpetiphtral enhancement. un-
,raJn««IS'S may OCCur on mctuta,ic, infb..mnatory, and
lymphomatous nodu ...... ' lot ~np~ral enhancement may
,,"ut on onflammatory and neoplutlC lymph noou' on -
fbmmuof)' lymph node. of[en ",h,b" I th,ek, 'tng~1ar
I
zom o( ~opheral enhancement around a n«ro<;c CenrCr
and mon o(ren are uen >n lubcrcuIOilS." ·" Me':Ulltic
lymp h t>Qdes O(len demonstr.uc J"'nphn.tl enhancement
IN.t 1$ ofun,(orm th'ckness and densiry. lymphomatous
nodes often an (ound as smooth. bulky nodes ,,'ith 1""_
(l pheral enhancement. Inflammllory and neopl:utic
lymph nodes ~an ""h,bi[ loss o(th. uiJaecnt fasci.tl planes;
howe""r, lhe degree o( obliurarion associated with in-
flammatory lymph node. i, Illiually more uuns;ve than
thac associated wilh metastaric dinuc.
ORBITAL INFLAMMATORY PROCESSES
CT represcnu the mosl commonh- u..,d ,magmg mod.tl·
'ry on Ih. evalualion o( orbllil ,nOammliory pro·
Ces.sc$."J'." CT JoC2Ilning o( the orbil is iduJ ly po:r(ormed
I ideally uSlng$lice thickne.~ 0(3,05 mm in rhe u,al and
dirKt coronal planes. AI rimes, imaging in the dinct coro-
nal plane may bc Impossible because pallents mUi( main-
lam Ihelr heads m an ""tmded posiuon while Ihe scan IS
J"'rformed; in panenrs ""Ih cervical spine problems, espe'
Clally th. dderly, this pomion oft.n is dIfficult or impos-
SIble to a!fam.ln addition. the pr •• ence of met.tlhc dent.tl
r"torllions may result in nondiagnos"c images. Mulri-
planar reformatted images in the coronal and pa.ruagitt.tl
planu can bc olxained using daca obeamed in Ihin-slice
uial scans. The gener.arion o( nformaned imagcs rrqulns
special software normall!" present on mosl CT scanners.
Intno""nous con nut, although (10( essential >n defining
normal OrbItal ana(Omy, may afford bcnu definition of a
puhologJcal proccss, cspcci~y absc~. MiU hu bHn re-
ported u$Cful in the cvalu.uion of o rbital inflammalory
proccsns and in the diffeuntiation of pseudolurnon from
oth .. inrtarnmMory pr<Kesses in"olving Ihe orbit {$te
Chapler IS).
Th. m;r.Jonty of ",f1ammalor~' F'OCCSI-CS involvmg lhe
orb" arc ",f.cllous m onl:'" usuaHv fuuhlng fro", mad·
equ;r.lely (relied ;lcme 01 ~h;o",c SI~U51"S. Howtwr, Ihl')'
;r.lso m:ay occur as ;I. resuh of infccnons elsewher. in Ihe
mUlliofac,al reg,on Orbital {omphuuOos ofIe" an Ihe
I1rS( numfcsution of an ethmOld,ns :and occur mosl of·
len 'n ch,ldren. '.K B;octCrt;o mGSI (ommonly Isolated from
<>,bu;r.llllrccllons ;Ire Sl"phvlococw- Sr.tplococ(J<f, PntlOmo-
I !.~~ ,••",,< 1.....1'~X oJ 1'>1_ ""/~' ~I • ...t r." wi i>J-~ iftjfi ,um,
cO<c~., P.~.. J,...,,,... ,, Nt .. ,,"., HM"'''~'''I.. ~. .
"
' . an ... "'y<-
_L. .
r " ,. 1""
"'.. "'. . Vllal ,nfccllon. are usually ""cond •• y her •
Slmpl. x 0 1 help'S :«nlcr VI ruS" Onnnrt . f P<
~F_·_u n" .. < ungal or
1'''.... ,,'' ,nfcctl ons Un dewlo p '" pacie-"
., ...·h 0 arc ""
munoco mprom.ud ",c lud,ng thon ,,"lth poo I
!rolled d,abetes" r y con
g Acute Orb~l.al co"'pw;aUOnJ resuillng from :an Utcns,on
of .mus",s ,"elude cclluhllS, o.b.t;ol abKUs form' _
. .• ,... , a'vn,
5U b penosle;u aUKe" ormation (seo; Figurc 4-13), 5upenor
orb".tI fissure syndrome, orbll.tl apex syndrnmc,:and os-
t~myellt1.. of the osseous waLk. Thc mildest comphcatlon
is reactionary .dcma of ~lid :and olbu.tl COntonts chat oc·
curs as a result of the clost pfOXlmuyoftheorbil [o.to.: ,n-
volved sinus. ThIS compliatlon (pr~pt.tl eduna) IS not
assoCIaccd wrth bactenal InVl110n of.he orbot. Opac.ofoca·
lion of ,h. 'nvolwd smus IS noted on plain film stud,es
cr stud,es show Inflammatory changes on tto.: ,nvolved ••.
nUS and soft tjuue and puiorbital edema, bul cwcous de·
strUCtion is absent. H.71..l'"
Bacr•• i.tl ;nvuion of the orb;. resulu inili.tlly In a cd·
luliris.. cr findmss au sim,lar to thoM. d6cr1bcd for reaC'
tionary edema. Orbital ccUuhtl$ may be comp!J.clU<! by the
fonnanon o( an orbiw or a ,ubperio.ste.tl ah$cess with or
without osteomyelitis of the orbit.tl ,,·.tIL Clinically, pa-
tients I t t first sun wich Vlf}"ng degrtts of proptosis., oph-
thalmopl.i11, a"d visual impairment. Plain film findings
demonstrate opacification of involod sinU5H. cr stUdies,
in addirion to the findings noted for orbit.tl inllammarion,
also demonstrate sinus opaciftc.a<ion, P[OptOS's, orbit~1
mas.s with or Wlth(>O.JI abKus., and subperioue.tl ahscus.
~uomyeliris with brukdown o( the orbital wall an occur
in untn:ated Or rapidly fulminaring infcct>Ons. Pouenor
and superior extension of the abJoCcss can nsult '" uv-
ernous sinus thrombosis. On MRJ cxammatiOnll, orbital
ccllulitis can result in a decreuc in the normally high s'g-
nal int.nsity of orbital far I«n on T1'UlC"ghtcdsequcnces.~
These changes arc bclicvcd to reflect an increuc in the frce
water COntent.
ORBITAL PSEUDOTtlMORS
Orbital p$Cudorumon (id.ioparhic orbit.tl inflammatOry syn-
drome) n:p~nt a group of orbital inflammatory disorckn
involving one or more uuuu of the orbit Ul:q>t the ~.!t
Orbital pseudorumors au bcloew:d to be of ImmWl()1ogIca.I
origin;~, no locU Of idcnrifiab1c cause an be idenri·
fied. !tNI Clinically, these patients usually NYr ptnprosiUs
a result ofinfiammacory infiltration of on. or more wsu.,.
Orbital pscudorurnors can aerur at any age cr plays a cen·
traJ rol. in the diagnostic imagong of orbital p'll'udoromors.
A number of systems h.ave been proposed for classifying or·
l"tal pseudoturnors; ho~r, one o( the eas,tst to under-
stand and .apply IS that proposed by Nugent ct al."1llcsc m·
~"g;u.ors proposed I d;wificanon of orb,tal pscudotumors
based on anltomicallocallon and radIOgraphIC futuns as
d«.rm,ncti bycr Accord.mgtO thlli SYSIC"m,orbllal ~
tumors are cluslfied.as bcr",uJ, antenor. post .. nor, ~
or myosi"c. Lacr,mal pseudo(Umors Ul\'oIH tlu: IacrimII.
fl~ al,d .>.,~ IO<~JN ,n ,I". "'I""ol~,r';oJ a5£",<' of th~ or
1»,. Inf(.on",dul d"plu ... n,.-,,, "pr~ ...nt III ,t.ev ~un. An·
trnot ~"do"'m0t5 "'~ 100'>'tN on Ih( 1><)51("Or a5pNt 01
the glol'>., ,esull,ng in ,hlCkc,,,ng of ,he p05ltnOr seier:>.
Th~ I~sioru abo f)I'~nd p"$!enony at v.>.nable d'$tane~
along tI,( optIC n('f'oO!. p.,..:o,"or pst'udol\lInors an: Ioc.a.ttd In
wap>e>J pornon oftM orb,t and roul, '" poordefilUoon or
1M. cxtnlXUlar musclts and orne nrM: Diffuse pseudow-
morl myo1~ rhe tn",., orbl! and cxlrnd rrom tht orbital
apa to the po$trnor tnargln or It." g:Iobt. MyOSlUC pRum..
rumorstnYOM the cxtl40cular m"",le or musdo:s, roulting
In <bffwunLargcmcm or t h( muscle. Orbital f'S"udottunOfS
can prc$tI1t as masses that an: ,so;ntcnK to orbi,;>J muscks
on T I Kqlltnctl and 1$Oint""'" or mtrumally hypcnntenst
toorbttal far on 1"2 sequenccs.'
DIAGNOSTIC IMAGING OF SALIVARY
INFlAMMATORY DISORDERS
Inflammuory d,sord~r. or the m:>.Jor ulivuy gl:>.nds or
sial<».denltis may 1>.. clustfied u acu.e or chronic (set
Ou.prtt 12). Aa.tu: 51;>Joad(fUtis m.>.y1>.. further subdivided
into obstrucu~ Or nonobstrucrive causes. Obstructive
mlo:adcn.iris is It.. mJuh of liialoliths (ducuJ stona) with
Or ""thOUt stncturu, when"" nonobstrucn"" 51:II0:>.c!enitis
;s most commonly the result of infectious agents such as
bacu,,,:>. and VlruSCS. Obst.ucri"" and nonobstrucrivo
swoac!U1imof'en are inte.ulutd ",."h respect 10GaU$.1.ti""
f&Ctorl and duual present;>,lton; ductal dam~ge (Slriclun)
<>.:td 'ntnducuJ debris from b;>,c[trul si:alo.ademus m.>.y 1>..
predISposing factors in the de""lopment of a s,alolith,
whaus i sialolith, snicruro, or both may r<:sult in i ducr:al
obsmIctlon faci.lil.llting a su~rimposed bactnial infection.
Chn<ully, I'~{i~n'~ ".-"h aLUJr obs'ruc u ..... ~laJo:>.Jell"" of.
'~n repo" <o!od.y I,a", and ~landub, or p''',gland,.1.,
swell"'g ;1$'100.>.,(<1 "'''h meal.. A<u't obslruc,,~ "~.
.nlt'" III [ht abStnc( of"" :u:comp"")1ttS :acute bact."at 'Il-
feellon IS te:acbly ....>.1,,;>,t~d USIng c r. TIun aJU;>J cr se~
through the susp«( gl""d and ,ts dutt demomnlte""",
only rhe offending scone but :abo ",flamm;>,lory change,.: io.
wiving the gJ""d and pengJandular USlU.S (F'gure 4.32).
Acute nonolntrucu"" ,,:aladent(Ls 's usu:ally relat..:! to
several VIral or bactetlal palhogcns. Mumps is th. "'<>st
common form of vtr;>J pal"O(itis, the diagnosis of whld. u
bUtd largdy on clinical and serological findtngs, ""th no
,ndica!!on rot addilion:al imag"'g studies. HO_r, <b ag_
n~nc ,maging can pl.>.y an Import""t role III tht ovaJ ...._
Iton of p;>.l'tn's wtlh ;>,cute pyogenic or SUPPUI;>.llY.,
s,aiadrnitlS. Suppurau"" puonus, ,he most common fOfTn
of ;!,Cute pyogemc s,;>Jadenitis, C.:u\ occur;>,{ any age &nd Ul
ehu;!,Cleriud by diffuSt s~Uing of the gw.d Uld ad~mt
soft t;uue." Suppurative parotitis us,,;>,lIy occurs III Pl'
t;ems who Ut immunocompromised Or debilitated and re.
suIts from an ucending retrograde infection. Bacu...a
(requ,""lly ropon$;ble fot this condit;on mclude Suphyl.
coccus _...rrHs, S. ""ndanJ, ""d pneumocOCCI. B2.C[eri:al si;>J.
adU>itis also Can OCCUr in obstructed glands, <:specially the:
submandibulu glmd..
cr scanning 1>..fot. and ilf"cer the admmtStn.CLon orin-
travenous contrut is the im.>.gmg study of choice 'n these
patients. The cr findings in nonobs[rucu~ sia!adenit;s
.>.,., v.>.nable and l4nge from gcneraliud mcreases III the
size ""d cr demit)' of the gland, [0 ;U·ddined areas ofin.
creased densiry reprucnting inflammatoty manes on
non-<ontrast-cnhanccd studies, to absass formation with
;>, low-density centra.! region and peripheral munl en-
•
 han.tm,'" On ,0ntn.o;t~n"atKrd sfud.u (~hgUf~ 4.32.
'''g thr ductal sy"rm. SIalography may dtmOnilrarr a
8) In ~Omt m.tanus fht mOanlnufOfY ",<tUn Of at>
spiayms of ,h, majOfdlKfal ' Y'trm:as a ruuh of pa".,d,y.
•,:t<Ofi nuy ~ mdut1llzu,.hablt froon nropl;u",~ ",,,hout mal,drma. ho~., no mo'phulogJal ehang~ OoC(ur
an aJ<'<IuU~ cI.nlCai hutory. cr ~CUons also onaydemon the dUHs
if"'" Slalol,[hs In thOStClSCS ""lfh an :USOCiatoed ducul ol>-
<tNerlon. Extens.on of the inflammatory proctU beyond
<...should ~ cons tdued m patt.n[$ln whom a urong
cl"neal indICatiOn for an obstruc"", and a 1')'<)8''''c
the gland mtO adjacent soft I1S1ue .uults in a lou or ,II s,alsdCn[['I II ....,d.n" In thue InstancH, non-contraSt.
dcfintfton of adpcent soft Quuc pla.nu. .nhanctd aJOal KCttOns may demonstrate <he p«SCn<. of d~
MRl can be us...:! In <he evaluation of acute and chrome Stalolnh, duaal dilation, and s'gns of pyogmi<: sialadcn,,,s.
",flammalory pf'OC6$(:S. Acute inflammation of the parotid
an ruult '" ,nctU_srd signal intensity on n._ight'oed sc-
qucncU and COntr.... t enhancement on TI· ...·eighled se- PEDIATRIC MAXILLOFACIAL INFECTIONS
quen,u. Chromc inflammation Can resull in I"nnhgt of The radiographic manifutations of pediatric maxillofu;",l
ria gbndand hypolnteruiry on TI and T2scquencn."' odontog.nic and IlOnodontogenic mftct.Oflll are "'rySlm-
Chrome t«ur...,nt ,ialoadcni(u; II charaacrizcd by .c- ilar jf not idrntical to .hostdtscribtd for the same d,sc;u.e
eurrtm ep'soou of pain and s_lhng, ofUn a.ssociaud procCSKS m ad,ul{£ (_ Chapetr 21).
Mth glandulars",-ellmg." As Ihe ru.~ tmplres, Ih,srond,.
uon u duratrerizc<i by a rCCUrnnt cycle of :ascendm g glan.
typES OF PEDIATRIC MAXILLOFACIAL
dular ",fccnons foLlO'.W<\ by sa.rring or stricture of the ma-
JNFECDONS
jor ducu. Often an acute ObstnlC1iw Or a nonobnructl'"
bacterW. "aI~enitis may occur in thcn glands.. Chron,c Periorbital and Orbital Infections Ptrio,bnal and or·
rerumm sialadcniris Can be evaluated with sialognphy.ln bital invc:>l",ment CXCUf f;urly cOllll1lO<'lly as a compllCUlOn
such p.a.w-nu, sialography is primarily intended to iL$stS$ of the sprud oC infCCtiofUl originating in the mHlUary den·
the StatuS of the ductal system; demonstrate thc prucnce, tition and paranasal sinuses or 'I. result of trauma to the
loarion, or both of strictures that may predi5pose or im- ar ..._ Prriorbital Of prescptal invc:>l",mcnl tends to o<:(ur
pede Ihe moycmmt of a StOne; and differu>bate betwttn in a younger ago group (younger .han 5 ~ars of age),
obstructi", SWQ.1Idcnitis and other fonnl of siaJo~en;lis WherUJi postseptal in~l"'ment lends 10 occur in older
thai can result m salivary enlargement. These may be mis- childrco.1J"Jt)1 Although plain films may be helpful in doc·
tahn for ob$uuct;~ sialoadenitis,... ,..,··Dt and inclu de umenung Ihe CllUK of ;nfcerion in Certain CIrcumstances
chronic rccumnc s;a1~enitis, sialosis, and auto,mmune (c.g., pfcscncc of a foreign body, dental mfecuons, S,nUS,
sialoadmiti~ · The sialographic hallm:uk or chro",c rt- tis), specific radiograplw: findmgs an: difficult to ddlnute ,
current sialad.eniris is ductal5CMring or ,.ncro..., forma. particularly if only the preseptal arca is involved (F,S"...,
tlon with focal areas or dilation involving the primary 4-33). Consequently, crscanning is C01l$tderm the rad,o-
duclS. Information provided by a cOntnSt sialogram can graphic study of (hOice.~·41 looted, a cr classific.a'ion of
play an Important role in detennining whether gland tc·
moval is warrant~d.
Auto.mmune sialosdenitis is uscd co describe a group
of salivary gland disordetS resulting from underlying au-
tOlmmunt processes such .... Sjllgren's syndrome and
MikullCz's di$eaK.t These conditions are c:han.cleriud
by $alivary gland enlargtment, diffuse lymphocytIC infil-
tration, and the form.ulon of ~nign Iymphotpllhellal
IUlons. In COntrast to ,hronic: recurrent sialadenitis, In
whICh extensive Involvemem of the pr.mary duclS oc-
curs, the sialographic findings In autoimmune sialadeni-
(is arc related to the rupture of weakened stc:ondary
ducts, tSIXcially early in the dise ....e proceSS, and is re ·
ferred to as pu"dosl.JtctMis. llO •lll Later s,aJograph.c
changes ",elude uviry formatiOn and the Slgtllficant
glandular destructIOn as a rcsult of cavItation caused by
abscus formation. IIO,ltl
Sialom or ~mgn parolid hyptrrrophy ,s a 1l0111nflam·
matory, nonntopla.mc bIlateral enla~mcnt of tht paro(,d
glands of unknown ong"'. The sla lographtc find",!;s ,n
SlnOSIS rencet th' underlYing pathological process_ Slnos.s
exclU51",ly ",~I~s the undtrl)1ng p<lrenchyma ..... htle Sp<lr·

"R.fe'encH 22. 21, 34. 40, 41,93. 109

IA.rfrr,'o..n 2.1. 30.110,111.123
 _.,01 I~frat-'

.. H Lattn.l.,_ of ntel, ,..;,h lOf, ''''uc <I.,a,1 <I.mon·

,",ure ';"rI<N ,on.illa, .nlugomon' ,nul"n, from ab.cns for.
~~~:::."n dIt on.... (F""" Dtl8alooAM, od~or:~.....,.
"'" PhOlIocltlph", 1990, WB S.un~l

orbi,ai,nyol"'"",n' by infectious pr~$ ~ !>ten de·

hnu.ee! .0 U$,st m d,agno.i.:llId Uu'mem plannmS by
use",ns racIJosraphlc ftUUTU ''''I<OC'ated ~Ih .'he pre·
upul rtgIon,oro.uJ mYOh.. mtnt, and comphcatlon ",,,h
or ""thout local UttnSlon. 'u....

Tonsillar and P.. ritonsjll&~ Infections Radiosuphic

dunStS in ,h. ,0nS1Uar:llld ptritonsillar rts,on C:llI bt
pro:lucod by hypertrophy, antrgic '''CIlOns, mrccuons,
and ntoplasms. Although thc~ chang•• C:llI be idcntlfied
On plaln film., MR!, and CT. a plain lattral ncek fi lm IS
of,cn ,he vi ..... obtamcd In,,ially to assess .he degrt< of
soft tissue enlargemen, and upper ai .....ay and nasopha.
ryngeal ~I'~ (Figure ..·34). In th. assessmen, of ade_
noidal hypurrophy. a ratio of adenoidal mass ,0 na.
sophuyru may be obuln.d 10 dtttnnme .... htthcr
adcnoockc:lomy i.$ n.cu... ry.".l>·" H~r,a rad.ograph
should 1\01 supplan, an od«ju;uc examination ofrhe air.
~y, and radJogn.ph)" IS probably no !>tacr in pupnS air. Fi"'......·36 Croup. Ant~OPO"f""" Y>eW ofa'rwaycltmonw-a.'
way ~I'nq ,han a thorough physical uamma.ion.")I~ "'I oymmettical na"""",,,, of Iht subglottic ........ y fQ.- .........1un-
In addinon, poor pnion, cooperation Or poor posllion. ,;met ..... below the VQCal cord •. (From Orl8also AM, ~d"or: Mol.<-
,ng On Ihe ,able may gi"" ,h. n.diographic appcaT:l.nce of i&«<"" ""'T~ Philadflph'&' 1990, WB s..und ...... )
adenoid hypt" ..oph~' and airway obstruction; agam, ra
d,ograph;c findIng' must b. correlated wilh Ih. physical
• ><amlnuion Although an anltropOSI.rior pIa", (olm Occasionally, pIa,,, films may b( of b~nefi, In aSsns .
may be ofl!!rl. UU m ,h. dcttrminal;on of.d.no,d hy. m~nt of a mass tfftCl 0' Ih. prUe"Ct or gas in ,h. I1sSUtS
p"nrophy,,, (~" bt of greal help III ,he tvalualion of Can as Ih( result of an "'(cel'on. b", Ih(~ fCatuf(S are mort
sollu hyptrtrophy,parucular:y if a small amoun, of l<ar rud,ly dOmOnslra.eo1 On &X1Jl nr coronal CT projecnon •.
,urn Ii u~d co (oa, 'il~ lon"ls 10 dd,nUle ,he lou "on Tht d'agnos"c npah.l",ts of th,s s.udy can be: tnhaneed
of,h~ mfwor pol~ " Lal.. al pl~in film. of Ih. n(ck c.n. . {u"her by 1tw-(omCld~", u~ of mrra\-'2S(ular comr:u •.
nOI be uud ," dt(~rm'no .holmp,"g~m.", oflons,llar
hypcruophy on ~"'uy palCncy [piglo tt iti. I:p'glol(II" 's an &cuu. bacr.nal .nilan"
maflon Or '"(<<\lOn of Iht cp'gIOttls. ,,,ually tau~d by
 II , ..jI.'u,u In the ped,alflC pOpulation, eplgl o,,,, ..
"s,,~Jly I><glns abluptly with a Uyerc pharyng'tls, hIgh
fr""r. aOld an onablllly 10 handle ul,,,,, h o rap.d p'Of.e •.
Jlon lud,ng 10 dysphagIa and uppt r a"""ay Ob5trU( I,On
.... ,ku" , ptd,alr" l1I~d,cal em ..gency. Rad, ographl .
cally, Ihe eplglo",. and .he arycp'glou,c folds I rc edem -
atOUS Ind swollen w"h smOOlh borden opumally feen
on a la ftra l nec k rilm (FIgure 4-35)_ The ep'glotus looks
Joke I thumb prOjecting imo and co mpromISing the hy_
poph arynx; 'ndeed, this feature is referred 10 as rhe
"rhumb •• gn ." Placement o f a rn,ient In the lupine pos i-
tion to obla,n I.a teral or amtr~posterior neck rilm s may
Iud t o aCUle ."""ay ob5f ruCl1on. In addition, Iht time
u p<'ndcd in obtaining the radiographs may delay the es-
Ilbbshmen l of In adequat e airway; conseq uently, these
films shou ld newr be p"rform~d unless Ihe muns to es-
Ilbhsh Ind mamlain an airway arc al hand . Finally,
rp,gJoUit is is occuiona lly accompanied by a baenrial
pneumonia, which is evidem on appropri ate chest
radiographs_
Croup As oppoHd (0 epiglortiris, croup, o r iaryngotra-
cheobronchiru, is a viral inf«tion chuacleriud by inspi-
ra[ory l[ridor, hoanenelis, and a distinctive Inrking cough.
Croup usually is caused by parainOuen:z.a or respiratory
5)'IlcytiaJ virus. In [hi. disease Ihe diagnostic radiograph is
(he plai n anteroposterior or posteroanterior projection,
which demonstrates a disrioctive subgl()( lic narrowing",-
suiting from mucosal and submucosal edema, glving Iht
apptuance ofa church SlKplt (stccple s.ign)O[ a WIne bot-
I~ (boule sign) (Figure 4-36).
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..2
105 Slt'IOh, 1l.RK, H~'n,b..'g.. IIR.,~. Dl~ .. .1. n.... ..... k
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YX, Ncwotony GN;
arwomy.pacholocr.anct .........
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7Jl&,I97I.
101 S..-ht. II TM Plo~g.:auooofdtnullnftcll"'" In So<Iwr H.
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,Ot~"Y"f:DI
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'" ""u.d".... a."
N(Xfb"" " 9.93, 1976.

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