Diagnostic Imaging: Head and Neck 4th Edition Bernadette L. Koch Md

Diagnostic Imaging: Head and Neck 4th Edition
Bernadette L. Koch Md install download
https://ebookmeta.com/product/diagnostic-imaging-head-and-
neck-4th-edition-bernadette-l-koch-md/
Download more ebook from https://ebookmeta.com

We believe these products will be a great fit for you. Click
the link to download now, or visit ebookmeta.com
to discover even more!
EXPERTDDX : Head and Neck. 2nd Edition Bernadette L.
Koch
https://ebookmeta.com/product/expertddx-head-and-neck-2nd-
edition-bernadette-l-koch/
Diagnostic Imaging: Obstetrics 4th Edition Paula J.
Woodward Md
https://ebookmeta.com/product/diagnostic-imaging-obstetrics-4th-
edition-paula-j-woodward-md/
Diagnostic Ultrasound: Head and Neck, 2nd Edition Ahuja
Mbbs (Bom) Md (Bom) Frcr Fhkcr Fhkam (Radiology)
https://ebookmeta.com/product/diagnostic-ultrasound-head-and-
neck-2nd-edition-ahuja-mbbs-bom-md-bom-frcr-fhkcr-fhkam-
radiology/
Social Work Practice with Transgender and Gender
Expansive Youth 3rd Edition Jama Shelton (Editor)
https://ebookmeta.com/product/social-work-practice-with-
transgender-and-gender-expansive-youth-3rd-edition-jama-shelton-
editor/

A Final Family Affair An Extreme Taboo Anthology 1st
Edition A A Davies Yolanda Olson Ally Vance Cole Denton
K Webster Jennifer Bene Winter Paige
https://ebookmeta.com/product/a-final-family-affair-an-extreme-
taboo-anthology-1st-edition-a-a-davies-yolanda-olson-ally-vance-
cole-denton-k-webster-jennifer-bene-winter-paige-3/
Your Towns Cities In World War Two South Shields At War
1939 45 Craig Armstrong
https://ebookmeta.com/product/your-towns-cities-in-world-war-two-
south-shields-at-war-1939-45-craig-armstrong/
Delightful Turkey Recipes Mouthwatering Turkey Dishes
of All Time Chiles Julia
https://ebookmeta.com/product/delightful-turkey-recipes-
mouthwatering-turkey-dishes-of-all-time-chiles-julia/
The Day Is Waiting Linda Zuckerman
https://ebookmeta.com/product/the-day-is-waiting-linda-zuckerman/
Management of Motor Speech Disorders in Children and
Adults 3rd Edition Kathryn M Yorkston David R Beukelman
Edythe Ha Strand Mark Hakel
https://ebookmeta.com/product/management-of-motor-speech-
disorders-in-children-and-adults-3rd-edition-kathryn-m-yorkston-
david-r-beukelman-edythe-ha-strand-mark-hakel/

Linear and Nonlinear Non-fredholm Operators: Theory and
Applications 1st Edition Messoud Efendiev
https://ebookmeta.com/product/linear-and-nonlinear-non-fredholm-
operators-theory-and-applications-1st-edition-messoud-efendiev/

FOURTH EDITION
Hamilton
|
Koch
Vattoth
|
Chapman

FOURTH EDITION
Bronwyn E. Hamilton, MD
Professor of Radiology, Otolaryngology – Head & Neck Surgery
Director of Head & Neck Radiology
Oregon Health & Science University
Portland, Oregon
Bernadette L. Koch, MD
Associate Director of Radiology
Cincinnati Children’s Hospital Medical Center
Professor of Radiology and Pediatrics
University of Cincinnati College of Medicine
Cincinnati, Ohio
Surjith Vattoth, MD, FRCR
Associate Professor of Radiology
Neuroradiology Division
University of Arkansas for Medical Sciences (UAMS)
Little Rock, Arkansas
Philip R. Chapman, MD
Professor of Radiology
Director of Head and Neck Radiology
Duke University
Durham, North Carolina
ii

Nicholas A. Koontz, MD
Director of Fellowship Programs
Dean D. T. Maglinte Scholar in Radiology Education
Assistant Professor of Radiology and Imaging Sciences
Otolaryngology – Head & Neck Surgery
Department of Radiology and Imaging Sciences
Indiana University School of Medicine
Indianapolis, Indiana
Daniel E. Meltzer, MD
Associate Professor of Radiology
Division of Neuroradiology
Department of Radiology
Icahn School of Medicine at Mount Sinai
New York, New York
C. Douglas Phillips, MD, FACR
Professor
Department of Radiology
Director of Head and Neck Imaging
Weill Cornell Medical College
New York-Presbyterian Hospital
New York, New York
Aparna Singhal, MD
Associate Professor
Chief, Neuroradiology Section
Department of Radiology
University of Alabama at Birmingham
Birmingham, Alabama
Joshua E. Lantos, MD
Assistant Professor
Department of Radiology
Weill Cornell Medical College
New York-Presbyterian Hospital
New York, New York
Hilda
E. Stambuk, MD
Attending Radiologist and
Director of Head and Neck Imaging
Department of Radiology
Memorial Sloan Kettering Cancer Center
Professor
Department of Radiology
Weill Cornell Medical College
New York, New York
Kathryn E. Dean, MD
Assistant Professor
Department of Radiology
Weill Cornell Medical College
New York, New York
Sara Strauss, MD
Assistant Professor
Department of Radiology
Weill Cornell Medical College
New York-Presbyterian Hospital
New York, New York
Karen L. Salzman, MD
Professor of Radiology and Imaging Sciences
Neuroradiology Section Chief and Fellowship Director
Leslie W. Davis Endowed Chair in Neuroradiology
University of Utah School of Medicine
Salt Lake City, Utah
Richard H. Wiggins, III, MD, CIIP,
FSIIM, FAHSE, FACR
Associate Dean, Professor
Department of Radiology and Imaging Sciences
University of Utah Health Sciences Center
Salt Lake City, Utah
Yoshimi
Anzai, MD, MPH
Professor
Department of Radiology and Imaging Sciences
University of Utah Health Sciences Center
Salt Lake City, Utah
Jaclyn Thiessen, MD
Assistant Professor of Neuroradiology
Department of Diagnostic Radiology
Oregon Health & Science University
Portland, Oregon
Blair A. Winegar, MD
Associate Professor
Department of Radiology and Imaging Sciences
University of Utah School of Medicine
Salt Lake City, Utah
William T. O'Brien, Sr., DO, FAOCR
Neuroradiology Section Chief and Fellowship Director
Cincinnati Children's Hospital Medical Center
Associate Professor of Radiology
University of Cincinnati College of Medicine
Cincinnati, Ohio
iii

Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
DIAGNOSTIC IMAGING: HEAD AND NECK, FOURTH EDITION ISBN: 978-0-323-79650-7
Copyright © 2022 by Elsevier. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying,
recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Previous edition copyrighted 2017.
Library of
Congress Control Number: 2021943200
Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Notices
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.
iv
Inkling: 978-0-323-79651-4

With warm appreciation to Ric Harnsberger for years of leading the way.
Without you, this book would not be here.
My heartfelt thanks to all of my family for their continual love and support.
You make everything else worthwhile!
BEH
To Peter, Jay, Katherine, Mom, Dad, and siblings for your
unconditional love and support.
To Drs. William Ball, Ric Harnsberger, Corning Benton, and all of the faculty
in the ASHNR who encouraged me to embark on this adventure of
head and neck imaging many years ago.
To fellows, residents, students, and colleagues for inspiring me to learn
each and every day. Thank you for your dedication to improving the care of
patients by always striving to enhance your knowledge
of head and neck imaging.
To Bronwyn, Surj, Phil, Nina, and all of those in the editorial and production
staff for your hard work, attention to detail, and passion for getting it right.
BLK
Dedicated to Fiju (Dr. Fathima Fijula P. Manzil), my wife and soulmate since
childhood; my son, Lazim, and my daughters, Lamis and Liya, who happily
sacrificed their precious countless hours of evening and weekend family
time with me while I was deeply indulged in the work of this book and other
projects as a passionate educator. I am also indebted to my parents and
sisters at the other side of the world, who let me fly high and far away from
them to fulfill my career dreams and disperse my knowledge in radiology for
the betterment of patient care.
SV
My contribution to this project is dedicated to my wife, April, and
two loving sons, Grayson and Garrison.
PRC
Dedications
v

vi

Contributing Author
Kalen Riley, MD, MBA
Neuroradiology Fellow
University of Utah
Salt Lake City, Utah
Additional Contributors
H. Christian Davidson, MD
H. Ric Harnsberger, MD
Patricia A. Hudgins, MD, FACR
Troy A. Hutchins, MD
Luke N. Ledbetter, MD
Luke L. Linscott, MD
A. Carlson Merrow, Jr., MD, FAAP
Kevin R. Moore, MD
Kristine M. Mosier, DMD, PhD
Emily S. Orscheln, MD
Anne G. Osborn, MD, FACR
Caroline D. Robson, MBChB
vii

Preface
What is new in head and neck diagnostic imaging since our last edition? Much has
changed. Diagnosis and treatment of many head and neck diseases, particularly
in the field of oncology, continue to evolve in the current era of personalized
medicine. The increasing complexity in medicine requires greater multidisciplinary
involvement than ever before. Radiologists and imaging specialists need to
practice with knowledge that reflects a working understanding of contemporary
terminology, diagnosis, and treatment for head and neck disorders. The following
changes are incorporated into this edition:
• Updated TNM staging information from the American Joint Committee on
Cancer (AJCC) Cancer Staging Manual, 8th edition
• Updates from the new 4th edition of the World Health Organization (WHO)
Classification of Head and Neck Tumours

• Revised nomenclature from the 2018 International Society for the Study of
Vascular Anomalies (ISSVA) for head and neck vascular malformations,
important to prevent misdiagnosis and inappropriate therapies or harm to
patients
• Improved immunohistochemical characterization of diseases that reflects
a better understanding of head and neck pathology, in turn leading to
improved diagnostic accuracy and, consequently, evolving treatment options
• Improved genetic characterization of many diseases and syndromes
• Changes in head and neck cancer treatment include immunotherapies and their
associated complications, which have implications for imaging surveillance

• Evolving imaging modalities with value in the head and neck, such as
Ga-68 DOTATATE PET for neuroendocrine tumors
• New chapters on COVID manifestations and IgG4-related disease in the
head and neck
You will enjoy the same information-dense material in an easily accessible format that appeared in prior editions, augmented by beautiful, enhanced, high-quality illustrations and accompanied by new and updated cases, including 1,455 new images. We are confident you will enjoy our 4th edition of Diagnostic Imaging:
Head and Neck as much as we enjoyed putting it together for you and trust that you will find it to be an invaluable reference in your reading room.
viii

Bronwyn E. Hamilton, MD
Professor of Radiology, Otolaryngology – Head & Neck Surgery
Director of Head & Neck Radiology
Oregon Health & Science University
Portland, Oregon
Bernadette L. Koch, MD
Associate Director of Radiology
Cincinnati Children’s Hospital Medical Center
Professor of Radiology and Pediatrics
University of Cincinnati College of Medicine
Cincinnati, Ohio
Surjith Vattoth, MD, FRCR
Associate Professor of Radiology
Neuroradiology Division
University of Arkansas for Medical Sciences (UAMS)
Little Rock, Arkansas
Philip R. Chapman, MD
Professor of Radiology
Director of Head and Neck Radiology
Duke University
Durham, North Carolina
ix

x

Acknowledgments
LEAD EDITOR
Nina Themann, BA
LEAD ILLUSTRATOR
Richard Coombs, MS
TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Terry W. Ferrell, MS
Megg Morin, BA
Kathryn Watkins, BA
IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS
ILLUSTRATIONS
Lane R. Bennion, MS
Laura C. Wissler, MA
ART DIRECTION AND DESIGN
Tom M. Olson, BA
PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS
xi

xii

Sections
SECTION 1: Introduction and Overview of Suprahyoid and Infrahyoid Neck
SECTION 2: Parapharyngeal Space
SECTION 3: Pharyngeal Mucosal Space
SECTION 4: Masticator Space
SECTION 5: Parotid Space
SECTION 6: Carotid Space
SECTION 7: Retropharyngeal Space
SECTION 8: Perivertebral Space
SECTION 9: Posterior Cervical Space
SECTION 10: Visceral Space
SECTION 11: Hypopharynx, Larynx, and Cervical Trachea
SECTION 12: Lymph Nodes
SECTION 13: Transspatial and Multispatial
SECTION 14: Oral Cavity
SECTION 15: Mandible-Maxilla and TMJ
SECTION 16: Introduction and Overview of Squamous Cell Carcinoma
SECTION 17: Primary Sites, Perineural Tumor and Nodes
SECTION 18: Posttreatment Neck
SECTION 19: Pediatric Lesions
SECTION 20: Syndromic Diseases
SECTION 21: Nose and Sinus
SECTION 22: Orbit
SECTION 23: Skull Base Lesions
SECTION 24: Skull Base, Facial, and Temporal Bone Trauma
SECTION 25: Temporal Bone
SECTION 26: CPA-IAC
xiii

xiv
TABLE OF CONTENTS
SECTION 1: INTRODUCTION AND
OVERVIEW OF SUPRAHYOID AND
INFRAHYOID NECK
4 Suprahyoid and Infrahyoid Neck Overview
H. Ric Harnsberger, MD and Philip R. Chapman, MD
SECTION 2: PARAPHARYNGEAL SPACE
12Parapharyngeal Space Overview
H. Ric Harnsberger, MD and Philip R. Chapman, MD
BENIGN TUMORS
14Parapharyngeal Space Benign Mixed TumorAparna Singhal, MD and H. Ric Harnsberger, MD
SECTION 3: PHARYNGEAL MUCOSAL
SPACE
18Pharyngeal Mucosal Space Overview
Philip R. Chapman, MD and H. Ric Harnsberger, MD
CONGENITAL LESIONS
22Tornwaldt CystSurjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
INFECTIOUS AND INFLAMMATORY LESIONS
24Retention Cyst of Pharyngeal Mucosal Space
Surjith Vattoth, MD, FRCR
26Tonsillar Inflammation
Bernadette L. Koch, MD and H. Ric Harnsberger, MD
28Tonsillar/Peritonsillar Abscess
Bernadette L. Koch, MD and H. Ric Harnsberger, MD
BENIGN AND MALIGNANT TUMORS
30Benign Mixed Tumor of Pharyngeal Mucosal Space
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
32Minor Salivary Gland Malignancy of Pharyngeal
Mucosal Space
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
34Non-Hodgkin Lymphoma of Pharyngeal Mucosal
Space
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
SECTION 4: MASTICATOR SPACE
40Masticator Space Overview
Bronwyn E. Hamilton, MD
PSEUDOLESIONS
44Pterygoid Venous Plexus Asymmetry
Bronwyn E. Hamilton, MD
46Benign Masticator Muscle Hypertrophy
Bronwyn E. Hamilton, MD
48CNV3 Motor Denervation
Bronwyn E. Hamilton, MD
INFECTIOUS LESIONS
52Masticator Space AbscessBronwyn E. Hamilton, MD
BENIGN TUMORS
56Masticator Space CNV3 SchwannomaBronwyn E. Hamilton, MD
MALIGNANT TUMORS
58Masticator Space CNV3 Perineural TumorBronwyn E. Hamilton, MD
62Masticator Space Chondrosarcoma
Bronwyn E. Hamilton, MD
66Masticator Space Sarcoma
Bronwyn E. Hamilton, MD
SECTION 5: PAROTID SPACE
72Parotid Space OverviewBronwyn E. Hamilton, MD
INFECTIOUS AND INFLAMMATORY LESIONS
76Acute ParotitisBernadette L. Koch, MD
80Parotid Sjögren SyndromeBronwyn E. Hamilton, MD
84Benign Lymphoepithelial Cysts of HIVPhilip R. Chapman, MD and H. Ric Harnsberger, MD
BENIGN TUMORS
88Parotid Benign Mixed TumorBronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
92Warthin TumorBronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
96Parotid SchwannomaHilda E. Stambuk, MD

xv
TABLE OF CONTENTS
MALIGNANT TUMORS
98Parotid Mucoepidermoid Carcinoma
Bronwyn E. Hamilton, MD
102Parotid Adenoid Cystic Carcinoma
Bronwyn E. Hamilton, MD
104Parotid Acinic Cell Carcinoma
Bronwyn E. Hamilton, MD
106Parotid Malignant Mixed Tumor
Bronwyn E. Hamilton, MD
108Parotid Non-Hodgkin Lymphoma
Bronwyn E. Hamilton, MD
112Metastatic Disease of Parotid Nodes
Bronwyn E. Hamilton, MD
SECTION 6: CAROTID SPACE
118Carotid Space OverviewH. Ric Harnsberger, MD and Philip R. Chapman, MD
NORMAL VARIANTS
122Tortuous Carotid Artery in NeckBronwyn E. Hamilton, MD
VASCULAR LESIONS
124Carotid Artery Dissection in NeckBronwyn E. Hamilton, MD
128Carotid Artery Pseudoaneurysm in NeckBronwyn E. Hamilton, MD
130Carotid Artery Fibromuscular Dysplasia in NeckPhilip R. Chapman, MD
132Acute Idiopathic Carotidynia
Bronwyn E. Hamilton, MD
134Jugular Vein Thrombosis
Bronwyn E. Hamilton, MD
138Postpharyngitis Venous Thrombosis (Lemierre)
Bronwyn E. Hamilton, MD
BENIGN TUMORS
140Carotid Body ParagangliomaSurjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
144Glomus Vagale Paraganglioma
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
148Carotid Space Schwannoma
Karen L. Salzman, MD
152Sympathetic Schwannoma
C. Douglas Phillips, MD, FACR
154Carotid Space Neurofibroma
Bernadette L. Koch, MD and H. Christian Davidson, MD
156Carotid Space Meningioma
Karen L. Salzman, MD
SECTION 7: RETROPHARYNGEAL SPACE
160Retropharyngeal Space OverviewBronwyn E. Hamilton, MD
INFECTIOUS AND INFLAMMATORY LESIONS
164Reactive Adenopathy of Retropharyngeal SpaceBronwyn E. Hamilton, MD
166Suppurative Adenopathy of Retropharyngeal SpaceBernadette L. Koch, MD and H. Ric Harnsberger, MD
168Retropharyngeal Space AbscessBernadette L. Koch, MD
172Retropharyngeal Space EdemaBronwyn E. Hamilton, MD
METASTATIC TUMORS
176Nodal Squamous Cell Carcinoma of Retropharyngeal
Space
Bronwyn E. Hamilton, MD
178Nodal Non-Hodgkin Lymphoma in Retropharyngeal
Space
Bronwyn E. Hamilton, MD
180Non-Squamous Cell Carcinoma Metastatic Nodes in
Retropharyngeal Space
Bronwyn E. Hamilton, MD
SECTION 8: PERIVERTEBRAL SPACE
184Perivertebral Space OverviewPhilip R. Chapman, MD and Troy A. Hutchins, MD
PSEUDOLESIONS
188Levator Scapulae Muscle HypertrophyC. Douglas Phillips, MD, FACR
INFECTIOUS AND INFLAMMATORY LESIONS
190Acute Calcific Longus Colli TendonitisC. Douglas Phillips, MD, FACR
192Perivertebral Space InfectionC. Douglas Phillips, MD, FACR
VASCULAR LESIONS
196Vertebral Artery Dissection in NeckC. Douglas Phillips, MD, FACR
BENIGN AND MALIGNANT TUMORS
198Brachial Plexus Schwannoma in Perivertebral SpaceC. Douglas Phillips, MD, FACR
200Chordoma in Perivertebral SpaceC. Douglas Phillips, MD, FACR
202Vertebral Body Metastasis in Perivertebral SpaceC. Douglas Phillips, MD, FACR
SECTION 9: POSTERIOR CERVICAL SPACE
208Posterior Cervical Space OverviewBronwyn E. Hamilton, MD
BENIGN TUMORS
210Posterior Cervical Space SchwannomaBronwyn E. Hamilton, MD

xvi
TABLE OF CONTENTS
METASTATIC TUMORS
214Squamous Cell Carcinoma in Spinal Accessory Node
Bronwyn E. Hamilton, MD
216Non-Hodgkin Lymphoma in Spinal Accessory Node
Bronwyn E. Hamilton, MD
SECTION 10: VISCERAL SPACE
220Visceral Space OverviewBronwyn E. Hamilton, MD
INFLAMMATORY LESIONS
224Chronic Lymphocytic Thyroiditis (Hashimoto)Bronwyn E. Hamilton, MD
METABOLIC DISEASE
226Multinodular GoiterH. Ric Harnsberger, MD and Kathryn E. Dean, MD
BENIGN TUMORS
230Thyroid AdenomaLuke N. Ledbetter, MD and Kathryn E. Dean, MD
234Parathyroid Adenoma in Visceral SpaceBronwyn E. Hamilton, MD
MALIGNANT TUMORS
238Differentiated Thyroid Carcinoma
Bronwyn E. Hamilton, MD
242Medullary Thyroid Carcinoma
Bronwyn E. Hamilton, MD
246Anaplastic Thyroid Carcinoma
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
250Non-Hodgkin Lymphoma of Thyroid
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
252Parathyroid Carcinoma
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
254Thyroglossal Duct Cyst Carcinoma
Jaclyn Thiessen, MD
258Cervical Esophageal Carcinoma
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
MISCELLANEOUS
260Esophagopharyngeal Diverticulum (Zenker)Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
262Colloid Cyst of ThyroidH. Ric Harnsberger, MD and Sara Strauss, MD
264Lateral Cervical Esophageal DiverticulumLuke N. Ledbetter, MD and Sara Strauss, MD
SECTION 11: HYPOPHARYNX, LARYNX,
AND CERVICAL TRACHEA
268Hypopharynx, Larynx, and Trachea Overview
Aparna Singhal, MD and Troy A. Hutchins, MD
INFECTIOUS AND INFLAMMATORY LESIONS
274CroupBernadette L. Koch, MD, Emily S. Orscheln, MD, and A.
Carlson Merrow, Jr., MD, FAAP
278Epiglottitis in Child
Bernadette L. Koch, MD
279Supraglottitis
Troy A. Hutchins, MD and Joshua E. Lantos, MD
TRAUMA
280Laryngeal TraumaTroy A. Hutchins, MD and Sara Strauss, MD
BENIGN AND MALIGNANT TUMORS
284Upper Airway Infantile HemangiomaBernadette L. Koch, MD
286Laryngeal ChondrosarcomaYoshimi Anzai, MD, MPH
TREATMENT-RELATED LESIONS
290Postradiation Larynx
Troy A. Hutchins, MD and Joshua E. Lantos, MD
MISCELLANEOUS
294Laryngocele
H. Ric Harnsberger, MD and Sara Strauss, MD
298Vocal Cord Paralysis
Aparna Singhal, MD and Troy A. Hutchins, MD
302Acquired Subglottic-Tracheal Stenosis
Troy A. Hutchins, MD and Sara Strauss, MD
SECTION 12: LYMPH NODES
308Lymph Node OverviewNicholas A. Koontz, MD
INFECTIOUS AND INFLAMMATORY LESIONS
312Reactive Lymph NodesNicholas A. Koontz, MD
316Suppurative Lymph NodesNicholas A. Koontz, MD
320Tuberculous Lymph NodesNicholas A. Koontz, MD
322Nontuberculous Mycobacterium NodesNicholas A. Koontz, MD
323Sarcoidosis Lymph NodesNicholas A. Koontz, MD
324Giant Lymph Node Hyperplasia (Castleman Disease)Luke N. Ledbetter, MD and Sara Strauss, MD
328Histiocytic Necrotizing Lymphadenitis (Kikuchi-
Fujimoto)
Luke N. Ledbetter, MD and Sara Strauss, MD
330Kimura Disease
Luke N. Ledbetter, MD and Sara Strauss, MD
MALIGNANT TUMORS
334Nodal Hodgkin Lymphoma in NeckSurjith Vattoth, MD, FRCR

xvii
TABLE OF CONTENTS
338Nodal Non-Hodgkin Lymphoma in Neck
Surjith Vattoth, MD, FRCR
342Nodal Differentiated Thyroid Carcinoma
Surjith Vattoth, MD, FRCR
344Systemic Nodal Metastases in Neck
Surjith Vattoth, MD, FRCR
SECTION 13: TRANSSPATIAL AND
MULTISPATIAL
348Transspatial and Multispatial Overview
H. Ric Harnsberger, MD and Kathryn E. Dean, MD
NORMAL VARIANTS
350Prominent Thoracic Duct in NeckRichard H. Wiggins, III, MD, CIIP, FSIIM
BENIGN TUMORS
352Lipoma of Head and NeckHilda E. Stambuk, MD
356Hemangiopericytoma of Head and NeckDaniel E. Meltzer, MD
358Plexiform Neurofibroma of Head and NeckDaniel E. Meltzer, MD and Luke N. Ledbetter, MD
MALIGNANT TUMORS
360Posttransplantation Lymphoproliferative DisorderSurjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
362Extraosseous Chordoma
Surjith Vattoth, MD, FRCR
364Non-Hodgkin Lymphoma of Head and Neck
Surjith Vattoth, MD, FRCR
368Liposarcoma of Head and Neck
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
370Synovial Sarcoma of Head and Neck
Hilda E. Stambuk, MD
372Malignant Peripheral Nerve Sheath Tumor of Head
and Neck
Hilda E. Stambuk, MD
MISCELLANEOUS
374Lymphocele of NeckBronwyn E. Hamilton, MD
376Sinus Histiocytosis (Rosai-Dorfman) of Head and
Neck
H. Ric Harnsberger, MD and Kathryn E. Dean, MD
378Fibromatosis of Head and Neck
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
382IgG4-Related Disease
Bronwyn E. Hamilton, MD
386COVID-19
Nicholas A. Koontz, MD
SECTION 14: ORAL CAVITY
392Oral Cavity OverviewAparna Singhal, MD and H. Ric Harnsberger, MD
PSEUDOLESIONS
398Hypoglossal Nerve Motor DenervationRichard H. Wiggins, III, MD, CIIP, FSIIM
CONGENITAL LESIONS
400Submandibular Space Accessory Salivary TissueDaniel E. Meltzer, MD
402Oral Cavity Dermoid and EpidermoidDaniel E. Meltzer, MD
406Oral Cavity Lymphatic MalformationBronwyn E. Hamilton, MD
408Lingual ThyroidDaniel E. Meltzer, MD
INFECTIOUS AND INFLAMMATORY LESIONS
410RanulaRichard H. Wiggins, III, MD, CIIP, FSIIM
414Oral Cavity SialoceleRichard H. Wiggins, III, MD, CIIP, FSIIM
416Submandibular Gland SialadenitisRichard H. Wiggins, III, MD, CIIP, FSIIM
418Oral Cavity AbscessRichard H. Wiggins, III, MD, CIIP, FSIIM
BENIGN TUMORS
422Submandibular Gland Benign Mixed TumorBronwyn E. Hamilton, MD
424Palate Benign Mixed TumorBronwyn E. Hamilton, MD
MALIGNANT TUMORS
426Sublingual Gland CarcinomaBronwyn E. Hamilton, MD
428Submandibular Gland CarcinomaBronwyn E. Hamilton, MD
430Oral Cavity Minor Salivary Gland MalignancyBronwyn E. Hamilton, MD
432Submandibular Space Nodal Non-Hodgkin
Lymphoma
Bronwyn E. Hamilton, MD
434Submandibular Space Nodal Squamous Cell
Carcinoma
Bronwyn E. Hamilton, MD
SECTION 15: MANDIBLE-MAXILLA AND
TMJ
438Mandible-Maxilla and TMJ Overview
Aparna Singhal, MD and Kristine M. Mosier, DMD, PhD
CONGENITAL LESIONS
444Solitary Median Maxillary Central IncisorBernadette L. Koch, MD
NONNEOPLASTIC CYSTS
446Nasolabial Cyst
Kathryn E. Dean, MD and Kristine M. Mosier, DMD, PhD

xviii
TABLE OF CONTENTS
448Periapical Cyst (Radicular)
Bernadette L. Koch, MD and Kristine M. Mosier, DMD,
PhD
450Dentigerous Cyst
Aparna Singhal, MD and Kristine M. Mosier, DMD, PhD
452Simple Bone Cyst (Traumatic)
Kristine M. Mosier, DMD, PhD and Kathryn E. Dean, MD
454Nasopalatine Duct Cyst
Joshua E. Lantos, MD and Kristine M. Mosier, DMD, PhD
INFECTIOUS AND INFLAMMATORY LESIONS
456TMJ Juvenile Idiopathic ArthritisBernadette L. Koch, MD
458Mandible-Maxilla OsteomyelitisPhilip R. Chapman, MD
TUMOR-LIKE LESIONS
460TMJ Calcium Pyrophosphate Dihydrate Deposition
Disease
Kristine M. Mosier, DMD, PhD and Joshua E. Lantos, MD
462TMJ Pigmented Villonodular Synovitis
Bronwyn E. Hamilton, MD and Kristine M. Mosier, DMD,
PhD
464TMJ Synovial Chondromatosis
Bronwyn E. Hamilton, MD and Kristine M. Mosier, DMD,
PhD
466Mandible-Maxilla Central Giant Cell Granuloma
Sara Strauss, MD and Kristine M. Mosier, DMD, PhD
BENIGN AND MALIGNANT TUMORS
468AmeloblastomaAparna Singhal, MD and Kristine M. Mosier, DMD, PhD
472Odontogenic KeratocystDaniel E. Meltzer, MD
476Mandible-Maxilla OsteosarcomaKristine M. Mosier, DMD, PhD and Kathryn E. Dean, MD
TREATMENT-RELATED LESIONS
478Medication-Related Osteonecrosis of Jaw (MRONJ)Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
SECTION 16: INTRODUCTION ANDOVERVIEW OF SQUAMOUS CELLCARCINOMA
482Squamous Cell Carcinoma Overview
Surjith Vattoth, MD, FRCR
SECTION 17: PRIMARY SITES,
PERINEURAL TUMOR AND NODES
NASOPHARYNGEAL CARCINOMA
490Nasopharyngeal Carcinoma
Aparna Singhal, MD and Luke N. Ledbetter, MD
OROPHARYNGEAL CARCINOMA
494Base of Tongue Squamous Cell CarcinomaAparna Singhal, MD
498Palatine Tonsil Squamous Cell CarcinomaBronwyn E. Hamilton, MD and Luke N. Ledbetter, MD
502Posterior Oropharyngeal Wall Squamous Cell
Carcinoma
Aparna Singhal, MD and Luke N. Ledbetter, MD
504HPV-Related Oropharyngeal Squamous Cell
Carcinoma
Surjith Vattoth, MD, FRCR and Philip R. Chapman, MD
508Soft Palate Squamous Cell Carcinoma
Kathryn E. Dean, MD and Luke N. Ledbetter, MD
ORAL CAVITY CARCINOMA
510Oral Tongue Squamous Cell CarcinomaNicholas A. Koontz, MD
514Floor of Mouth Squamous Cell CarcinomaNicholas A. Koontz, MD
516Alveolar Ridge Squamous Cell CarcinomaNicholas A. Koontz, MD
518Retromolar Trigone Squamous Cell CarcinomaNicholas A. Koontz, MD
520Buccal Mucosa Squamous Cell CarcinomaNicholas A. Koontz, MD
522Hard Palate Squamous Cell CarcinomaNicholas A. Koontz, MD
HYPOPHARYNGEAL CARCINOMA
524Pyriform Sinus Squamous Cell Carcinoma
Surjith Vattoth, MD, FRCR
528Postcricoid Region Squamous Cell Carcinoma
Surjith Vattoth, MD, FRCR
530Posterior Hypopharyngeal Wall Squamous Cell
Carcinoma
Surjith Vattoth, MD, FRCR
LARYNGEAL CARCINOMA
532Supraglottic Laryngeal Squamous Cell CarcinomaSurjith Vattoth, MD, FRCR
536Glottic Laryngeal Squamous Cell CarcinomaSurjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
538Subglottic Laryngeal Squamous Cell Carcinoma
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
540Laryngeal Squamous Cell Carcinoma With Secondary
Laryngocele
H. Ric Harnsberger, MD and Sara Strauss, MD
PERINEURAL TUMOR
542Perineural Tumor SpreadHilda E. Stambuk, MD
SQUAMOUS CELL CARCINOMA LYMPH
NODES
546Nodal Squamous Cell Carcinoma
Hilda E. Stambuk, MD

xix
TABLE OF CONTENTS
SECTION 18: POSTTREATMENT NECK
554Nodal Dissection in Neck
Surjith Vattoth, MD, FRCR
558Reconstruction Flaps in Neck
Surjith Vattoth, MD, FRCR
562Expected Changes of Neck Radiation Therapy
Surjith Vattoth, MD, FRCR
566Complications of Neck Radiation Therapy
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
570Osteoradionecrosis
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
574Post Laryngectomy
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
SECTION 19: PEDIATRIC LESIONS
582Approach to Congenital Cystic Neck Masses
Bernadette L. Koch, MD
CONGENITAL LESIONS
586Lymphatic MalformationBernadette L. Koch, MD
590Venous MalformationBernadette L. Koch, MD
594Congenital Vallecular CystBernadette L. Koch, MD
596Thyroglossal Duct CystBernadette L. Koch, MD
600Cervical Thymic CystBernadette L. Koch, MD
6041st Branchial Cleft CystBernadette L. Koch, MD
6082nd Branchial Cleft CystBernadette L. Koch, MD
6123rd Branchial Cleft CystBernadette L. Koch, MD
6164th Branchial Cleft CystBernadette L. Koch, MD
620Dermoid and Epidermoid CystsBernadette L. Koch, MD
BENIGN TUMORS AND TUMOR-LIKE LESIONS
624Infantile HemangiomaBernadette L. Koch, MD
628Fibromatosis ColliBernadette L. Koch, MD
MALIGNANT TUMORS
630RhabdomyosarcomaBernadette L. Koch, MD
631Primary Cervical NeuroblastomaBernadette L. Koch, MD
632Metastatic NeuroblastomaBernadette L. Koch, MD, Kevin R. Moore, MD, and Anne G.
Osborn, MD, FACR
SECTION 20: SYNDROMIC DISEASES
638Neurofibromatosis Type 1
Bernadette L. Koch, MD
642Schwannomatosis
Nicholas A. Koontz, MD
644Neurofibromatosis Type 2
Bernadette L. Koch, MD
646Basal Cell Nevus Syndrome
Bernadette L. Koch, MD
648Branchiootorenal Syndrome
William T. O'Brien, Sr., DO, FAOCR and Caroline D.
Robson, MBChB
652CHARGE Syndrome
William T. O'Brien, Sr., DO, FAOCR and Caroline D.
Robson, MBChB
656Hemifacial Microsomia
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
658Treacher Collins Syndrome
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
659Pierre Robin Sequence
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
660X-Linked Stapes Gusher (DFNX2)
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Caroline D. Robson, MBChB
662McCune-Albright Syndrome
Bernadette L. Koch, MD
663Cherubism
Bernadette L. Koch, MD
664Mucopolysaccharidosis
Bernadette L. Koch, MD
SECTION 21: NOSE AND SINUS
668Sinonasal OverviewPhilip R. Chapman, MD
CONGENITAL LESIONS
674Nasolacrimal Duct MucoceleBernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
676Choanal AtresiaBernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
680Nasal GliomaBernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
684Nasal Dermal SinusBernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
688Frontoethmoidal CephaloceleBernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
692Congenital Nasal Pyriform Aperture StenosisBernadette L. Koch, MD
INFECTIOUS AND INFLAMMATORY LESIONS
694Acute RhinosinusitisNicholas A. Koontz, MD
698Chronic Rhinosinusitis
Philip R. Chapman, MD
702Complications of Rhinosinusitis
Nicholas A. Koontz, MD

xx
TABLE OF CONTENTS
706Allergic Fungal Sinusitis
Bronwyn E. Hamilton, MD and H. Christian Davidson, MD
708Sinus Mycetoma
Aparna Singhal, MD and H. Christian Davidson, MD
710Invasive Fungal Sinusitis
Nicholas A. Koontz, MD
714Sinonasal Polyposis
Nicholas A. Koontz, MD
718Solitary Sinonasal Polyp
Philip R. Chapman, MD
722Sinonasal Mucocele
Philip R. Chapman, MD
726Sinonasal Organized Hematoma
Philip R. Chapman, MD
728Silent Sinus Syndrome
Philip R. Chapman, MD
730Granulomatosis With Polyangiitis (Wegener)
Philip R. Chapman, MD
734Nasal Cocaine Necrosis
Philip R. Chapman, MD
BENIGN TUMORS AND TUMOR-LIKE LESIONS
736Sinonasal Fibrous Dysplasia
Yoshimi Anzai, MD, MPH
738Sinonasal Osteoma
Daniel E. Meltzer, MD
742Sinonasal Ossifying Fibroma
Blair A. Winegar, MD
746Juvenile Angiofibroma
Bernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
750Sinonasal Inverted Papilloma
Yoshimi Anzai, MD, MPH
754Sinonasal Hemangioma
Yoshimi Anzai, MD, MPH
756Sinonasal Nerve Sheath Tumor
Yoshimi Anzai, MD, MPH
758Sinonasal Benign Mixed Tumor
Yoshimi Anzai, MD, MPH
MALIGNANT TUMORS
760Sinonasal Squamous Cell CarcinomaYoshimi Anzai, MD, MPH
764EsthesioneuroblastomaYoshimi Anzai, MD, MPH
768Sinonasal Melanoma
Yoshimi Anzai, MD, MPH
770Sinonasal Adenocarcinoma
Blair A. Winegar, MD
772Sinonasal Non-Hodgkin Lymphoma
Yoshimi Anzai, MD, MPH
776Sinonasal Neuroendocrine Carcinoma
Blair A. Winegar, MD
778Sinonasal Undifferentiated Carcinoma
Blair A. Winegar, MD
779Sinonasal Adenoid Cystic Carcinoma
Blair A. Winegar, MD
780Sinonasal Chondrosarcoma
Blair A. Winegar, MD
781Sinonasal Osteosarcoma
Blair A. Winegar, MD
SECTION 22: ORBIT
784Orbit OverviewAparna Singhal, MD and H. Christian Davidson, MD
CONGENITAL LESIONS
788ColobomaBernadette L. Koch, MD
792Persistent Hyperplastic Primary VitreousBernadette L. Koch, MD and H. Christian Davidson, MD
794Coats DiseaseBernadette L. Koch, MD and H. Christian Davidson, MD
796Orbital Dermoid and Epidermoid
H. Christian Davidson, MD and Joshua E. Lantos, MD
800Orbital Neurofibromatosis Type 1
Surjith Vattoth, MD, FRCR and Joshua E. Lantos, MD
VASCULAR LESIONS
804Orbital Lymphatic MalformationJoshua E. Lantos, MD and H. Christian Davidson, MD
808Orbital Venous VarixJoshua E. Lantos, MD and H. Christian Davidson, MD
810Orbital Cavernous Venous Malformation
(Hemangioma)
Aparna Singhal, MD and H. Christian Davidson, MD
INFECTIOUS AND INFLAMMATORY LESIONS
814Ocular ToxocariasisH. Christian Davidson, MD and Joshua E. Lantos, MD
816Orbital Subperiosteal Abscess
Bronwyn E. Hamilton, MD and H. Christian Davidson, MD
820Orbital Cellulitis
Bronwyn E. Hamilton, MD and H. Christian Davidson, MD
822Idiopathic Orbital Inflammation (Pseudotumor)
Bronwyn E. Hamilton, MD and H. Christian Davidson, MD
826Orbital Sarcoidosis
Philip R. Chapman, MD and H. Christian Davidson, MD
828Thyroid-Associated Orbitopathy
Bronwyn E. Hamilton, MD
832Optic Neuritis
Bronwyn E. Hamilton, MD
TUMOR-LIKE LESIONS
836Orbital Langerhans Cell Histiocytosis
Bernadette L. Koch, MD and H. Christian Davidson, MD
BENIGN TUMORS
838Orbital Infantile HemangiomaDaniel E. Meltzer, MD and Surjith Vattoth, MD, FRCR
842Optic Pathway GliomaDaniel E. Meltzer, MD
846Optic Nerve Sheath MeningiomaDaniel E. Meltzer, MD
850Lacrimal Gland Benign Mixed TumorDaniel E. Meltzer, MD

xxi
TABLE OF CONTENTS
MALIGNANT TUMORS
852Retinoblastoma
Daniel E. Meltzer, MD
856Ocular Melanoma
Daniel E. Meltzer, MD
860Orbital Lymphoproliferative Lesions
Joshua E. Lantos, MD and H. Christian Davidson, MD
864Lacrimal Gland Carcinoma
Daniel E. Meltzer, MD
SECTION 23: SKULL BASE LESIONS
868Skull Base OverviewH. Ric Harnsberger, MD and Philip R. Chapman, MD
CLIVUS
874Ecchordosis PhysaliphoraC. Douglas Phillips, MD, FACR
876Fossa Navicularis MagnaH. Ric Harnsberger, MD and Sara Strauss, MD
878Invasive Pituitary MacroadenomaC. Douglas Phillips, MD, FACR
880ChordomaHilda E. Stambuk, MD
SPHENOID BONE
884Persistent Craniopharyngeal CanalC. Douglas Phillips, MD, FACR
886Sphenoid Benign Fatty LesionC. Douglas Phillips, MD, FACR
887Central Skull Base Trigeminal Schwannoma
Daniel E. Meltzer, MD
OCCIPITAL BONE
888Hypoglossal Nerve Schwannoma
C. Douglas Phillips, MD, FACR
JUGULAR FORAMEN
890Jugular Bulb PseudolesionKaren L. Salzman, MD
892High Jugular BulbKaren L. Salzman, MD
894Dehiscent Jugular BulbH. Ric Harnsberger, MD and Sara Strauss, MD
896Jugular Bulb DiverticulumKaren L. Salzman, MD
898Glomus Jugulare Paraganglioma
Karen L. Salzman, MD and Kalen Riley, MD, MBA
902Jugular Foramen Schwannoma
Karen L. Salzman, MD
906Jugular Foramen Meningioma
Karen L. Salzman, MD
DURAL SINUSES
908Dural Sinus and Aberrant Arachnoid GranulationsSurjith Vattoth, MD, FRCR
912Skull Base Dural Sinus ThrombosisC. Douglas Phillips, MD, FACR
916Cavernous Sinus ThrombosisBernadette L. Koch, MD
918Dural Arteriovenous FistulaC. Douglas Phillips, MD, FACR
DIFFUSE OR MULTIFOCAL SKULL BASE
DISEASE
922Skull Base Cephalocele
Bernadette L. Koch, MD
926Skull Base CSF Leak
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
928Skull Base Fibrous Dysplasia
C. Douglas Phillips, MD, FACR
932Skull Base Paget Disease
C. Douglas Phillips, MD, FACR
934Skull Base Langerhans Cell Histiocytosis
C. Douglas Phillips, MD, FACR
938Skull Base Osteopetrosis
H. Ric Harnsberger, MD and Kathryn E. Dean, MD
940Skull Base Giant Cell Tumor
Daniel E. Meltzer, MD
942Skull Base Meningioma
Daniel E. Meltzer, MD
946Skull Base Plasmacytoma
Philip R. Chapman, MD
950Skull Base Multiple Myeloma
Philip R. Chapman, MD
952Skull Base Metastasis
Philip R. Chapman, MD
954Skull Base Chondrosarcoma
Philip R. Chapman, MD
958Skull Base Osteosarcoma
Philip R. Chapman, MD
960Skull Base Osteomyelitis
Philip R. Chapman, MD
SECTION 24: SKULL BASE, FACIAL, AND
TEMPORAL BONE TRAUMA
966Skull Base and Facial Trauma Overview
Kristine M. Mosier, DMD, PhD and Kathryn E. Dean, MD
SKULL BASE AND TEMPORAL BONE
970Temporal Bone FracturesDaniel E. Meltzer, MD
974Ossicular Dislocations and DisruptionsBernadette L. Koch, MD
976Skull Base TraumaKristine M. Mosier, DMD, PhD and Kathryn E. Dean, MD
FACIAL BONES
980Orbital Foreign BodyH. Christian Davidson, MD and Joshua E. Lantos, MD
982Orbital Blowout Fracture
Daniel E. Meltzer, MD
984Transfacial Fractures (Le Fort)
H. Christian Davidson, MD and Kathryn E. Dean, MD

xxii
TABLE OF CONTENTS
988Zygomaticomaxillary Complex Fracture
Blair A. Winegar, MD
990Complex Facial Fracture
Blair A. Winegar, MD
992Nasoorbitoethmoid (NOE) Fracture
Bernadette L. Koch, MD
994Mandible Fracture
Blair A. Winegar, MD
996TMJ Disc Displacement
Daniel E. Meltzer, MD
SECTION 25: TEMPORAL BONE
1000 Temporal Bone Overview
Karen L. Salzman, MD and Caroline D. Robson, MBChB
EXTERNAL AUDITORY CANAL
CONGENITAL LESIONS
1008 Foramen Tympanicum
Bernadette L. Koch, MD and H. Ric Harnsberger, MD
1010 Congenital External and Middle Ear Malformation
William T. O'Brien, Sr., DO, FAOCR, Caroline D. Robson,
MBChB, and H. Ric Harnsberger, MD
INFECTIOUS AND INFLAMMATORY
LESIONS
1014 Necrotizing External Otitis
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1016 Keratosis Obturans
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1018 Medial Canal Fibrosis
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1022 EAC-Acquired Cholesteatoma
Nicholas A. Koontz, MD
BENIGN AND MALIGNANT TUMORS
1024 EAC Osteoma
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1026 EAC Exostoses
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1028 EAC Skin Squamous Cell Carcinoma
Hilda E. Stambuk, MD
MIDDLE EAR-MASTOID
CONGENITAL LESIONS
1030 Congenital Middle Ear Cholesteatoma
William T. O'Brien, Sr., DO, FAOCR and H. Ric
Harnsberger, MD
1034 Congenital Mastoid Cholesteatoma
William T. O'Brien, Sr., DO, FAOCR and H. Ric
Harnsberger, MD
1036 Oval Window Atresia
William T. O'Brien, Sr., DO, FAOCR, Surjith Vattoth, MD,
FRCR, and H. Ric Harnsberger, MD
1038 Lateralized Internal Carotid Artery
Aparna Singhal, MD and Troy A. Hutchins, MD
1040 Aberrant Internal Carotid Artery
Karen L. Salzman, MD
1044 Persistent Stapedial Artery
H. Ric Harnsberger, MD and Philip R. Chapman, MD
INFECTIOUS AND INFLAMMATORY
LESIONS
1046 Coalescent Otomastoiditis With Complications
William T. O'Brien, Sr., DO, FAOCR, Caroline D. Robson,MBChB, and H. Ric Harnsberger, MD
1050 Chronic Otomastoiditis With Ossicular Erosions
Nicholas A. Koontz, MD
1052 Chronic Otomastoiditis With Tympanosclerosis
Nicholas A. Koontz, MD
1054 Pars Flaccida Cholesteatoma
Nicholas A. Koontz, MD
1058 Pars Tensa Cholesteatoma
Nicholas A. Koontz, MD
1062 Mural Cholesteatoma
Nicholas A. Koontz, MD
1064 Middle Ear Cholesterol Granuloma
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
BENIGN AND MALIGNANT TUMORS
1068 Glomus Tympanicum Paraganglioma
Richard H. Wiggins, III, MD, CIIP, FSIIM
1072 Temporal Bone Meningioma
Richard H. Wiggins, III, MD, CIIP, FSIIM
1076 Middle Ear Schwannoma
Richard H. Wiggins, III, MD, CIIP, FSIIM and Bronwyn E.
Hamilton, MD
1078 Middle Ear Adenoma
Richard H. Wiggins, III, MD, CIIP, FSIIM and Bronwyn E.
Hamilton, MD
1080 Temporal Bone Rhabdomyosarcoma
Hilda E. Stambuk, MD
MISCELLANEOUS
1084 Temporal Bone Cephalocele
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1086 Ossicular Prosthesis
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
INNER EAR
PSEUDOLESIONS
1090 Petromastoid Canal
H. Ric Harnsberger, MD and Joshua E. Lantos, MD
1092 Cochlear Cleft
Bernadette L. Koch, MD and Caroline D. Robson, MBChBCONGENITAL LESIONS
1094 Labyrinthine Aplasia
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Luke L. Linscott, MD
1096 Cochlear Aplasia
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Caroline D. Robson, MBChB

xxiii
TABLE OF CONTENTS
1098 Cochlear Hypoplasia
Bernadette L. Koch, MD and Surjith Vattoth, MD, FRCR
1100 Common Cavity Malformation
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Caroline D. Robson, MBChB
1102 Cystic Cochleovestibular Malformation (IP-I)
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Caroline D. Robson, MBChB
1104 Cochlear Incomplete Partition Type I (IP-I)
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
1106 Cochlear Incomplete Partition Type II (IP-II)
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
1108 Large Vestibular Aqueduct
Surjith Vattoth, MD, FRCR, William T. O'Brien, Sr., DO,
FAOCR, and Bernadette L. Koch, MD
1112 Cochlear Nerve and Cochlear Nerve Canal Aplasia-
Hypoplasia
Bernadette L. Koch, MD, Surjith Vattoth, MD, FRCR, and
Caroline D. Robson, MBChB
1114 Semicircular Canal Hypoplasia-Aplasia
Surjith Vattoth, MD, FRCR, William T. O'Brien, Sr., DO,
FAOCR, and Caroline D. Robson, MBChB
1118 Semicircular Canal-Vestibule Globular Anomaly
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
INFECTIOUS AND INFLAMMATORY
LESIONS
1120 Labyrinthitis
Bernadette L. Koch, MD and Troy A. Hutchins, MD
1122 Otosyphilis
Joshua E. Lantos, MD and Troy A. Hutchins, MD
1124 Labyrinthine Ossificans
Bernadette L. Koch, MD and Troy A. Hutchins, MD
1128 Otosclerosis
Bronwyn E. Hamilton, MD and Troy A. Hutchins, MD
1132 Temporal Bone Osteogenesis Imperfecta
Philip R. Chapman, MD and Troy A. Hutchins, MD
BENIGN AND MALIGNANT TUMORS
1134 Intralabyrinthine Schwannoma
Karen L. Salzman, MD
1138 Endolymphatic Sac Tumor
Hilda E. Stambuk, MD
MISCELLANEOUS
1140 Intralabyrinthine Hemorrhage
Philip R. Chapman, MD and Troy A. Hutchins, MD
1142 Semicircular Canal Dehiscence
Bronwyn E. Hamilton, MD and Troy A. Hutchins, MD
1144 Cochlear Implant
Bronwyn E. Hamilton, MD and Troy A. Hutchins, MD
PETROUS APEX
PSEUDOLESIONS
1148 Petrous Apex Asymmetric Marrow
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
1150 Petrous Apex Cephalocele
Aparna Singhal, MD and H. Ric Harnsberger, MD
CONGENITAL LESIONS
1152 Congenital Petrous Apex Cholesteatoma
Philip R. Chapman, MD
INFECTIOUS AND INFLAMMATORY
LESIONS
1156 Petrous Apex Trapped Fluid
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
1158 Petrous Apex Mucocele
Luke N. Ledbetter, MD and Jaclyn Thiessen, MD
1160 Petrous Apex Cholesterol Granuloma
Jaclyn Thiessen, MD and Luke N. Ledbetter, MD
1164 Apical Petrositis
Jaclyn Thiessen, MD
VASCULAR LESIONS
1168 Petrous Internal Carotid Artery Aneurysm
Philip R. Chapman, MD and H. Ric Harnsberger, MD
INTRATEMPORAL FACIAL NERVE
PSEUDOLESIONS
1170 Intratemporal Facial Nerve Enhancement
Philip R. Chapman, MD
1172 Middle Ear Prolapsing Facial Nerve
Philip R. Chapman, MD and H. Ric Harnsberger, MDINFECTIOUS AND INFLAMMATORY
LESIONS
1174 Bell Palsy
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
BENIGN AND MALIGNANT TUMORS
1178 Temporal Bone Facial Nerve Venous Malformation
(Hemangioma)
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
1182 Temporal Bone Facial Nerve Schwannoma
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
1186 Temporal Bone Perineural Parotid Malignancy
Hilda E. Stambuk, MD
TEMPORAL BONE, NO SPECIFIC ANATOMIC
LOCATION
1190 Temporal Bone CSF Leak
Surjith Vattoth, MD, FRCR and Patricia A. Hudgins, MD,
FACR
1192 Temporal Bone Arachnoid Granulations
H. Ric Harnsberger, MD and Philip R. Chapman, MD
1194 Temporal Bone Fibrous Dysplasia
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1196 Temporal Bone Paget Disease
Philip R. Chapman, MD
1198 Temporal Bone Langerhans Cell Histiocytosis
Richard H. Wiggins, III, MD, CIIP, FSIIM
1200 Temporal Bone Metastasis
Hilda E. Stambuk, MD
1202 Temporal Bone Osteoradionecrosis
Hilda E. Stambuk, MD

xxiv
TABLE OF CONTENTS
SECTION 26: CPA-IAC
INTRODUCTION AND OVERVIEW
1206 CPA-IAC Overview
Philip R. Chapman, MD and H. Ric Harnsberger, MD
CONGENITAL LESIONS
1210 CPA-IAC Epidermoid Cyst
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1214 CPA-IAC Arachnoid Cyst
H. Ric Harnsberger, MD and Philip R. Chapman, MD
1218 Lipoma in CPA-IAC
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1222 IAC Venous Malformation
Philip R. Chapman, MD and H. Ric Harnsberger, MD
INFECTIOUS AND INFLAMMATORY LESIONS
1224 CPA-IAC Meningitis
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1226 Ramsay Hunt Syndrome
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1228 CPA-IAC Neurosarcoid
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
BENIGN AND MALIGNANT TUMORS
1230 Vestibular Schwannoma
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1234 PHACE(S) Syndrome
Bernadette L. Koch, MD and Caroline D. Robson, MBChB
1236 CPA-IAC Meningioma
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
1240 CPA-IAC Facial Nerve Schwannoma
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
1242 CPA-IAC Metastases
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD
VASCULAR LESIONS
1246 Trigeminal Neuralgia
Philip R. Chapman, MD
1248 Hemifacial Spasm
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1250 CPA-IAC Aneurysm
Philip R. Chapman, MD and H. Ric Harnsberger, MD
1252 CPA-IAC Superficial Siderosis
Bronwyn E. Hamilton, MD and H. Ric Harnsberger, MD

This page intentionally left blank

FOURTH EDITION
Hamilton
|
Koch
Vattoth
|
Chapman

SECTION 1
Introduction and Overview of Suprahyoid
and Infrahyoid Neck
Suprahyoid and Infrahyoid Neck Overview
4

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
4
Suprahyoid and Infrahyoid Neck Overview
Imaging Approaches and Indications
Many indications exist for imaging the extracranial H&N.
Exploratory imaging, tumor staging, and abscess search
comprise 3 common reasons imaging is ordered in this area.
Global evaluation of the neck from the skull base to the
clavicles is most often accomplished using CECT. Axial images
can be rapidly obtained after IV iodinated contrast and
multiplanar reformations are created. This provides
reasonable spatial and contrast resolution.
MR is less readily accessible and used less often but is
especially useful in the suprahyoid neck (SHN) because it is less
affected by oral cavity dental amalgam artifact. Axial and
coronal T1 fat-saturated enhanced MR is superior to CECT in
defining the soft tissue extent of a tumor, perineural tumor
spread, marrow space invasion, and intracranial spread. When
MR is combined with bone CT of the facial bones and skull
base, precise preoperative lesion mapping results.
CECT is the modality of choice when infrahyoid neck (IHN) and
mediastinum are imaged. Swallowing, coughing, and
breathing make this area a "moving target" for the imager. MR
quality is often degraded as a result. Multislice CT with
multiplanar reformations now permits exquisite images of the
IHN unaffected by movement.
High-resolution ultrasound also has a role. Superficial lesions,
thyroid disease, and nodal evaluation with biopsy are best
done by skilled ultrasonographers.
Squamous cell carcinoma (SCCa) staging is best started with
CECT, as both the primary tumor and nodes must be imaged,
requiring imaging from the skull base to clavicles. MR imaging
times and susceptibility to motion artifact make it a less
desirable exam in this setting. Instead, MR is best used when
specific delineation of exact tumor extent, perineural tumor,
or intracranial invasion is needed. PET/CT is emerging as a
useful adjunctive test in complex tumor detection and
monitoring.
When the type and cause of H&N infection are sought, CECT is
the best exam. CECT can readily differentiate cellulitis,
phlegmon, and abscess. CT can also identify salivary gland
ductal calculi, teeth infection, mandible osteomyelitis, and
intratonsillar abscess as causes of infection.
Imaging Anatomy
In discussing the extracranial H&N soft tissues, a few
definitions are needed. The SHN is defined as deep facial
spaces above the hyoid bone, including parapharyngeal
space (PPS), pharyngeal mucosal space (PMS), masticator
space (MS), parotid space (PS), carotid space (CS),
retropharyngeal space (RPS), danger space (DS), and
perivertebral (PVS) space. The IHN soft tissue spaces are
predominantly below the hyoid bone, with some continuing
inferiorly into the mediastinum or superiorly into the SHN,
including the visceral space (VS), posterior cervical space (PCS),
CS, RPS, and PVS.
Important SHN space anatomic relationships include their
interactions with the skull base, oral cavity, and IHN. When one
thinks about the SHN spaces and their relationships with the
skull base, perhaps the most important consideration is to
examine each space alone to see what critical structures
(cranial nerves, arteries, veins) are at the point of contact
between the space and the skull base. Space by space, the
skull base interactions above and IHN extension below are
apparent.
•PPS has bland triangular skull base abutment without
critical foramen involved; it empties inferiorly into
submandibular space (SMS)
•PMS touches posterior basisphenoid and anterior
basiocciput, including foramen lacerum; PMS includes
nasopharyngeal, oropharyngeal, and hypopharyngeal
mucosal surfaces
•MS superior skull base interaction includes zygomatic
arch, condylar fossa, skull base, including foramen ovale
(CNV3), and foramen spinosum (middle meningeal
artery); MS ends at inferior surface of body of mandible
•PS abuts floor of external auditory canal, mastoid tip,
including stylomastoid foramen (CNVII); parotid tail
extends inferiorly into posterior SMS
•CS meets jugular foramen (CNIX-XI) floor, hypoglossal
canal (CNXII), and petrous internal carotid artery canal;
CS can be followed inferiorly to aortic arch
•RPS contacts skull base along lower clivus without
involvement of critical structures; it continues inferiorly
to empty into DS at T3 level
•PVS touches low clivus and encircles occipital condyles
and foramen magnum; PVS continues inferiorly to level
into thorax
In addition to skull base interactions, the relationships of the
SHN spaces to the fat-filled PPSs are key to analyzing SHN
masses. The PPSs are a pair of fat-filled spaces in the lateral
SHN surrounded by the PMS, MS, PS, CS, and RPS. When a
mass enlarges in one of these spaces, it displaces the PPS fat.
Larger masses define their space of origin based on this
displacement pattern.
• Medial PMS mass displaces PPS laterally
• More anterior MS mass displaces PPS posteriorly
• Lateral PS mass displaces PPS medially
• Posterolateral CS mass displaces styloid process and PPS
anteriorly
• More posteromedial lateral RPS nodal mass displaces
PPS anterolaterally
The IHN space anatomic relationships are defined by their
superior and inferior projections. The VS has no SHN
component, instead projecting only inferiorly into the superior
mediastinum. The PCS extends superiorly to the mastoid tip
and ends inferiorly at the clavicle. It is predominantly an IHN
space, however. The CS begins at the floor of the jugular
foramen and carotid canal and extends inferiorly to the aortic
arch. The RPS begins at the ventral clivus superiorly and
traverses SHN-IHN to the T3 level. The DS is immediately
posterior to the RPS but continues beyond the T3 level into
the mediastinum. For imaging purposes, RPS and DS can be
considered a single entity. The PVS can be defined from the
skull base above to the clavicle below. The PVS is divided by
fascial slip into prevertebral and paraspinal components.
The deep cervical fasciae (DCF) of the neck subdivide and
define the spaces we use radiologically to construct space-
specific DDx lists and evaluate disease of the neck. It is
imperative that a clear understanding of these fasciae be
grasped by any imager involved in evaluating this area.
Many nomenclatures have been used to describe the neck
fasciae. The following is a practical distillate meant to simplify
this challenging subject. There are 3 main DCF in the neck. The
same names are used in the SHN and IHN. The superficial layer

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
5
Suprahyoid and Infrahyoid Neck Overview
Common Tumors in Spaces of the Neck
Pharyngeal mucosal space Warthin tumor Posterior cervical space
Pharyngeal SCCa Carotid space Pharyngeal SCCa nodal metastasis
Tonsillar NHL Glomus vagale paraganglioma NHL nodal disease
Masticator space Carotid body paraganglioma Differentiated thyroid carcinoma nodes
Sarcoma Schwannoma of CNIX-XII Visceral space
Perineural CNV3 SCCa Retropharyngeal space Differentiated thyroid carcinoma
Parotid space SCCa nodal metastasis Anaplastic thyroid carcinoma
Mucoepidermoid carcinoma NHL nodal disease Thyroid NHL
Adenoid cystic carcinoma Perivertebral space Cervical esophageal carcinoma
Malignant nodal metastases Vertebral body systemic metastasis Parathyroid adenoma
Benign mixed tumor Brachial plexus schwannoma
SCCa = squamous cell carcinoma; NHL = non-Hodgkin lymphoma.
(SL-DCF), the middle layer (ML-DCF), and the deep layer of
DCF (DL-DCF) are the 3 important fasciae in the neck.
In the SHN, the SL-DCF circumscribes MS and PS and
contributes to the carotid sheath. In the IHN, it "invests" the
neck by surrounding the infrahyoid strap,
sternocleidomastoid, and trapezius muscles. It also
contributes to the carotid sheath of the CS in the IHN.
The ML-DCF in the SHN defines the deep margin of the PMS.
It contributes to carotid sheath in both the SHN and IHN. In
the IHN, it also circumscribes the VS.
In both the SHN and IHN, the DL-DCF surrounds PVS. A slip of
DL-DCF dives medially to the transverse process, dividing the
PVS into prevertebral and paraspinal components. Another
slip of DL-DCF, the alar fascia, provides the lateral wall to the
RPS and DS, as well as the posterior wall to the RPS,
separating the RPS from the DS. DL-DCF contributes to the
carotid sheath, like the SL-DCF and ML-DCF.
The internal structures of the spaces of the neck are for the
most part responsible for the diseases there. Let us begin by
defining the critical contents of the SHN spaces.
•PPS contains fat with rare minor salivary glands
•PMS contains mucosa, lymphatic ring, and minor salivary
glands; in nasopharyngeal mucosal space, opening of
eustachian tube, torus tubarius, adenoids, superior
constrictor, and levator palatini muscles can be seen;
oropharyngeal mucosal space contains anterior and
posterior tonsillar pillars and palatine and lingual tonsils
•MS includes posterior mandibular body and ramus, TMJ,
CNV3, masseter, medial and lateral pterygoid and
temporalis muscles, and pterygoid venous plexus
•PS houses parotid, extracranial CNVII, nodes,
retromandibular vein, and external carotid artery
•CS contains CNIX-XII, internal jugular vein, and internal
carotid artery
•RPS has fat and medial and lateral RPS nodes inside
• Prevertebral PVS contains vertebral body, veins, arteries,
and prevertebral muscles (longus colli and capitis); in
paraspinal PVS reside posterior elements of vertebra and
paraspinal muscles
The critical contents of IHN spaces are defined next.
•VS contains thyroid and parathyroid glands, trachea,
esophagus, recurrent laryngeal nerves, and pretracheal
and paratracheal nodes
•PCS has fat, CNXI, and level V nodes inside
•CS houses common carotid artery, internal jugular vein,
and CNX
•IHN RPS has no nodes and contains only fat
• Prevertebral PVS has brachial plexus and phrenic nerve,
vertebral body, veins, arteries, and prevertebral and
scalene muscles within; paraspinal PVS contains only
posterior vertebra elements and paraspinal muscles
Approaches to Imaging Issues in SHN and IHN
It is crucial that the imager has a method of analysis when a
mass is found in the neck. In the SHN, mass evaluation
methodology begins with defining mass space of origin (PMS,
MS, PS, CS, lateral RPS). When small, this is simple, as the mass
is seen within the confines of 1 space. In larger masses, ask,
"How does the mass displace the PPS?" Next, utilize a space-
specific DDx list. Match the imaging findings to the diagnoses
within this list to narrow your differential.
With IHN masses, a similar evaluation methodology can be
employed. First, determine what space the mass originates in
(VS, CS, PCS). Then, review the space-specific DDx list. Match
radiologic findings of your case to this DDx list. In all neck
masses, knowing the clinical findings can be very helpful.
Lesions of posterior midline spaces (RPS and PVS) of the neck
need different image evaluation. When a lesion is defined
here, first ask, "How does the mass displace prevertebral
muscles (PVM)?" In the case of an RPS mass, PVMs are
flattened posteriorly or invaded from anterior to posterior.
Contrast this imaging appearance to that of the PVS mass in
which the PVMs are lifted anteriorly or invaded from posterior
to anterior. Since most PVS lesions arise from the vertebral
body, vertebral body destruction and epidural disease will be
linked. The DL-DCF "forces" PVS disease into the epidural
space.
Selected References
1.Ferguson A et al: Analysis of misses in imaging of head and neck pathology
by attending neuroradiologists at a single tertiary academic medical centre.
Clin Radiol. ePub, 2021
2.Kitamura S: Anatomy of the fasciae and fascial spaces of the maxillofacial
and the anterior neck regions. Anat Sci Int. 93(1):1-13, 2018

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
6
Suprahyoid and Infrahyoid Neck Overview
(Top) Axial graphic depicts the spaces of the suprahyoid neck. Surrounding the paired fat-filled parapharyngeal spaces (PPSs) are the 4
critical paired spaces of this region, the pharyngeal mucosal (PMS), masticator (MS), parotid (PS), and carotid spaces (CS).
Retropharyngeal (RPS) and perivertebral spaces (PVS) are the midline nonpaired spaces. A PMS mass pushes the PPS laterally, an MS
mass pushes the PPS posteriorly, a PS mass pushes the PPS medially, and a CS mass pushes the PPS anteriorly. Lateral RPS mass pushes
PPS anteriorly without lifting styloid process. The superficial (yellow line), middle (pink line), and deep (turquoise line) layers of deep
cervical fascia outline the spaces. (Bottom) Axial CECT at the level of the nasopharyngeal suprahyoid neck shows the 4 key spaces
surrounding the PPS: The PMS, MS, PS, and CS. Notice the retropharyngeal fat stripe is not seen in the high nasopharynx between the
prevertebral muscles and the pharyngeal mucosal surface.
Deep layer, deep cervical
fascia
Middle layer, deep cervical
fascia
Superficial layer, deep cervical
fascia
Buccal space, retromaxillary
fat pad
Perivertebral space, paraspinal
component
Perivertebral space,
prevertebral component
Retropharyngeal space
Carotid space
Parapharyngeal space
Pharyngeal mucosal
space/surface
Parotid space
Masticator space
Internal carotid artery
Internal jugular vein
Lateral pterygoid muscle
Temporalis muscle
Masseter muscle
Styloid process
Pharyngeal mucosal
space/surface
Retromaxillary fat pad (buccal
space)
Carotid space
Parapharyngeal space
Parotid space
Masticator space

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
7
Suprahyoid and Infrahyoid Neck Overview
(Top) Axial graphic shows the suprahyoid neck spaces at the level of the oropharynx. The superficial (yellow line), middle (pink line), and
deep (turquoise line) layers of deep cervical fascia outline the suprahyoid neck spaces. Notice that the lateral borders of the RPS and
danger spaces are called the alar fascia, which represents a slip of the deep layer of deep cervical fascia. The CS has a tricolored fascial
representation for the carotid sheath. This is because all 3 layers of deep cervical fascia contribute to the carotid sheath. (Bottom) In
this image, through the low oropharynx, the PMS and the PVS have been outlined. The space between them is the RPS. The alar fascia
that makes up the lateral borders of the RPS is not shown.
Submandibular space
Superficial layer, deep cervical
fascia
Alar fascia
Deep layer, deep cervical
fascia
Perivertebral space, paraspinal
component
Perivertebral space,
prevertebral component
Danger space
Retropharyngeal space
Pharyngeal mucosal
space/surface
Middle layer, deep cervical
fascia
Posterior cervical space
Posterior belly, digastric
muscle
Parapharyngeal space
Carotid space
Parotid space
Masticator space
Submandibular gland
Pharyngeal mucosal space
Platysma muscle
Trapezius muscle
Sternocleidomastoid muscle
Retropharyngeal/danger
space
Jugulodigastric node
Parotid space (tail)
Posterior cervical space
Prevertebral component,
perivertebral space
Paraspinal component,
perivertebral space
Perivertebral space

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
8
Suprahyoid and Infrahyoid Neck Overview
(Top) Axial graphic depicts the fascia and spaces of the infrahyoid neck. The 3 layers of deep cervical fascia are present in the
suprahyoid and infrahyoid neck. The carotid sheath is made up of all 3 layers of deep cervical fascia (tricolor line around CS). Notice that
the deep layer (turquoise line) completely circles the PVS, diving in laterally to divide it into prevertebral and paraspinal components.
The middle layer (pink line) circumscribes the visceral space, while the superficial layer (yellow line) "invests" the neck deep tissues.
(Bottom) In this axial CECT, the middle layer of deep cervical fascia is drawn to delineate the margins of the visceral space. The visceral
space contains the high-density thyroid gland, the upper cervical esophagus, and the cricoid cartilage. The CSs are lateral to the visceral
space, while the RPS and PVS are posterior.
Deep layer, deep cervical
fascia touches transverse
process
Perivertebral space, paraspinal
component
Perivertebral space,
prevertebral component
Danger space
Retropharyngeal space
Anterior cervical space
Visceral space
Middle layer, deep cervical
fascia
Carotid sheath
Deep layer, deep cervical
fascia
Superficial layer, deep cervical
fascia
Carotid space
Posterior cervical space
Cricoid cartilage
Esophagus
Trapezius muscle
Levator scapulae muscle
Middle scalene muscle
Anterior scalene muscle
Sternocleidomastoid muscle
Platysma muscle
External jugular vein
Thyroid gland
Posterior cervical space
Paraspinal component,
perivertebral space
Prevertebral component,
perivertebral space
Carotid space
Anterior cervical space
Visceral space

Introduction and Overview of Suprahyoid and
Infrahyoid Neck
9
Suprahyoid and Infrahyoid Neck Overview
(Top) Coronal graphic shows suprahyoid neck spaces as they interact with the skull base. The MS has the largest area of abutment with
the skull base, including CNV3. The PMS abuts the basisphenoid and foramen lacerum. The foramen lacerum is the cartilage-covered
floor of the anteromedial petrous internal carotid artery (ICA) canal. (Bottom) Sagittal graphic depicts longitudinal spatial relationships
of the infrahyoid neck. Anteriorly, the visceral space is seen surrounded by the middle layer of deep cervical fascia (pink line). Just
anterior to the vertebral column, the RPS and danger space run inferiorly toward the mediastinum. Notice the fascial "trap door" found
at the approximate level of T3 vertebral body that serves as a conduit from the RPS to the danger space. RPS infection or tumor may
access the mediastinum via this route of spread.
Anteromedial tip, petrous
internal carotid artery
Basisphenoid
Foramen lacerum
Zygomatic arch
Sublingual space
Oropharyngeal mucosal space
Nasopharyngeal mucosal
space
Middle layer, deep cervical
fascia
Submandibular space
Superficial layer, deep cervical
fascia
CNV3 in foramen ovale
Parapharyngeal space
Infrazygomatic masticator
space
Suprazygomatic masticator
space
Anterior parotid space
Submandibular space
Visceral space
Hyoid bone
Superficial layer, deep cervical
fascia
Middle layer, deep cervical
fascia
Trachea
Esophagus
Retropharyngeal space
Danger space
Perivertebral space, paraspinal
component
T3 vertebral body
Fascial "trap door"
Deep layer, deep cervical
fascia
Perivertebral space,
prevertebral component

Parapharyngeal Space Overview 12
Benign Tumors
Parapharyngeal Space Benign Mixed Tumor 14

SECTION 2
Parapharyngeal Space

Parapharyngeal Space
12
Parapharyngeal Space Overview
Summary Thoughts: Parapharyngeal Space
The parapharyngeal space (PPS) is an important radiologic
landmark in the suprahyoid neck (SHN). It is predominantly fat-
filled, which makes it easily identifiable on CT and MR. The PPS
is surrounded by 4 key spaces in the SHN, all of which can give
rise to pathologic lesions. When a large lesion affects the SHN,
it may displace the PPS fat away from the space of origin.
Therefore, the displacement of PPS becomes a useful
secondary clue to identifying the space of origin of the lesion.
Once a space of origin is assigned, the space-specific
differential diagnosis can be applied to narrow the diagnostic
possibilities.
Imaging Anatomy
The PPSs are paired, central, fat-filled spaces in the lateral SHN
around which most of the important spaces are located. These
surrounding important spaces are the pharyngeal mucosal
space (PMS), masticator space (MS), parotid space (PS), carotid
space (CS), and the retropharyngeal space (RPS). The PPS
contents are limited; therefore, few lesions actually occur in
this space. Diseases (tumor and infection) of the PPS usually
arise in the adjacent spaces (PMS, MS, PS, CS) and spread
secondarily into PPS.
The importance of the fat-filled PPS is its conspicuity on CT
and MR. Even when large lesions are present in the SHN, it is
still usually possible to find the PPS. Identifying the direction
of displacement of the PPS by a mass lesion from a
surrounding space can be a key finding in determining its
space of origin. The PPS displacement direction defines the
space of the primary lesion.
• PMS mass lesion pushes PPS laterally
• MS mass lesion pushes PPS posteriorly
• PS mass lesion pushes PPS medially
• CS mass lesion pushes PPS anteriorly
• Lateral RPS mass (nodal) pushes PPS anterolaterally
The PPS is a crescent-shaped, fat-filled space extending in
craniocaudal dimension from the skull base superiorly to the
superior cornu of hyoid bone inferiorly. As paired, fatty tubes
separating other SHN spaces from one another, the PPS
serves as a corridor through which infection and tumor from
these adjacent spaces can extend to other spaces both
vertically and transversely.
The PPS has multiple important anatomic relationships with
surrounding spaces. As there is no fascia separating the
inferior PPS from the submandibular space (SMS), open
communication between the PPS and posterior SMS exists.
Since the PPS empties inferiorly into the SMS, PPS infection or
malignancy spread inferiorly from the upper SHN to present
as an angle of the mandible mass. Superiorly, the PPS interacts
with the skull base in the bland triangular area on the inferior
surface of the petrous apex. No exiting skull base foramina are
found in this area of attachment. In the axial plane, the PMS is
medial, the MS anterior, the PS lateral, the CS posterior, and
the lateral RPS posteromedial to the PPS.
The PPS has limited internal contents aside from conspicuous
fat. There are no mucosa, muscle, bone, nodes, or major
salivary gland tissue within the PPS boundaries. Minor salivary
glands can be found there but are considered ectopic and
relatively rare. While most of the pterygoid venous plexus is
found in the deep portion of the MS, a part of the plexus can
extend to the PPS. The PPS contains no significant lymph
nodes, and metastatic disease to PPS is highly unusual.
The fascia surrounding the PPS is complex. Different layers of
the deep cervical fascia combine to circumscribe the PPS. The
medial fascial margin of the PPS is made up of the middle
layer of the deep cervical fascia as it curves around the lateral
margin of PMS. The lateral fascial margin of the PPS is
comprised of the medial slip of the superficial layer of deep
cervical fascia along the deep border of the MS and PS. The
posterior fascial margin of the PPS is formed by the deep layer
of the deep cervical fascia on the anterolateral margin of the
RPS and the anterior part of the carotid sheath (made up of
components of all 3 layers of deep cervical fascia).
Approaches to Imaging Issues of
Parapharyngeal Space
When you discover a lesion in the PPS on CT or MR, answer
the following question first: "Is this lesion really primary to the
PPS?" This question needs to be answered because there are
so few things that actually originate from the PPS. In fact, the
vast majority of lesions of the PPS arise in an adjacent space
and spread secondarily into the PPS. To conclude that a lesion
is primary to the PPS, it must be completely surrounded by
PPS fat. In most cases in which a lesion is thought to be
primary to the PPS, careful observation will find a connection
to one of the surrounding spaces.
Lesions that are primary to the PPS itself include an atypical
2nd branchial cleft cyst and a benign mixed tumor and lipoma.
All are rare. Far more common lesions can be seen spreading
into the PPS, such as an abscess or invasive squamous cell
carcinoma of the nasopharynx and oropharyngeal palatine
tonsil. When a large primary parotid neoplasm of the deep
lobe extends medially into the PPS, it may at first glance
appear to be primary to the PPS. Careful inspection will reveal
a connection to the deep lobe of the parotid in the vast
majority of cases.
Differential Diagnosis
DDx of PPS lesion includes
• Congenital: Atypical 2nd branchial cleft cyst, lymphatic
malformation, venous malformation
• Inflammatory: Large diving ranula spreading from SMS
into PPS
• Infection: Spreading from PMS, MS, PS, or RPS; most
commonly peritonsillar abscess from palatine tonsil
(PMS) involves PPS
• Benign tumor: Lipoma, benign mixed tumor (from minor
salivary gland rest in PPS)
• Malignant tumor: Spreading from PMS, MS, PS or RPS
into PPS; most commonly squamous cell carcinoma
spreading from naso- or oropharynx (PMS) into PPS
Selected References
1.Huang W et al: MRI of nasopharyngeal carcinoma: parapharyngeal subspace
involvement has prognostic value and influences T-staging in the IMRT era.
Eur Radiol. ePub, 2021
2.Larson AR et al: Transoral excision of parapharyngeal space tumors.
Otolaryngol Clin North Am. 54(3):531-41, 2021
3.Mendenhall WM et al: Radiotherapy for parapharyngeal space tumors. Am J
Otolaryngol. 40(2):289-91, 2019
4.Sun F et al: Surgical management of primary parapharyngeal space tumors in
103 patients at a single institution. Acta Otolaryngol. 138(1):85-9, 2018
5.Paderno A et al: Recent advances in surgical management of parapharyngealspace tumors. Curr Opin Otolaryngol Head Neck Surg. 23(2):83-90, 2015
6.Stambuk HE et al: Imaging of the parapharyngeal space. Otolaryngol ClinNorth Am. 41(1):77-101, vi, 2008

Parapharyngeal Space
13
Parapharyngeal Space Overview
(Top) Axial graphic of the normal parapharyngeal space at the level of the nasopharynx demonstrates the complex fascial margins and
the fat-only contents. Mass lesions originating in the surrounding pharyngeal mucosal, masticator, parotid, and carotid spaces can
extend into the parapharyngeal space. The resulting displacement pattern of the parapharyngeal space may be helpful in defining the
space of origin of a mass in the suprahyoid neck. (Bottom) Coronal graphic shows suprahyoid neck spaces as they interact with the skull
base superiorly and submandibular space inferiorly. The parapharyngeal space interacts with no critical structures as it abuts the skull
base. Inferiorly it empties into the posterior submandibular space along the posterior margin of the mylohyoid muscle. As a
consequence of this anatomic arrangement, it is possible for an infection or a malignant tumor that breaks into the parapharyngeal
space to present inferiorly as an angle of a mandible mass.
Tricolor carotid sheath
Deep layer, deep cervical
fascia
Superficial layer, deep cervical
fascia
Middle layer, deep cervical
fascia
Perivertebral space
Retropharyngeal space
Carotid space
Pharyngeal mucosal
space/surface
Parotid space
Masticator space
Parapharyngeal space
Mylohyoid muscle
Basisphenoid
CNV3 in foramen ovale
Superficial layer, deep cervical
fascia
Oropharyngeal mucosal space
Nasopharyngeal mucosal
space
Middle layer, deep cervical
fascia
Anterior parotid space
Parapharyngeal space
Submandibular space
Infrazygomatic masticator
space

Parapharyngeal Space
14
Parapharyngeal Space Benign Mixed Tumor
KEY FACTS
TERMINOLOGY
• Synonyms: Pleomorphic adenoma
IMAGING
• Precontrast T1 MR without fat suppression best to identify
fat-filled parapharyngeal space (PPS) and identify
boundaries
• Rounded, well-defined lesion within PPS fat
○ Distinct from parotid deep lobe
• Well-defined, rounded lesion when small
• More lobulated when larger
• Marked T2 hyperintensity similar to CSF
TOP DIFFERENTIAL DIAGNOSES
• Benign mixed tumor, parotid deep lobe
• Neurogenic tumor, PPS
• Pterygoid venous plexus asymmetry
• 2nd branchial cleft cyst
PATHOLOGY
• Benign tumor arising in aberrant salivary gland rests
• Solid but often heterogeneous with hemorrhage, cystic
degeneration, or necrosis
• Occasional ossific or calcific degeneration
CLINICAL ISSUES
• Most asymptomatic, or minimally so, because of deep
location and slow growth
• Small lesion, usually incidental imaging finding
• Larger lesion may be found at dental/oral exam
DIAGNOSTIC CHECKLIST
• Primary PPS lesions are uncommon
• MR: T2 signal similar to CSF but solidly enhances
• Look for fat plane to distinguish from parotid deep lobe
benign mixed tumor
(Left) Axial CECT
demonstrates a well-defined,
slightly lobulated mass ﬅ
within the left parapharyngeal
space (PPS). The mass is
completely surrounded by fat,
separating it from the
pharyngeal mucosal space
medially, parotid deep lobe
laterally ﬆ, and carotid space
posteriorly. (Right) Axial CECT
at PPS level in a 70-year-old
woman shows an incidental,
well-circumscribed lesion ﬅ
that abuts deep parotid lobe
but is otherwise surrounded by
PPS fat ﬆ. Transfacial biopsy
confirmed the presence of a
benign mixed tumor.
(Left) Axial T1WI MR reveals awell-defined mass within theright deep face ﬅ, completelysurrounded by parapharyngealfat. Note the mass is distinctfrom the medial aspect of theright parotid deep lobe ﬆ.(Right) Axial T2WI FS MRshows homogeneoushyperintensity of a slightlylobulated mass ﬅ.Hyperintensity similar to CSF istypically seen with benignmixed tumors, althoughpostcontrast images confirm itto be a solid mass.

Parapharyngeal Space
15
Parapharyngeal Space Benign Mixed Tumor
TERMINOLOGY
Abbreviations
• Parapharyngeal space (PPS) benign mixed tumor (BMT)
Synonyms
• Pleomorphic adenoma
Definitions
• Benign tumor arising from aberrant minor salivary gland
rests in PPS
IMAGING
General Features• Best diagnostic clue
○ Rounded, well-defined lesion within PPS fat
– Distinct from parotid deep lobe
• Location
○ Within parapharyngeal fat of deep face
• Size
○ Variable: 1-8 cm
○ If large, often indistinguishable from deep parotid tumor
• Morphology
○ Well-defined, rounded lesion when small
○ More lobulated with increasing size
Imaging Recommendations
• Best imaging tool
○ Readily seen on CT or MR; MR allows improved
delineation from adjacent structures
– Parotid deep lobe, internal carotid artery (ICA)
• Protocol advice
○ T1 MR best to delineate fat of PPS and identify
boundaries
CT Findings
• CECT
○ Heterogeneous, well-defined mass within PPS fat
○ Occasional focal ossification or calcification
MR Findings
• T1WI
○ Well-circumscribed, rounded lesion within PPS fat
• T2WI FS
○ Marked hyperintensity due to myxoid stroma, can be
similar to CSF in signal
• DWI
○ Higher ADC values reflect more myxoid stroma
• T1WI C+ FS
○ Heterogeneous enhancement, especially when large
DIFFERENTIAL DIAGNOSIS
Benign Mixed Tumor, Parotid Deep Lobe
• Identical appearance but within parotid deep lobe
Pterygoid Venous Plexus Asymmetry
• Tubular enhancing structures in PPS or medial masticator
space
Neurogenic Tumor, PPS
• Well-defined, oval mass, intermediate T2
• Typically within carotid space (displacing ICA anteriorly) vs.
BMT-PPS ventral to styloid
2nd Branchial Cleft Cyst
• Type IV branchial cleft cyst lies within PPS
• Cystic mass abutting lateral pharyngeal wall
PATHOLOGY
General Features
• Etiology
○ Benign tumor arising in aberrant salivary gland rests
Gross Pathologic & Surgical Features
• Solid but often heterogeneous with hemorrhage, cystic
degeneration, or necrosis
• Occasional ossific or calcific degeneration
Microscopic Features
• As name implies, morphologically diverse
○ Epithelial and myoepithelial cells, mesenchymal or
stromal elements
CLINICAL ISSUES
Presentation• Most common signs/symptoms
○ Most asymptomatic with deep location and slow growth
– Small lesion, usually incidental imaging finding
– Large lesion may be found at dental/oral exam
○ Large mass often has minimal symptoms
– Painless oral swelling or dysphagia
Demographics
• Age
○ Adults; peak in 5th decade
• Sex
○ Slight female predominance
Natural History & Prognosis
• Slow growing; may be asymptomatic even when large
• Uncommonly degenerates to malignant mixed tumor
(carcinoma ex pleomorphic adenoma)
Treatment
• Resection for definitive pathology or if symptomatic
• Operative tumor cell spillage may result in recurrence
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Primary PPS lesions are uncommon
○ Should be entirely surrounded by fat
• Look for fat at posterolateral margin to distinguish BMT of
PPS from parotid deep lobe lesion
SELECTED REFERENCES
1.Bulut OC et al: Primary neoplasms of the parapharyngeal space: diagnostic
and therapeutic pearls and pitfalls. Eur Arch Otorhinolaryngol. ePub, 2021
2.Kuet ML et al: Management of tumors arising from the parapharyngeal
space: a systematic review of 1,293 cases reported over 25 years.
Laryngoscope. 125(6):1372-81, 2015
3.Riffat F et al: A systematic review of 1143 parapharyngeal space tumors
reported over 20 years. Oral Oncol. 50(5):421-30, 2014

SECTION 3
Pharyngeal Mucosal Space
Pharyngeal Mucosal Space Overview 18
Congenital Lesions
Tornwaldt Cyst 22
Infectious and Inflammatory Lesions
Retention Cyst of Pharyngeal Mucosal Space 24
Tonsillar Inflammation 26
Tonsillar/Peritonsillar Abscess 28
Benign and Malignant Tumors
Benign Mixed Tumor of Pharyngeal Mucosal Space 30
Minor Salivary Gland Malignancy of Pharyngeal Mucosal Space 32
Non-Hodgkin Lymphoma of Pharyngeal Mucosal Space 34

Pharyngeal Mucosal Space
18
Pharyngeal Mucosal Space Overview
Summary Thoughts: Pharyngeal Mucosal Space
The pharyngeal mucosal space (PMS) is a key conceptual
"space" that represents the mucosal surface and superficial
elements of nasopharynx, oropharynx, and hypopharynx.
Important PMS contents include the mucosa itself,
lymphoepithelial tissue of Waldeyer ring, minor salivary
glands, and the pharyngeal muscle layer.
An enlarging PMS mass of the palatine tonsil or
nasopharyngeal lateral pharyngeal recess displaces the
parapharyngeal space (PPS) fat laterally. Disruption of the
mucosal and submucosal landmarks also occurs in PMS
masses.
Important PMS malignancies include squamous cell
carcinoma (SCCa) arising from the mucosal surface, non-
Hodgkin lymphoma (NHL) from the pharyngeal lymphatic
ring, and minor salivary gland carcinoma. Of these, SCCa is by
far the most frequent and the most important. Staging of
SCCa primary and nodal disease is one of the most common
reasons for imaging studies in the head and neck.
The PMS is not a true space, as it is not enclosed on all sides by
fascia. It is an imaging concept to overcome the problems
encountered in describing a lesion of the pharynx as
nasopharyngeal, oropharyngeal, and hypopharyngeal. These
terms, although universally applied to lesions of the PMS
surface, do not address the deep tissue component of an
invasive PMS mass. Describing a lesion as primary to the PMS
with extension into the adjacent suprahyoid neck spaces
clearly delineates lesion extent in a radiologic report.
Imaging Techniques & Indications
CECT remains the workhorse for imaging lesions of PMS in a
routine radiologic practice. On CECT, neoplasms may present
as mucosal thickening or asymmetry, an exophytic mass, an
invasive lesion that penetrates the mucosa and muscular layer
to enter an adjacent space, or a combination of these findings.
Enhanced fat-saturated multiplanar MR can exquisitely
demonstrate tumor extent and is useful in some cases when
dental amalgam artifact limits CECT or when finer detail is
warranted, such as in the search for perineural tumor spread.
CE-PET is advocated in some cases in which routine imaging is
equivocal.
Imaging Anatomy
The anatomic relationships of the PMS and surrounding
deep tissue anatomy are extremely important because both
PMS malignancy and infection readily spread into these
adjacent areas. Directly posterior to the PMS is the
retropharyngeal space (RPS). The PPS is lateral to the PMS.
Superiorly, the PMS abuts the skull base along the roof and
posterosuperior portion of the nasopharynx. This broad
abutment with the skull base includes the posterior
basisphenoid (sphenoid sinus floor) and the anterior
basiocciput (anterior clival margin). The foramen lacerum
[cartilaginous floor of the anteromedial petrous internal
carotid artery (ICA) canal] is a key area of abutment of the PMS
with the skull base. Nasopharyngeal carcinoma (NPCa) can
invade the cartilage of the foramen lacerum and extend
intracranially along the ICA and into the cavernous sinus.
The PMS extends from the roof of the nasopharynx above to
the hypopharynx below as a continuous superficial sheet that
includes the mucosa itself. The PMS mucosal space/surface is
subdivided into nasopharyngeal, oropharyngeal, and
hypopharyngeal components.
The PMS is a space with fascia on each deep margin but no
superficial fascia. With no fascia on the surface of the PMS, it is
not a true fascia-enclosed space. In fact, it represents a
conceptual construct to complete the spatial map of the
suprahyoid and infrahyoid neck. The PMS is often synonymous
with the pharyngeal mucosa itself. However, remember that
the pharyngeal mucosa is a microscopic layer that cannot be
distinguished radiologically. In general, a soft tissue lesion of
the mucosa identified on CT or MR is not readily
distinguishable from the deeper muscle layer of the PMS.
Therefore, in this imaging construct, the PMS internal
structures include the mucosa, lymphatic ring (of Waldeyer),
microscopic minor salivary glands, and the muscular layer.
The middle layer of deep cervical fascia (ML-DCF) defines
the deep margin of the PMS. Just below the skull base, the
ML-DCF encircles the lateral and posterior margins of the
pharyngobasilar fascia that connects the superior constrictor
muscle to the skull base. More inferiorly, the ML-DCF resides
on the deep margin of the superior, middle, and inferior
constrictor muscles.
The pharyngeal lymphatic ring is divided into 3 components:
The nasopharyngeal adenoids and the oropharyngeal
palatine and lingual tonsils (base of tongue). The lymphatic
tissue normally declines in volume with age. Microscopic
minor salivary glands are found in the submucosa and lamina
propria throughout the PMS with the highest concentrations
found in the tongue base and palate.
The nasopharyngeal mucosal space also contains the superior
constrictor muscle and the pharyngobasilar fascia. Along the
posterosuperior margin of the pharyngobasilar fascia, there is
a notch referred to as the sinus of Morgagni. The levator
palatini muscle and the distal eustachian tube (torus tubarius)
project into the PMS through this notch. NPCa may escape the
PMS through this notch.
Approaches to Imaging Issues of Pharyngeal
Mucosal Space
The answer to the question, "What imaging findings define a
PMS mass?" depends on the area of the PMS where the mass
originates. The most common PMS mass arises in the lateral
pharyngeal recess of the nasopharynx or in the palatine tonsil
of the oropharynx. As such, it is medial to the PPS, displacing
the PPS fat laterally as it enlarges. A PMS mass of the lingual
tonsil projects into the posterior sublingual space of the
tongue as it enlarges. The rare posterior nasopharyngeal or
oropharyngeal wall mass pushes posteriorly into the RPS as it
grows. No matter where in the PMS a mass grows, disruption
of the mucosal and submucosal architecture occurs. In
addition, the growing airway side of the mass projects out into
the adjacent PMS airway.
Traditionally, the pharynx is divided into the nasopharynx,
oropharynx, and hypopharynx as a method to describe where
on this continuous sheet of mucosa a lesion is found. This
surface of the pharynx is referred to here as the PMS. To
unify these 2 terminologies, it is possible to refer to the
nasopharyngeal, oropharyngeal, or hypopharyngeal mucosal
space. It is not helpful to merely refer to a tumor as either in
the oropharynx or found in the oropharyngeal mucosal space.
The radiologist must also describe what other deep facial
spaces are involved by a PMS tumor. This requires bringing the

Other documents randomly have
different content

Fig. 818.—Part of a
massive gold
pommel of sword
found in a field in
Leijeby, Halland.
Real size.
The mækir, the sverd, and the sax seem to have been the three
kinds of swords used by the people.
Fig. 819.—Silver
ornament for
scabbard, real size.
—Norway.
Fig. 820.—Pommel of
sword of massive gold,
ornamented with garnets
enchassés. Real size.
Earlier iron age.—
Bohuslan.
Fig. 821.—Reverse view of
Fig. 822.

Fig. 822.—Silver ornament
(both sides shown) found
in the sand. Real size.—
Scania.
Fig. 823.—Silver
thong aiguillette.
Real size.
Fig. 824.—Gold ornament
of sword belt. Real size.—
Thureholm,
Södermanland.
Fig. 825.—Bronze mounting
to a belt, found, when
ploughing, with a short
single-edged sword, four

arrow-heads, a shield-boss,
iron bit, a round fibula of
bronze, and thirty glass
beads, &c. Real size.—
Götland.
Fig. 826.—Ornament of gilt
bronze, with border in
silver, found in a mound.
Real size.—Öland.
Fig. 827.—Mounting of thong,
⅔ real size, with leather still
attached to it, in gilt bronze
with red enamel. With it were
an iron sword with gilt bronze
handle, two bits, two stirrups,
more than 100 clinch nails of
the size of those in the
Ultuna mound, a clay urn
with burnt bones, and the
unburnt jaw of a dog, &c.—
Scania.
Fig. 828.—
Ornament of gilt
bronze, real
size.—Norway.

Fig. 829.—
Ornament of gilt
bronze, ⅔ real
size; found in a
tumulus, with
fibula, horse’s bit,
&c.—Norway.
Fig. 830.—Ornament of solid
gold for the mouth of a
scabbard.—Malby,
Vestergötland.
Fig. 831.—Reverse view of
Fig. 830.
In all ornamentation one side
is not similar to the other.
Fig. 832.—
Massive ring of
gold (probably
fixed at the
mouth of a
scabbard);
weight, 5 oz.
Real size.—
Vestergötland.

Fig. 833.
Fig. 834.—Reverse
of Fig. 833.
Ornaments for the mouthpiece of a
scabbard seen from both sides. The two
sides are always unlike. Real size.—
Thureholm.
Fig. 835.—Double-edged
sword-hilt and mounting of
scabbard of gilt bronze and of
silver. ½ real size.—Ultuna,
Upland.
The sax had only one sharp edge in contrast to the sverd, which had
two.

Upon the swords more than upon all other weapons the poets
lavished their most figurative and poetical names; they are called:—
Odin’s flame:
The gleam of the battle;
The ice of battle;
The serpent of the wound;
The wolf of the wound;
The dog of the helmet;
The battle snake;
The glow of the war;
The injurer of the shields;
The fire of the shields;
The fire of the battle;
The viper of the host;
The torch of the blood;
The snake of the brynja;
The fire of the sea-kings;
The thorn of the shields;
The fear of the brynja;
The tongue of the scabbard.
Among the most celebrated swords were Tyrfing, the sword of
Sigurlami, son of Odin, which had come down to Angantyr and his
descendants. It shone like a ray of sunshine, and slew a man every
time it was drawn. It was always to be sheathed with man’s blood
upon it; it never failed, and always carried victory with it.
“In the battle Heidrek was in the foremost array, and he carried
Tyrfing in his right hand, and cut down the host of the jarl like
saplings, and neither helmet nor armour could resist; he went
through the host; he slew all who were near him” (Hervarar Saga, c.
10).
Some weapons had special names given to them, and the great
fame they had acquired was doubtless due to the personal bravery
of the warriors who had owned them, to the great skill with which
they were handled, and to their superior workmanship. People

believed in their supernatural qualities; some were even thought by
them to have been forged by the Dvergar, others were supposed to
have been given by Odin himself; while some had become infallible
by akvœdi, that is, by charms and incantations used over them while
they were being made, or else by mal, i.e., mystic signs engraved or
inlaid upon them.
Fig. 836.—Sword, found in a
tumulus with two spear-heads,
shield-boss, and a garniture of a
shield handle.—Norway.
Fig. 837.—Found amongst some burnt
bones and objects of iron; ⅕ real size.—
Norway.
Fig. 838.—Sax found in a small
tumulus with a human cranium;
two spear-points; ¼ real size.—
Norway.
Fig. 839.—Sword-
hilt with an outer
sheet of thin silver,
very much injured
by fire; nearly ⅓
real size.—Norway.

Fig. 840.—
Sword-hilt with
wood and
bronze bands;
nearly ⅓ real
size.—Norway.
Fig. 841.—Sax or single-edged
sword found with an umbo shield
boss of iron in a cairn. ⅕ real size.
—Långlöt, Öland.
Fig. 842.—Sax or single-edged iron
sword, found in a stone cist of over nine
feet in height, with a skeleton, spear-
point, clay urn, &c. ¼ real size.—Öland.
Fig. 843.—Double-edged sword, with
bronze mounting for scabbard; found
by the side of a skeleton in a tumulus
at Hammenhöj, Scania, together with
an iron shield boss, a clay urn, two
bone dice, forty bone checkers and
other things. ⅕ of real size.
“Hraungvid said: ‘I have ravaged for thirty-three years, summer and
winter, and I have fought in sixty battles, generally gaining victory;

the name of my sword is Brynthvari, and it has never been dulled”
(Hrómundar Saga Greipssonar, ch. 1).
Grettir asked for a weapon, and Asmund, his father, answered:
“‘Thou hast not been obedient to me, and as I do not know what
thou wilt do with weapons, so I will not give thee any.’ Grettir
replied: ‘Then there is nothing to repay, where nothing has been
given.’ Father and son parted with little affection. Many wished
Grettir farewell, but few safe return. His mother followed him on the
way, and before they parted she said: ‘Thou art not fitted out from
home, my kinsman, as I would like, able as thou art; it seems to me
the greatest want, that thou hast no weapon fit for use, and my
mind tells me that thou wilt need one.’ She took an ornamented
sword from under her cloak; it was very costly, and said: ‘This sword
my grandfather Jökul owned, and the old Vatnsdælir, it used to give
them victory. I will give thee the sword; use it well.’ Grettir thanked
her much for the gift, saying he liked it better than greater
valuables” (Gretti’s Saga, ch. 17).
The jarl Viking said to his son Thorstein:
“The only thing that gladdens me is that no man will stand over thy
scalp (have thy head at his feet), although thou wilt have a narrow
escape. Here is a sword, kinsman Thorstein, which I want to give
thee; its name is Angrvadil, and victory has always followed it; my
father took it from the slain Björn Blue-tooth; I have no other
remarkable weapons, excepting an old spear which I took from
Harek Jarnhaus, and I know it is not manageable by any man”
(Thorstein Vikingsson’s Saga, ch. 10).

“When Viking drew it (‘Angrvadil’) it was as if lightning flashed from
it. Harek seeing this, said: ‘I should never have fought against thee,
if I had known thou hadst Angrvadil; it is most likely it will be as my
father said, that we brothers and sisters would be short-lived, except
that one only who was named after him; it was the greatest
misfortune, when Angrvadil went out of our family;’ and at that
moment Viking struck down on the head of Harek, and cleft him in
two from head to feet, so that the sword entered the ground up to
the hilt” (Thorstein Vikingsson, ch. 14).
[93]
“King Athelstan gave him a sword, with hilt and guards of gold, but
the blade was still better; with it Hakon cut a millstone through to
the centre hole,
[94]
and therefore the sword was afterwards called
kvernbit (mill-biter). It was the best sword that ever came to
Norway” (Olaf Tryggvason’s Saga; Fornmanna Sögur).
Many were considered valuable heirlooms in families, and their
possession was so much coveted that even burial mounds were
broken open in order to get them.
Grettir had broken into the mound of the Norwegian chief Kár, with
whose son, Thorfinn, he was residing, and had taken therefrom a
great deal of property.
“Late at night he returned to his house, and placed on the table
before Thorfinn the property he had taken from the mound. Among
the treasures was a sax, such a good weapon that Grettir said he
had never seen a better. He wanted to have this very much, but
produced it last of all (the treasures). Thorfinn’s face brightened
when he saw the sax, for it was a great treasure, and had never
gone out of his family; he asked how he (Grettir) got it, and Grettir
told him.... Thorfinn said: ‘Thou must accomplish something that I
think famous, before I will let thee have the sax, for my father never
allowed me to use it’” (Gretti’s Saga, ch. 18).

“Arinbjörn gave to Egil a sword called Dragvandil, which Thórólf
Skallagrimsson had given to him; Skallagrim had got it from his
brother Thórólf, and Grim Lodinkinni (shaggy-cheek) had given it to
Thórólf. Ketil Hœng, Grim’s father, had owned it, and carried it in
single-fights; it was sharper than any other sword” (Egil’s Saga, c.
64).
“He (King Magnus) was girt with a sword called Leggbit (the leg-
biter); its guards were of walrus-tusk, and its hilt was covered with
gold; it was one of the best of weapons” (Magnus Barefoot’s Saga,
ch. 26).
[95]
In time of peace warriors wrapped round their swords what was
called Fridbönd (peace-band). This was a strap wound round the
sheath, and fastened to the hilt, but unfastened in case of war.
Thorkel, Gisli’s brother, was well dressed at the Thorskafjardar-thing.
“He wore a hat from Gardariki and a grey cloak and a gold fibula on
his shoulder, and he carried a sword in his hand.”
Two boys came walking up to him.
“The older boy said: ‘Who is the noble-looking man sitting here? Saw
never I a better-looking or more dignified man.’ Thorkel answered:
‘Thou speakest well; I am called Thorkel.’ The boy said: ‘The sword
in thy hand must be very precious; wilt thou allow me to look at it?’
Thorkel answered: ‘This is strange, but I will allow thee to look,’ and
handed the sword to him. The boy took the sword, turned a little
aside, unloosed the peace bands and drew the sword. When Thorkel
saw this, he said: ‘I did not allow thee to draw the sword.’ ‘I asked
no leave from thee,’ said the boy; and he brandished the sword and

struck at the neck of Thorkel, taking off his head” (Gisli Sursson’s
Saga, ch. 55).
[96]
A Valkyria says to Helgi:
I know swords lying
In Sigarsholm
Four less
Than fifty;
One is
The best of them all.
The harmer of war-knittings
[97]
Covered with gold.
For him who gets it
A ring is in the guard,
Courage in the middle,
Terror in the point,
A blood-dyed serpent
Lies along the edge,
The serpent throws its tail
On the valbost.
[98]
(Helgi Hjörvardsson.)
Spears.—Different kinds of spears are mentioned, such as kesja;
höggspjót (hewing-spear); gaflak (javelin); snœris-spjót (string-
spear); which last was thrown with the aid of a string fastened to
the spear; pál-staf (pole-staff), a pole provided with an iron spike;
skepti-fletta (cord-shaft), a shaft with a cord attached to it; atgeir, a
kind of halberd.
The sockets were often richly ornamented with gold or silver inlaid in
beautiful patterns, sometimes with fine notches of silver, or were
covered over with sheets of silver, upon which were engraved the
serpentine ornamentation peculiar to the North.

Fig. 844.—⅔ real
size.
Fig. 845.—Spear-head. ½ real size.
Fig. 846.—Damascene spear-
head, found with a fragment
of a single-edged sword with
hilt, a key, a scythe, iron
blade, &c. ⅓ real size.—
Norway.
Fig. 847.—Spear-head. In a
tumulus. The upper line in the
handle has been filled with silver.
⅓ real size.—Norway.
Fig. 848.—Spear-point, with
lower part plated with silver
and gold. ⅓ real size.—
Götland.
Fig. 849.—Spear-head, found with
two swords, iron knife, and three
bronze buckles. ¼ real size.—
Götland.
Fig. 850.—Spear-point, ⅓ real size,
found in Kragehul bog.

Fig. 851.—Spear-
head. ½ real size.
—Norway.
Fig. 852.—Spear-
point. ⅓ real size.
—Norway.
Fig. 853.—Spear-
point. ⅓ real size. In
a tumulus with two
bent double-edged
swords, another
similar spear-head,
&c., &c., and the
bones of two horses.
—Norway.
Fig. 854.—Spear-head of
iron. ⅔ real size.
Fig. 855.—Spear-point.
½ real size. In a round
tumulus with a gold
ring, pieces of a glass
cup or vase, fragments
of silver repoussé and
gilt, and part of a
bracelet.—Norway.

Fig. 856.—Spear-
head of iron, found
with two other
larger spear-heads,
a single-edged
sword, and the
bottom of a Roman
vase in bronze, &c.
½ real size.
Fig. 857.—Spear-point. ½ real size.
Found in a round tumulus with a two-
edged sword, &c.—Norway.
From the more numerous finds of spears, of which great numbers
have been discovered together, we gather that the spear was a more
common weapon than the sword. We also learn that spear-shafts
were generally made of ash, and that they were sometimes more
than eleven feet long, while their thickness rarely exceeded an inch;
on some spears the centre of gravity was marked by nails or strings,
in order that the thrower might quickly give the spear the right
position in his hand.
Fig. 858.—
Triangular
arrow-point. ½
real size.
Fig. 859.—Iron
spear-point. ¼
real size.—Karleby,
Upland.

Fig. 860.—Iron
spear-point,
found with a
skeleton, double-
edged sword,
knife, two spear-
points, and
shield-boss, in a
cairn at
Folkeslunda,
Öland. ⅓ real
size.
Fig. 861.—Iron arrow-head.
½ real size, found with 11
others of the same shape.—
Vestana, Upland.
Fig. 862.—Spear-
point. ¼ real size.—
Hade in Gestrikland,
Sweden.
Fig. 863.—Ornamentation of a
spear-handle, ½ real size, from
Thorsbjerg bog.
Spears, like swords, had numerous poetical names. Odin’s spear was
called Gungnir. Some other names were—

The pole of Darrad (Odin).
The sounding fish of the armour.
The snake of the corpse.
The flying dragon of the wounds.
The snake of the attack.
The venom-thong of the fight.
The thorn of the wound.
The serpent of blood.
The serpent of battle.
The serpent of wound.
The serpent of shield.
The shooting-serpent.
These are of many shapes, and it is impossible to tell those which
were used for war, or for household, or for felling trees.
“It was seen from the Thing that a body of men rode down along
Gljúfrá (a river), and that shields glittered there. When these arrived
a man in a blue cloak rode foremost; he had a gilt helmet on his
head and a gold-ornamented shield at his side; in his hand a hooked
spear; the socket of its head was inlaid with gold; he was girt with a
sword. This was Egil Skallagrimsson” (Egil’s Saga, ch. 85).
The axe.—The axe is frequently mentioned in the Sagas, and must
often have been a formidable weapon. Some were artistically and
splendidly made, and inlaid with precious metal, each side being
made of different patterns.
Fig. 864.—Axe inlaid
with metal, of silver
mixed with gold. ½
real size.—Bjerringhoï

mound at Mammen,
near Viborg.
One of the earliest forms of this weapon is probably the one here
represented (Fig. 865), for it was found with a bronze sword, and
shows the transition that was taking place, when iron was to
supersede bronze in the making of weapons.
They also had peculiar figurative names—
The fiend of the shield.
The witch of the battle.
The witch of the armour.
The witch of the helmet.
The witch of the shield.
The wolf of the wound, &c.
The most celebrated axe in later times was that of Skarphédin,
called Rimmugýg (the war-witch).
Fig. 865.—Iron axe, ⅓ real
size, probably of early iron
age, found in a small stone
cist with a short bronze
sword and burnt bones.—
Götland.
Fig. 866.—A
little less than
¼ real size.
Iron axe, with a
celt, a two-

edged sword
with hilt, a
spear-head, an
axe, two blades
of knives, a
horse-bit, a
scythe-blade,
&c., all of iron.—
Norway.
Fig. 867.—A little less
than ¼ real size. Iron
axe, in a half-ruined
tumulus, with two other
axes, a horse-bit, and a
little bell.—Norway.
Fig. 868.—Axe
head, ⅔ real
size.—Sweden.
Fig. 869.—A little less
than ¼ real size. Iron
axe, in a tumulus with
charcoal, a spear-
head, a knife-blade, a

fire-steel, a single-
edged sword, and end
of an iron chain.—
Norway.
Fig. 870.—⅓ real
size. Iron axe, found
with checkers in a
round tumulus with a
stone vessel, which
contained burnt
bones and a
purposely-broken
and bent sword, with
hilt inlaid with silver,
a spear-head bent,
two shield-bosses, a
horse-bit, a pair of
stirrups defaced by
blows of a hammer,
two buckles, and an
iron ornament for a
belt, fragments of
bone comb, &c.—
Norway.
Fig. 871.—¼ real
size. Iron axe.—
Norway.

Fig. 872.—¼ real
size. Iron axe.—
Norway.
“The jarl (Hakon) asked (Hallfred) who he was? He said: ‘I am an
Icelander; but my errand is, lord, that I have composed a song
about you, and wish you to listen to it.’ The jarl replied: ‘Thou
lookest to be a man who would be bold in the presence of chiefs,
and thou shalt have a hearing.’ Hallfred recited the poem; it was a
drápa (laudatory poem); he delivered it with skill. The jarl thanked
him, gave him a large silver ornamented axe, and good clothes, and
invited him to remain with him over winter; and this Hallfred
accepted” (Hallfred’s Saga, ch. 5).
“As they parted, the jarl (Hakon) gave him (Olaf Höskuldsson) a
most costly gold ornamented axe” (Laxdæla, ch. 29).
Fig. 873.—Iron axe. ¼
real size. Found in a
field with another axe,
&c.—Karleby, Upland,
Sweden.
Fig. 874.—Small
axe. ½ real size.
Found with
double-edged

sword, 10 arrow-
points, &c.—
Forneby,
Vestmanlan.
The bow (bogi) and the arrow (ör) were among the most important
weapons for war. The bows discovered are generally about six feet
long.
Arrows were called by the poets—
The bird of the string.
The swift-flyer.
The hail of the battle.
The hail of the wound.
The herrings of the corpse.
The ice of the bow.
The rain of the string.
The twigs of the corpse.
The clutching one (one of three arrows of Orvar Odd).
The glad flyer.
The weapon of the Finns.
The work of Gusi (king of the Finns).
The followers of Gusi.
The flowing streams of the bow.
The rain of the bow.
The quick one of the shaft.
The fire of the bow, &c.
The quivers from the earlier iron age were occasionally of wood,
sometimes with bronze mountings, and were made to hold a score
of arrows. Some arrows were ornamented with gold, were long, and
often barbed with iron or bone. The arrow-shafts, of wood, were two
or three feet long, with four rows of feathers, fastened into pitched
thread; they, as well as the spears, often bore the marks of
ownership; while some were engraved with runes.
Svein (England’s conqueror), King Harald’s son, Pálnatóki’s foster-
son, went on warfare in his father’s realm and fought a battle at sea

against him near Bornholm. He was defeated and shut up in a bay,
Harald’s ships lying across it, each stem being fastened to the other.
Fig. 875.
Fig. 876.
Arrow-heads. ⅔ real size.—Norway.
“The same evening Pálnatóki came to the island with twenty-four
ships. He laid his ships on the other side of the cape, and there
tented over his host (on board). Thereupon he went ashore alone
with his bow and arrows, and his sword at his belt. Now it must be
told of King Harald that he went ashore with eleven men. They
walked into the wood, made a fire there, and warmed themselves at
it. They sat on a felled tree, and it had become dark as the night fell
on. Pálnatóki went into the wood opposite where the king sat, and
stood there. The king warmed himself at the fire, and came with his
back close to it. Clothes were laid under him. He was on his knees,
and stooped forward so low while warming his back and shoulders
that the hind part of his thighs stood out. Pálnatóki heard the king’s
voice, and recognised that of his father’s brother, Fjölnir. He laid an
arrow on his (bow) string and shot at the king, and, it is told, that
the arrow hit the king straight between his thighs and came out of
his mouth. The king fell dead, as was to be expected. When his
followers saw what had happened, Fjölnir said: ‘A great mishap has
occurred to the man who has done this deed, or caused it to be
done. A strange wonder is the way in which this deed has been
committed.’ He asked what should be done. They left to him to
decide that, for he was the wisest of them. It is told that he took the
arrow out of the king’s mouth, and put it by as it was. It was easy to
know, for it was bound with gold. Fjölnir said to the men: ‘I think it

advisable that we all tell the same tale about this event, and it
seems to me we cannot do better than say he was shot in the battle
to-day. That is more likely than the wonder which has occurred
here.’ They all bound themselves firmly to tell the same story”
(Jomsvikinga Saga).
Fig. 877.—½ real
size. Arrow-head.
In a round
tumulus, with
fragments of two
stone vases,
pincers of iron for
blacksmith, a
two-edged sword
with hilt inlaid
with silver, the
blade bent and
the inlaid silver
half melted; a
bent spear-head,
one axe, one
shield-boss,
fifteen arrow-
heads, a horse-
bit, two stirrups,
two spears, four
buckles for belts,
and many
ornaments for
harness; two
hammers, an
anvil, fragments
of a stone mould,
remains of a
bronze balance,
two files, two
blades of knives,
and two celts of

iron, a gimlet,
two sharpening
stones, a piece of
flint, an iron key,
fragments of
checkers of
bones, &c.—
Norway.
Fig. 878.—½ real
size. Arrow-head
of iron.—Norway.
The most celebrated mythical arrows
[99]
of the Sagas were the Gusi
arrows, which had come into the possession of Ketil Hœng, and
were owned afterwards by his grandson, Orvar Odd.
There are several accounts of these wonderful arrows in the Sagas.
“Grím (father of Orvar-Odd) followed them (Odd, Gudmund, Sigurd)
to the ships and said: ‘Here are the costly things which I want to
give thee, Odd, my kinsman; they are three arrows which have a
name and are called Gusi’s nautar (Gusi’s followers).’ He gave the
arrows to Odd, who looked at them and said: ‘They are very costly.’
The feathers were gilded, and the arrows flew off and on the string
by themselves, and one never needs to search for them. These
arrows Ketil Hœng took from Gusi, the king of the Finnar; they bite
everything they are aimed at, for they are forged by Dvergar. Odd
said: ‘No gifts have I which I think equally fine.’ He thanked his
father, and they parted with friendship” (Orvar Odd’s Saga, c. 4).
[100]
Slings and stones thrown.—Stone-throwing was an important means
of attack. Stones were sometimes thrown by hand, but oftener with
slings, particularly in sea-fights, and the art was brought to great

perfection. Slings were also used on land by bodies of men who had
no other weapons.
[101]
The stone-throwers are mentioned as
occupying the flanks in King Hedin’s army; and the slingers stood in
the last ranks of King Hring’s order of battle on Brávalla heath.
As heavy stones could not be thrown any great distance by mere
muscular strength, machines were employed, called Valslöngva.
The chief Sturla Sighvatsson was attacking his enemies, who
defended themselves inside a high wall.
“Sturla walked about outside, and took a stone; he threw stones
better than any man, and usually hit the mark. He said: ‘It seems to
me if I wished to throw a stone, that I, rather than you, would
choose where it should hit; but I will not try it now,’ and he then
threw down the stone” (Sturlunga, v., ch. 17).
“Búi (the son of Andrid, in Brautarholt) would never carry any
weapon but a sling, which he always wore tied round him. Búi was
outlawed because he did not want to sacrifice. Once when he was
on a journey, Thorstein, a son of the chief Thorgrim, attacked him
with eleven men. Búi had come to a hill called Kleberg, where he
saw them pursuing him; he stopped and gathered some stones.
Thorstein and his men went fast, and when they had passed a brook
which was there, they heard the sling of Búi whistle and a stone
flew; it struck the breast of one of Thorstein’s men and killed him.
Búi sent more stones, and hit a man with each one. By this time
Thorstein had almost come up to him; Búi retreated down the hill on
the other side” (Kjalnesinga Saga, ch. 3).
Defensive weapons.—The shield, the form of which, as we see from
the finds, was always round, and somewhat convex. Almost all
shields were probably covered with leather. They were of wood, the
boards surrounded on the rim by a ring of metal, sometimes of gold,
and they were braced and furnished with a boss and handle of iron

or bronze. Many were painted in different colours, or richly
ornamented, and sometimes covered with gold.
Many figurative names were given to them:—
The sun of the battle.
The moon of the battle.
The sun of Odin.
The moon of Odin.
The cloud of the battle.
The wall of the battle.
The board of victory.
The net of the spears.
The wheel of Hild (a Valkyria).
Hild’s wall.
The sun of the sea kings.
The leaf of the Vikings.
The land of the arrows.
The path of the spears.
The fence of the bardi (ironclad ship).
The hall-roof of Odin.
The one that shelters.
The battle-shelterer.
The glittering sun.
The fire-shelterer.
The burgh of the swords.
Thjódolf of Hvin, one of Harald Fairhair’s scalds, got as a gift from
the Norwegian chief Thorleif
[102]
a shield. The shield was painted
with subjects from Norse mythology. On these Thjódolf wrote the
poem Haustlöng (autumn-long), which is preserved in the later Edda
in two parts. The first part tells about the journey of Odin, Loki, and
Hœnir; how on their way they met the Jötun Thjassi; and it also
describes the rape of Idun, and Thjassi’s death. This part of the
poem winds up thus:—
This is painted
On my shield;
I received the coloured shield
From Thorleif.

The second part of the poem tells the fight of Thor with the Jötun
Hrungnir, and Thjódolf ends it with these words:—
I see distinctly
These events on the shield;
I got the coloured shield
From Thorleif.
(Later Edda.)
“When the jarl heard the poem, he gave Einar a most costly shield.
It was painted with old Sagas, and all the spaces between the
paintings were covered with plates of gold and set with stones.
“When he was ready he went to the seat of Egil, and hung the costly
shield there, telling the servants that he gave it to Egil, and then
rode away.
“It is said that Egil took the shield on a bridal journey to Vidimyri,
where it was spoiled by being thrown into a tub of sour milk; he had
the ornaments taken off, and there were twelve aurar of gold in the
plates” (Egil’s Saga, ch. 82).
[103]
Fig. 879.—Shield-boss of
bronze, with handle of
iron covered with
bronze. ½ real size.—
Ultuna.
“Sigurd rode away, his shield had many layers, and was covered with
red gold, and on it was painted a dragon. It was dark brown on the
upper part, and light red on the lower, and in the same way were

coloured his helmet, saddle, and armour. He had a gold coat-of-mail
(gullbrynja), and all his weapons were ornamented with gold and
marked with a dragon, so that every one who saw the dragon might
know who the man was, if he had heard that Sigurd slew the large
dragon which the Vœrings call Fafnir” (Volsunga Saga, ch. 22).
Fig. 880.
Fig. 881.
Shield boss with handle of bronze, found
with the iron spear-point. ½ real size.—
Folkeslunda, Öland.
Fig. 882.—Shield
boss of iron. ½ real
size.—Hammenhoj,
Scania.
Fig. 883.—Button of
shield boss of bronze,
plated with silver gilt;
the heads of the nails

Diagnostic Imaging: Head and Neck 4th Edition Bernadette L. Koch Md

About This Presentation

Slide Content

Tags

Categories

Download

Quick Actions

Statistics

Related Slideshows

Diagnostic Imaging: Head and Neck 4th Edition Bernadette L. Koch Md

About This Presentation

Slide Content

Slide 1

Slide 2

Slide 3

Slide 4

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23

Slide 24

Slide 25

Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Slide 31

Slide 32

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 48

Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Slide 54

Slide 55

Slide 56

Slide 57

Slide 58

Slide 59

Slide 60

Slide 61

Slide 62

Slide 63

Slide 64

Slide 65

Slide 66

Slide 67

Slide 68

Slide 69

Slide 70

Slide 71

Slide 72

Slide 73

Slide 74

Slide 75

Slide 76

Slide 77

Slide 78

Slide 79

Tags

Categories