Differential Diagnosis in Head and Neck Imaging: A Systematic Approach to the Radiologic Evaluation of the Head and Neck Region and the Interpretation of Difficult Cases

Anatomy and pathology of the head and neck region is quite complex, and to gain a thorough understanding of this material is a daunting task for any neuroradiologist as well as for the general radiologist and radiology residents. This textbook endeavors to simplify this challenge by illustrating a systematic approach to differential diagnosis based upon regions of anatomic interest as well as the descriptive features of lesions on imaging studies. Although this textbook does provide a differential diagnosis based upon location and imaging appearance, it is quite limited in depth when addressing specific types of lesions and pathology. The review of pertinent anatomy and clinical issues is often cursory. There is a relative paucity of images and a plethora of tables. For a book of 381 pages, there are only 309 illustrations, compared with “Head and Neck Imaging” by Valvassori et al that includes a comparable 345 pages and 1118 illustrations. (The two-volume set by Som et al, contains 3800 illustrations). Thus, as a guidebook through the maze of head and neck imaging, this textbook is somewhat disappointing.

Each chapter begins with a brief (often too brief) review of normal anatomy as well as the clinical manifestations of disease affecting that particular region. This is followed by a discussion of the relative merits of different imaging techniques in evaluating pathology and anatomy within a particular anatomic region. Typical imaging findings are then reviewed for congenital, neoplastic, inflammatory, traumatic, and iatrogenic disorders affecting the region of interest. Each chapter then presents a differential diagnosis based upon the imaging appearance of an abnormality. This is often done in table form, which is quite instructive. Differentiating criteria are listed, which may help to distinguish one entity from another. This textbook could have been superb had these differentiating criteria been more insightful. Particular “clues” that specifically help to distinguish one entity from another would have been extraordinarily useful. Often, the differentiating criterion listed is only “topography” or “morphology,” which is inherently vague, and certainly not as instructive as hoped for.

In general, the images are of very good quality. There is a preponderance of MR scans over CT studies. This seems to be the authors' preference for imaging. In fact, they state CT has only a “minor role” in the imaging evaluation of the salivary glands. Good-quality CT studies delineate quite well many of the disorders that affect the salivary glands, and in only a small number of cases are MR studies necessary in order to answer a particular clinical issue. CT is invaluable for detecting sialoliths, phleboliths, and other focal calcifications that may not be evident from MR imaging. Thus, it is unfortunate that the authors did not include any CT studies in the chapter on salivary gland imaging. In our experience, CT is the study most frequently ordered by referring otolaryngologists and it is thus imperative that neuroradiologists, general radiologists, and residents-in-training become familiar with the interpretation of these CT studies. The authors also include a number of examples of a 3D magnetization-prepared rapid-acquisition gradient-echo (MP-Rage) sequence, in which there is a 3D MR reconstruction of the surface features of the facial region with a very small “cutout” showing the focal region of pathology. More than one or two of these is unnecessary, as it is often difficult to appreciate the pathology, because the “cutout” area is so small relative to the overall image. The presence of the facial surface features does not add to the depiction of the lesion under discussion.

Although there are numerous tables included, some of which are superfluous (“increased pneumatization of the temporal bone”), there are glaring omissions on other topics. For example, there is no differential given for pulsatile tinnitus, a common clinical problem and favorite of board examiners. Although the legends for the illustrations are usually quite accurate, the diagrams are often not well labeled and are too few in number. A coronal diagram of the osteomeatal complex (and adjacent structures) in the paranasal sinus chapter would have been helpful. The inclusion of a coronal diagram in the larynx chapter would also have been particularly useful in understanding the regional anatomy in its cranial/caudal extent.

As mentioned above, the review of normal anatomy is quite sketchy in certain chapters. There is only one axial CT image and one coronal CT image included in the discussion of the basal foramina of the skull. This is simply inadequate. The review of normal temporal bone anatomy is also quite cursory, which is unfortunate, as this is one area in particular that prompts radiologists to refer to a text to refresh their memory. In the chapter on paranasal sinuses, there is no mention of normal variants, which may play a role in the development of sinus inflammatory disease. Knowledge of these normal variants is also essential for preoperative planning prior to endoscopic sinus surgery.

Surprisingly, there is only one figure depicting squamous cell carcinoma of the paranasalsinuses. This is not an uncommon entity, and this is a lesion that must be recognized by all neuroradiologists and those in training. There is noT2-weighted image showing hypointensity within a sinus owing to aspergillosis. The paucity of images is often frustrating. Also of note, one of the four images on the cover is upside down. The lack of attention to such detail is surprising.

There are a number of misspellings and inaccuracies noted throughout the text. The phrasing is often awkward, perhaps because this edition was translated from the original, which was in German. The references are limited in number, but appear to be in scholarly journals, mostly from the early-to-mid 1990s.

In conclusion, this textbook offers a systematic approach to differential diagnosis of lesions affecting the head/neck region based upon lesion location and imaging appearance. This book may therefore be helpful to general radiologists and those in training who are less familiar with the anatomy/pathology in this anatomic region. The lack of detail, however, may require consultation from a more comprehensive text. Neuroradiologists may find that the review of anatomy and the illustration of pathology in this text are insufficient for the needs of their practice, although some of the tables are certainly helpful in directing a sensible differential diagnosis.