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IMAGING FINDINGS OF PERINEURAL TUMOR SPREAD ALONG PERIPHERAL BRANCHES OF THE FACIAL NERVE (CN7) Submission #: 682 Authors: N Patel , R Beegle , I Schmalfuss University of Florida College of Medicine, Gainesville, FL & North Florida/South Georgia Veterans Administration Purpose Imaging findings of perineural tumor spread (PNTS) along the facial nerve (CN7) main trunk are well established. However, many cancer patients suffer from PNTS along peripheral branch(es) of CN7. Recognition of early PNTS is critical as it is often resectable, allowing for more favorable patient outcome. Objective Familiarize the radiologist with the imaging spectrum of PNTS along the peripheral branches of CN7 to facilitate early detection. Approach/Methods: Review of the anatomy of the peripheral branches of CN7 and their relation to the superficial muscular aponeurotic system (SMAS) of the face. Presentation of PNTS along the different peripheral branches of CN7 illustrating the spectrum of imaging findings on CT MRI Development CN7 originates from the hyoid arch (2nd branchial arch) Course, branching pattern, and anatomical relationships of CN7 are established in the first 3 months of prenatal life with full development reached at age 4. During the 8th week of gestation, the temporofacial and cervicofacial divisions form followed by subdivision into the 5 major terminal branches. Five terminal branches of CN7 Temporal (frontal) Zygomatic Buccal Marginal mandibular Cervical Five terminal branches of CN7 Modification of Temporal (frontal) branches Cross the zygomatic arch to the temporal region: Modification of Temporal (frontal) branches Supply muscles that wrinkle the forehead, close the eyelids and wiggle the ear Auricularis anterior and superior muscles Frontalis, orbicularis oculi, procerus & currugator supercilii muscles via the anterior branches Zygomatic branches Run along anterior aspect of the zygomatic bone to lateral and inferior orbit: Modification of Zygomatic branches Supply the muscles that close the eye, move the nose, and raise the corners of the mouth: Zygomaticus major and minor muscles Orbicularis oculi muscle Levator labi superioris muscle Levator labii superioris muscle Depressor and compressor nasi muscles Dilator naris muscles Buccal branches Extend horizontally along the cheek to face midline: Modification of Buccal branches Buccal branches of CN7 are larger in size than the other CN7 terminal branches. Supply the muscles below the orbit and around the mouth: Superior part of the orbicularis oris muscle Buccinator muscle Marginal mandibular branch Courses anteriorly along the mandibular ramus and body: Modification of Marginal mandibular branch Supplies the muscles of the lower lip and chin: Quadratus labii inferioris muscle Lower part of the orbicularis oris muscle Triangularis muscle Mentalis muscle Cervical branch Extend anteriorly to form a series of arches along the lateral suprahyoid neck: Modification of Cervical branch Supplies Platysma musculatur Depressor anguli oris muscle One branch descends to join the cervical cutaneous nerve from the cervical plexus. Pathology: PNTS along CN7 is most commonly related to cutaneous squamous cell carcinoma or primary parotid gland malignancies. PNTS often extends in retrograde direction; however, antegrade growth can also be present but is often overlooked. Clinical presentation: Depends upon involved peripheral branch of CN7 Prabhu RK et al. Evaluation of facial nerve function following surgical approaches for maxillofacial trauma. Ann Maxillofac Surg 2012;2:36-40. Clinical presentation: Inability to wrinkle forehead & eyebrow Drooping eye & inability to close eye No muscle tone & inability puff cheeks Drooping mouth & inability to smile Imaging findings of PNTS along peripheral branches of CN7 Thickening along the SMAS of the face, platysma of the upper neck, or within the superficial parotid gland Enhancement along the SMAS of the face, platysma of the upper neck, or within the superficial parotid gland Case 1:PNTS along temporal branch of CN7 76 year old male with skin lesion in the lateral upper cheek region on the right presents with inability to wrinkle the forehead. Biopsy reveals squamous cell carcinoma. Imaging is performed for staging purposes. Case 1:PNTS along temporal branch of CN7 Post contrast CT image shows thickening of SMAS superior to the right zygomatic arch (arrow) when compared to its normal appearance on the left (arrow). T1 GdT1FS T1 images confirm the thickening of the right SMAS (arrow) when compared to its normal appearance on the left (arrow) . There is associated with marked enhancement on the Gadolinium T1 fat suppressed (GdT1FS) image (arrow). The CT & MRI findings are consistent with PNTS along the temporal branch of CN7 and explain the patient’s inability to wrinkle the forehead. Case 2:PNTS along zygomatic branch of CN7 65 year old male with right preauricular skin lesion presents with inability to completely close his right eye. Biopsy reveals squamous cell carcinoma. Imaging is performed for staging purposes. Case 2:PNTS along zygomatic branch of CN7 Post contrast CT image demonstrates preauricular thickening of the SMAS at the level of the zygomatic arch (arrow) that extends in antegrade fashion from the infiltrating skin lesion (arrow). Normal SMAS is seen on the left (arrow). FST2 GdT1FS MRI images confirm thickening of the right SMAS (arrow) with marked edema on fat suppressed T2 (FST2) and enhancement on the GdT1FS images that extends in antegrade fashion from the deeply infiltrating skin lesion (arrow). Normal appearing SMAS is seen on the left (arrow). The CT & MRI findings are consistent with PNTS along the zygomatic branch of CN7 and explain the patient’s inability to close the eye. Case 3:PNTS along zygomatic and buccal branches of CN7 69 year old male with right cheek skin lesion presents without symptoms of facial paralysis. Biopsy reveals squamous cell carcinoma. Imaging is performed for staging purposes. Case 3:PNTS along zygomatic and buccal branches of CN7 T1 GdT1FS * * T1 & GdT1FS images at the level of mid maxillary sinus show the right cheek cancer (*) with thickening of the SMAS posterior to the lesion (arrow) and enhancement along the SMAS anterior to the mass (arrow) when compared to the normal side (arrow). These findings are consistent with antegrade & retrograde PNTS along the buccal branch of CN7. Case 3:PNTS along zygomatic and buccal branches of CN7 T1 GdT1FS T1 & GdT1FS images at the level of zygomatic arch show subtle thickening and more apparent enhancement of the SMAS (arrows) superior to the cheek mass (not shown) when compared to the normal side (arrow). These findings are consistent with antegrade & retrograde PNTS along the zygomatic branch of CN7. Case 4:PNTS along buccal branches of CN7 70 year old female with biopsy proven facial squamous cell carcinoma presents with recent inability to play her trumpet. Imaging is performed for staging purposes. Case 4:PNTS along buccal & marginal mandibular branches of CN7 Post contrast CT image shows marked thickening of the right SMAS at the level of the lower maxilla (arrows) when compared to the normal other side (arrows). These findings are consistent with PNTS along the buccal branch of CN7. Case 4:PNTS along buccal & marginal mandibular branches of CN7 m * m * Post contrast CT images reveal a mass (*) infiltrating the right mandibular body (m) and subtle thickening of the SMAS posterior to it (arrows) when compared to the normal side (arrows). These findings are consistent with PNTS along the marginal mandibular branch of CN7. Take Home Points: Look for thickening /enhancement of SMAS around a mass to suggest the diagnosis of PNTS Changes might be subtle. Comparison with the normal side may be helpful. PNTS can occur in antegrade and/or retrograde fashion. Buccal & zygomatic branches are most often affected by PNTS No cases of PNTS along the cervical branch of CN7 have been published or seen in our practice . 30% of patients with PNTS are asymptomatic Always look for it! Summary/Conclusion: After reviewing this educational exhibit, the radiologist should be familiar with the spectrum of imaging findings of PNTS along peripheral branches of CN7 and be able to suggest such a diagnosis with a higher level of confidence. Early detection of this type of PNTS is critical to allow for early surgical intervention and more favorable outcome. References: Caldemeyer KS, Mathews VP, Righi PD, Smith RR. Imaging features and clinical significance of perineural spread or extension of head and neck tumors. Radiographics 1998;18:97–110. Galloway TJ, Morris CG, Mancuso AA, Amdur RJ and Mendenhall WM. Impact of radiographic findings on prognosis for skin carcinoma with clinical perineural invasion. Cancer (2005), 103: 1254–1257. 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