Eur Arch Otorhinolaryngol (2013) 270:10451053

DOI 10.1007/s00405-012-2084-6

HEAD AND NECK

Diagnostic efficiency of multidetector computed tomography

versus magnetic resonance imaging in differentiation of head
and neck paragangliomas from other mimicking vascular lesions:
comparison with histopathologic examination
Mohammed Farghally Amin Nadia Farouk El Ameen

Received: 19 March 2012 / Accepted: 6 June 2012 / Published online: 27 June 2012
 Springer-Verlag 2012

Abstract The purpose of this study was to determine

the efficiency of Multidetector Computed Tomography
(MDCT) versus MRI in detection and characterization of
paragangliomas and differentiating them from other vascular mimicking conditions in the neck and skull base in
comparison with histo-pathological results as a gold standard. A prospective study included 30 patients with vascular
neck lesions. They were susceptible for MDCT and MRI for
characterization of the nature of the lesions. Histo-pathological evaluation was performed in all lesions for confirmation. As a result of this study included 30 patients: 22
males and 8 females. Paragangliomas were the commonest
detectable lesions; 12/30 patient had glomus tumor (1 glomus tympanicum, 2 glomus vegale, 4 glomus jugulo-tempanicum, and 5 glomus jugular), 6 carotid body tumor, 2
hemangiopericytoma, 3 vegal Schwanoma, 4 lymphadenopathy, 2 juvenile angiofibroma, and one neurofibroma.
The sensitivity of MDCT was higher than MRI in differentiation of paragangliomas from other mimicking lesions,
where MDCT sensitivity was 83.33 % and the NPV was
80 % while that of MRI was 77.7 % and the NPV 75 %, but
both techniques have moderate agreement between them in
differentiating paragangliomas from other mimicking vascular lesion. MDCT with its new utilities has near degree of
accuracy in detection and localization of paragangliomas as
the same that of MRI. Both techniques have moderate
agreement between them in differentiating paragangliomas
from other mimicking vascular lesions. So, it is better to use

M. F. Amin (&)
N. F. E. Ameen

Department of Radiodiagnosis, ElMinia University Hospital,
ElMinya High Road, ElMinya, Egypt
e-mail: Mohammed_amin37@yahoo.com

both of them as complementary techniques for accurate

diagnosis and grading of paraganglioma.
Keywords Paraganglioma
Glomus tumor
Carotid
body tumors
MDCTA
CT angiography
MRI MRA

Introduction
Vascular tumors of head and neck region comprise a heterogeneous group of lesions that have a very different
histology, clinical courses, and treatment options. They are
rarely encountered in clinical practice, but a solid understanding of their diagnosis and management is very
important [1].
Paragangliomas of the head and neck are hypervascular
benign neoplasms which are derived from neural crest cells
of the autonomic nervous system. They account for 0.6 %
of all neoplasms in the head and neck region. The most
common locations are carotid space and jugular fossa.
Recently, a gene focus in families with inherited paragangliomas or glomus tumors has been identified. Despite
paragangliomas are classified as benign tumors WHO
grade I, distant metastases have been published. On the
other hand, 10 % of glomus tumors may be multicentric in
origin [2]. Combinations of head and neck paragangliomas
include vagalcarotid body paragangliomas; carotid body
glomus jugulare tumors are also reported [2].
They are usually seen in four primary locations; the
jugular bulb, middle ear cavity, vagus nerve, and carotid
body. Tumors in the jugular bulb region called glomus
jugulare and arise in adventitia of the dome of the jugular
bulb. Tumors in middle ear cavity called glomus tympanicum and it arise from the glomus bodies that run with the
tympanic branch of the glossopharyngeal nerve. They are

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the most common primary neoplasms of the middle ear.

Glomus vagal has close association with vagus nerve. They
arise infratemporally along the course of the cervical vagus
nerve. At the bifurcation of the common carotid artery they
are called carotid body tumor. Less common sites include
the sella turcica, pineal gland, cavernous sinus, larynx,
orbit, thyroid gland, nasopharynx, mandible, soft palate,
face, and cheek [35].
These masses harbor characteristic findings on radiologic imaging. Neuroimaging shows them as a well-circumscribed, strongly enhancing mass associated with
paraganglionic structures indicating abundant blood supply. Erosions of adjacent bony structures, expansive
growth, and characteristic salt-and-pepper appearance of
the tumor are usually diagnostic [5, 6].
This study aimed to evaluate efficacy of Multi Detector
Computed Tomography (MDCT) in comparison with MRI
as a promising imaging modality in detection and characterization of vascular neck lesions with special emphasis on
paraganglioma.

Patients and methods

Between January 2009 and December 2010, 30 consecutive
patients, 22 males and 8 females, were recorded in a prospective study. Their age ranged between 17 and 51 years,
average 34 years. All of them referred from the otolaryngeal department to the radiology department at El Minia
university hospital. The study was approved by our institutional ethics committee.

by inspection of ear canal and ear drum with otoscopt as

well as the tympanic membrane; also basic hearing tests
were done, including Tuning fork tests, Webers test, and
Rinnes test.
Examination of the Throat
This includes examination of mouth, the condition of the
tongue and back of tongue and tonsils, palpation of the
base of the tongue, inspection of the uvula, soft palate and
hard palate, examination of the buccal area and the gingivolabial (gingivobuccal) sulcus and the floor of the mouth
as well as the nasopharynx and larynx with a flexible fiber
optic nasendoscope.
Then all patients undergo the following after giving
written consent:1.

MDCT examination
Performed using 16-detector MDCT scanner (Bright
Speed 16; GE Medical Systems). The entire neck and
skull base was scanned starting from the superior
border of the petrous bone till the thoracic inlet in less
\10 s in a craniocaudal direction. Contrast material
was injected with a power injector (Medrad, Stellant)
through an 18- or 20-gauge catheter into the antecubital vein. The injection rate was 4 mL/sec. A total of
90 mL of nonionic water-soluble contrast material was
used. The acquisition parameters were 120 kVp,
440 mAs, a helical pitch of 1.375:1, 0.5-second scan
time, 16 9 1.25 mm detector configuration, 1.25 mm
helical slice thickness, and 0.625 mm reconstruction
interval with a large FOV. CTA was done for all
patients.

Inclusion criteria

Image display

Axial source images were displayed in two different gray

scales for interpretation using soft tissue window (WW

Patients with slowly growing palpable neck masses.

Patients with tongue paresis, bulbar symptoms or
paroxysmal attacks of hypertension.

Exclusion criteria

Patients
Patients
Patients
stroke.
Patients

with painful, inflammatory neck masses.

with otitis media or inner ear disease.
with persistent hypertensions, diabetes or

Clinical presentation

Number

Palpable mass

10

33.3

13.3

Deafness

suspected to have pheochromocytoma.

All of the patients had complete otolaryngeal examination;

the protocol of otolaryngeal examination in our institution
included
Examination of the Ear
This includes an assessment of hearing as well as the
appearance of the ear. The external ear was inspected
before examination with an otoscope/auriscope, followed

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Table 1 Clinical presentation of all patients

Percent
(%)

Hoarseness of voice

13.3

Deviated tongue

13.3

Vertigo

13.3

Bruit

13.3

Pulsatile tinnitus
Bulbar palsy

2
2

6.6
6.6

Horner syndrome

3.3

More than one symptom was in the same patient

Eur Arch Otorhinolaryngol (2013) 270:10451053

268/WL39 HU) and bone window (WW 2000/WL 400

HU).
Image reconstruction

1047

volume rendering image and MIP reconstruction (maximum intensity projection) were applied for evaluation of
tumor extension, vascularity, and detection of relation to
the surrounding vessels.

Axial source images with a 1.25-mm slice were transferred

to an Advantage Workstation (AW) Volume Share 2 (GE
Healthcare). Multiplanar reformatted images (MPR) were
obtained in the coronal and sagittal planes. MPR used to
localize the exact extension of the lesions and the affected
neck compartment. CT angiography (CTA) using 3D

2.

Fig. 1 27-year-old female presented with deafness. a, b axial CT

showed the tumor mass (arrow head) at the left side of the skull base;
note marked bony erosion of the jugular fossa, clivus (white arrow)
and the left petrous bone (moose eaten appearance). c, d coronal
T2WI and axial T1WI MRI showed the soft tissue mass involving the

left jugular fossa, extending to the middle ear and naso-pharynx (thin
white arrows) note the extensive vascular signal voids (thick white
arrow). Histopathological examination revealed jugulo- tympanicum
glomus

MRI examination
All the patients were instructed to remove all metallic
articles, e.g. hair pins and coins. They were asked
about the presence of metallic prosthesis, coils or
implants or any other articles interfering with MRI
examination.

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Fig. 2 51-year-old male presented with pulsatile tinnitus. a, b sagittal

reconstructed CT image and axial CT showing a small tumor mass at
the right hypotympanum (black arrow) with extension to the right
jugular fossa; note the intact bony ossicles and the widened jugular
fossa with eroded jugular spine (black arrow). c coronal MRI

showing Jugulo-tempanicum paraganglioma with extensive vascular

signal voids (white arrow), not the middle ear extension of the lesion
(white arrow). d DSA of the right ascending pharyngeal artery
showed the tumor plush

Imaging protocol

Final diagnosis in all lesions was made histopathologically using either surgery or biopsy from the lesion.

Axial T1WI (TR 510/TE 14, FOV 24 cm, Matrix

160 9 256, slice thickness 4 mm, band width 7.8); Axial
and coronal T2WI (TR 4700/TE 110, FOV 24 cm, Matrix
128 9 256, slice thickness 4 mm, band width 7.8); STIR
coronal and/or sagittal (TR 3500/TE 37, FOV 24 cm,
Matrix 128 9 256, slice thickness 4 mm, band width 6.9);
TOF MRA (TR43/TE 7, FOV 19 cm, Matrix 256, flip
angle 45, overlap 2 mm) and post GAD evaluation was
applied on T1WI.

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Image Analysis
Images were read by two radiologists in consensus with
11 years out of training, both of them were unware of
patients clinical data.
Our study included 30 patients presenting with variable
clinical presentations: the most common was palpable non
painful neck swelling that was seen in 10/30 patients

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Fig. 3 A 62-year-old female presented with bulber palsy and

difficulty in swallowing. a axial CT showed intensely enhanced mass
at the right carotid space, not the laterally displaced vessel (black
arrow). b axial T1WI showed the mass with extensive vascular signal
voids (white arrow), note the laterally displaced vessel (black arrow).

c Sagittal T1WI showed the mass extending along the jugular vein till
the jugular fossa; no intra cranial extension. d DSA showed marked
tumor plush displacing the carotid artery anteriorly. Histopathological
examination revealed Glomus vegale

(33.3 %); deafness, hoarseness of voice, deviated tongue,

vertigo, and bruit was seen in 4/30 patients for each
(13.3 %); pulsatile tinnitus and bulber palsy were seen in two
patients for each 2/30 (6.6 %). Horner syndrome was seen in
one patient 1/30 (3.3 %) (Table 1; Figs. 1, 2, 3, 4, 5).
In our study 12/30 (40 %) had histopathological proven
diagnosis of glomus tumor. Carotid body tumors were
diagnosed in 6/30 patients (20 %). There were 4/30 patients
(13.3 %) diagnosed as enlarged cervical lymph node.
Schwanoma, angiofibroma, hemangiopericytoma, and neurofibroma were diagnosed in 3/30 (10 %), 2/30 (6.6 %), 2/3
(6.6 %), and 1/30 (3.3 %) patients, respectively (Table 2).
MDCT and MRI showed an accurate diagnosis in 24/30
(80 %). Both techniques accurately diagnose all glomus
tumors as well as the carotid body tumors correctly and
differentiate them well from nodal enlargement. As regards

other included pathologies, angiofibroma was diagnosed

accurately in MDCT but in MRI we had a false-negative
diagnosis in one of the patients, where it was diagnosed as
inverted papilloma. In patients with hemangiopericytoma;
MDCT diagnosis in one of them was mucocele and
inverted papilloma in the other one, while in MRI our
diagnosis was a highly vascular tumor with no specific
pathological diagnosis. As regards neurogenic tumors CT
diagnosis was schwanoma in all four patients, while MRI
diagnosis was schwanomas in three patients and neurofibroma in the last one (Table 3).
The sensitivity of MDCT was higher than MRI in differentiation of paragangliomas from other mimicking
lesions, where MDCT sensitivity was 83.33 % and the
NPV was 80 % while that of MRI was 77.7 % and the
NPV 75 % (Table 4).

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Fig. 4 A 35-year-old female presented with neck swelling. a axial

CT showed intensely enhanced tumor mass at the right carotid space;
note the displaced vessels and the splay of both carotids (black
arrows). b axial 2WI showed the tumor mass and the displaced

jugular and splayed carotids. c DSA showed the characteristic splayed

internal and external carotids and the tumor plush in-between.
Histopathological examination revealed right carotid body tumor

In our study we found that moderate agreement between

the MRI findings and MDCT results using Kappa value that
was 0.667 with standard error 0.146 and 95 % CI 0.38 to
0.953 (Table 5).

RK et al. and others who stated that 15 % of paragangliomas arise extra-adrenal and 80 % of them are either
carotid body or glomus tumors [4, 912]. The fact that 3/30
(10 %) of our patients showed bilateral paraganglioma
agreed with the findings of Arnlod et al. and others who
reported that 10 % of paragangliomas are multicentric in
origin [2, 5, 13, 14].
In our results MRI has been accurate in evaluating paragangliomas. Its high soft tissue resolution and multiplaner capabilities detect lesion, determine its extension, and
evaluate its relation to surrounding vessels. It demonstrated
paragangliomas as well circumscribed, expanding, intensely enhanced masses with marked internal vascularity that
appeared as multiple signal voids. This agreed with the
report by Arnold et al. and other several reports [2, 1520].
MRA was good determinant for tumor resectability
according to Glasscock-Jackson classification. It clarifies
the relation to carotid arteries or jugular veins, splaying of
carotids and their antro-medial displacement. Also glomus

Discussion
Vascular lesions of head and neck include many different
types: benign neoplasms, malignant neoplasms, and non
neoplastic growths. They are challenging for surgical
resection. Determination of the degree of vascularization of
these lesions and their extension is very important. Imaging
studies depict the location and extent of tumor involvement, help determine the surgical approach, and help predict operative morbidity and mortality [5, 79].
In our study, paragangliomas including glomus and
carotid body tumors were the commonest detectable
lesions. This was concordant with the findings of Whalen

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Fig. 5 A 45-years-old male presented with neck mass and difficulty

in swallowing. a axial CT showed a non enhancing mass at the left
carotid space, not the vascular displacement (back arrows). b axial

T1WI showed the mass and the displaced vessels. c axial T2WI
showed the mass and the displaced vessels. Histopathological
examination revealed schwanoma

Table 2 Histo-pathological diagnosis for all lesions

Diagnosis

Number

Percent
(%)

Glomus tumors

12

40

20

Carotid body tumors

Lymphadenopathy

13.3

Schwanoma

10

Hemangiopercytoma

6.6

Angiofibroma

6.6

Neurofibroma

3.3

30

100

Total

mimicking lesions such as high-riding jugular bulb,

dehiscent jugular bulb, and jugular vein thrombosis could
be confidently excluded after revision of MRA. This agreed

with the reports of Rao et al., Sahdev et al. and van den
Berg [5, 15, 16].
The treatment options for paragangliomas depend on
many parameters. MRA was good determinant for tumor
resectibility. In our study we found that MRA added to the
merits of MRI and helped in confirmation of the diagnosis
via providing us more details about the relation of paraganglioma to carotid arteries or jugular veins. Splaying of
carotids and their antro-medial displacement could be
accurately recorded that helps in grading of tumors. Glomus mimicking lesions such as high-riding jugular bulb,
dehiscent jugular bulb, and jugular vein thrombosis could
be confidently excluded after revision of MRA that agreed
with several recent reports by Rao et al., Sahdev et al. and
van den Berg [5, 15, 16].

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Table 3 MDCT, MRI diagnoses, and pathological diagnosis

Diagnosis

MDCT

MRI

Glomus tumor

10 (33.3 %)

Pathology

9 (30 %)

12 (40 %)

Carotid body tumor

5 (16.6 %)

5 (16.6 %)

6 (20 %)

Lymphadenopathy

4 (13.3 %)

4 (13.3 %)

4 (13.3 %)

Schwanoma

5 (16.6 %)

6 (20 %)

3 (10 %)

Neurofibroma

0 (0 %)

2 (6.6 %)

1 (3.3 %)

Mucocele

1 (3.3 %)

0 (0 %)

0 (0 %)

Inverted papilloma

2 (6.6 %)

1 (3.3 %)

0 (0 %)

Angiofibroma

2 (6.6 %)

1 (3.3 %)

2 (6.6 %)

Hemangiopericytoma

0 (0 %)

0 (0 %)

2 (6.6 %)

Non specific
Total

1 (3.3 %)

2 (6.6 %)

0 (0 %)

30 (100 %)

30 (100 %)

30 (100 %)

Table 4 The sensitivity and specificity as well as the PPV and NPV
of MDCT and MRI in comparison to histopathological results
Sensitivity

Specificity

PPV

NPV

MDCT

83.33 %

100 %

100 %

80 %

MRI

77.7 %

100 %

100 %

75 %

However, in our study we found that high quality

MDCT with its advanced application of multiplaner projection reconstruction gives us an equivalent opportunity to
MRI capabilities. Coronal and sagittal reconstructed images allowed evaluation of tumor extension into middle ear
and skull base, especially in patients with glomus tympanicum and jugulo-tympanicum that was clearly depicted
at the hypotympanum and cochlear promontory. Also
applications of Maximum Intensity Projection (MIP)

reconstruction and 3D volume render CTA (VR CTA)

highlight the extension of paragangliomas and help in
determination of tumor resectibility as equal as MRA. This
agreed with Quint et al. [5, 17] reports about the new
capabilities of MDCT.
In addition, we found that MDCT abilities make it equal
to MRI in evaluation of temporal bone and aids in defining
its involvement. It detected the characteristic moth-eaten
appearance of the skull base erosion, destruction of jugular
foramen, destruction of the carotico-jugular spine and also
erosion of bony labyrinth, ossicular chain, and facial nerve
canal. At this point MDCT was much far superior to MRI
in our opinion that agreed with many authors as Noujaim
SE et al. [22].
Also Bozek et al. [23] reported that MDCT scanning is
especially useful to show subtle destruction of the temporal
bone on early stage of disease. MR is the modality of
choice in assessing middle ear, skull base or posterior fossa
involvement, and monitoring growth of paraganglioma.
MR and CT angiography are both useful methods to
identify arterial feeders of the paragangliomas and in some
cases due to better availability in clinical practice can be
alternative to angiography.
Regarding the differentiation between paraganglioma
and other mimicking condition we believe that MDCT was
equal to MRI. As MIP reconstruction, VR, and CTA can
adequately evaluate jugular vein adequately in a way that
could confidently exclude any anomalies, variants, or
pathology. It can demonstrate smooth bone remolding and
expansion rather than destruction or erosion in schwannoma and also demonstration of its cystic component and
lack of high vascularity [24]. In our study we found that

Table 5 Correlation between MDCT & MRI results

Diagnosis

Glomus
tumor

Carotid
body
tumor

LN

Schwannoma

Neurofibroma

Mucocele

Inverted
papilloma

Angiofibroma

HPC

NS

Total

Glomus tumor

10

Carotid body tumor

Lymphadenopathy

Schwanoma

Neurofibroma

Mucocele

Inverted papilloma

Angiofibroma

Hemangiopericytoma

Non specific

Total

30

Kappa value 0.667

Standard error 0.146
95 % CI 0.38 to 0.953

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Schwannomas, hypervascular lymphadenopathy, and nodular fasciitis showed no uniform enhancement as that of
paraganglioma and also no abnormal feeding vessels to the
tumors. This is concordant with the report of Dhiman et al.
[25]. Because of this we believe that MPR and MIP are
merits of MDCT that rise the efficacy of MDCT in diagnosis of paragangliomas and differentiate it from its
mimicking conditions.
Limitations of our study were, first, our study included
small number of patients, so further studies with larger
number of patients are needed; second, readers interpret
results in consensus and so inter-observer reliability could
not be calculated.

Conclusion
MDCT with its new utilities has near degree of accuracy in
detection and localization of paragangliomas as the same
that of MRI. Both techniques have moderate agreement
between them in differentiating paragangliomas from other
mimicking vascular lesions. So, it is better to use both of
them as complementary techniques for accurate diagnosis
and grading of paraganglioma.

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