“Blind spots” in the analysis of computed tomography of the head and neck area

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BACKGROUND: Diagnostic errors in radiology occur in 2–5% of cases and most of them are due to perception errors, when a pathological change is not detected during the initial analysis, although its presence is very obvious during a retrospective analysis. In some cases, the errors appear due to the presence of «blind spots» — anatomical areas that most often go unnoticed when interpreted by a radiologist. It is extremely important to know their features when analyzing the CT study of the head and neck area for a targeted and systematic search for pathology.

AIM: To determine the most common anatomical areas in which radiologists frequently miss pathological changes when analyzing computed tomograms of the head and neck area.

METHODS: We have retrospectively analyzed 62 computed tomography scans of the head and neck region in cancer patients, in which there was no description of additional clinically significant pathological changes at the initial assessment. All the cases of missed pathology were identified after the repeat radiological examination or after the retrospective analysis of the CT study.

RESULTS: Several anatomical zones were identified in which most frequently the pathological findings were not described in the initial analysis of computed tomography studies of the head and neck area: brachiocephalic vessels (n=15; 24,2%), parotid salivary glands (n=10; 16,1%), paranasal sinuses (n=8; 12,9%), lungs and mediastinum (n=9; 14,6%), brain and temporal bones (n=5; 8,1%), soft tissues of the neck (n=4; 6,5%), thyroid gland and cervical spine (n=3; 4,8%).

CONCLUSION: The most common «blind spots» in the analysis of computed tomography scans of the head and neck region have been identified. The knowledge about such regions may potentially lead to the reduced incidence of missed pathology when interpreting a computed tomography study of those anatomical locations.

About the authors

Valentin A. Nechaev

Moscow City Hospital named after S.S. Yudin, Moscow Healthcare Department

Author for correspondence.
Email: dfkz2005@gmail.com
ORCID iD: 0000-0002-6716-5593
SPIN-code: 2527-0130

MD, PhD

Russian Federation, Moscow

Alexander Y. Vasiliev

Russian University of Medicine; Central Research Institute of Radiological Diagnostics

Email: auv62@mail.ru
ORCID iD: 0000-0002-0635-4438
SPIN-code: 3519-0938

MD, PhD, Professor, Corresponding Member of Russian Academy of Sciences

Russian Federation, Moscow; Moscow

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2. Fig. 1. Computed tomograms of the head and neck, axial planes (а, б). 82-year-old patient with laryngeal cancer T2N0M0 had hemodynamically significant stenosis of the right internal carotid artery (75%) due to a mixed atherosclerotic plaque (а, white arrow). 73-year-old patient with oropharyngeal cancer T4N0M0 in processive polychemotherapy, there is no contrast of the right jugular vein (б, yellow arrow), its diameter is increased relative to the contralateral side, the outer contour is unclear, the surrounding tissues are edematous, there is a venous port (б, green arrow) in its lumen.

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3. Fig. 2. Computed tomograms of the head and neck, axial planes (а, б). A 54-year-old patient with a suspected tumor of the larynx has a rounded formation with clear uneven contours in the left parotid salivary gland, a homogeneous structure of a 13×11 mm size — adenocarcinoma, histologically verified subsequently (а, white arrow). In a 49-year-old patient with laryngeal cancer pT3N0M0 (combined laryngectomy), the right maxillary sinus is subtotally filled with a pathological substrate of liquid density (б, yellow arrow), its walls having signs of hyperostosis.

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4. Fig. 3. Computed tomograms of the head and neck, axial (а) and sagittal (б) planes. A 55-year-old patient with laryngeal cancer cT2N0M0 has a saccular aneurysm of the left anterior cerebral artery A1 segment, diameter 5 mm (а, white arrow). A 76-year-old patient with laryngeal cancer T4N1M0 in the right parietal region has a round-shaped hypervascular formation with clear, even contours, a wide base adjacent to the inner surface of the right parietal bone (б, yellow arrow).

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5. Fig. 4. Computed tomograms of the head and neck, axial planes (а–в). In a 71-year-old patient with basal cell skin cancer on the left side of the neck cT1N0M0, a single solid round-shaped lesion with clear, even contours of soft tissue density with a diameter of 12 mm is identified in the upper lobe of the right lung (а, yellow circle). In a 68-year-old patient with suspected cancer of the left half of the larynx, a peripheral formation of soft tissue density with clear uneven contours measuring 37×28 mm is visualized in the upper lobe of the left lung (б, black arrow). In a 79-year-old patient with suspected cancer of the left half of the larynx, a saccular expansion of the aortic arch along its internal-superior surface is detected (в, yellow arrow).

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6. Fig. 5. Computed tomograms of the head and neck, sagittal planes (а, б). A 63-year-old patient with cancer of the red border of the lower lip pT3N0M0 has a round-shaped submental lymph node (group Ia) with clear, even contours, heterogeneously accumulating the contrast agent, measuring up to 11×9 mm (а, yellow arrow). A control study after 3 months showed the enlargement of the above-described lymph node to 33×24 mm (б, yellow arrow).

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7. Fig. 6. Computed tomograms of the head and neck, coronal (а) and axial (б) planes. A 67-year-old patient with follicular thyroid cancer has an osteolytic focus of destruction in the left arch of the C6 vertebra (yellow arrows).

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