Interactive Transcript
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So, we're just going to get right to it.
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Um, so a little bit about the format, we're going
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to show you an indicative image, then we're
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going to preview the audience question, show you
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the case, go through a little bit of didactics.
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And then go to an audience poll for the question.
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So, the first case we're going to review is
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retropharyngeal lymph node of Rubier.
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Um, so this is the indicative lesion, um, and, um,
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think about it and we'll discuss it here shortly.
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And this is the audience question that I want you
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all to think about, um, as we do the presentation.
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So, nodes of Rubier displace
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the longest colic muscle how?
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A, there's no displacement, B, anteriorly,
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C, posteriorly, or D, I don't know.
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So, um, let me show you the image.
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So this is a patient that came to us, um,
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with, uh, difficulty swallowing and some, um,
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dysphagia, and you can see that there is this,
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uh, rim-enhancing lesion, centrally necrotic.
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Located at the lateral retropharyngeal space
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and extending into the peripharyngeal space.
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You can see the normal peripharyngeal
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space on the contralateral side here, and
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you can see how small it is on the other side.
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There is mass effect on the mucosal space and the
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oropharynx here, and this is the torus tubarius.
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This is the fossula supramandibularis.
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You can see how there's mass
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effect from that lesion as well.
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Now, the reason, and I just have the component or
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the associated PET CT image for you to see that
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it was abnormally metabolically active, right?
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Um, so the reason I wanted to
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discuss this area of the, um,
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of the, um, suprahyoid neck, um,
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is that it is an area that is very
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difficult for clinicians to see.
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So just a little bit of history
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on the name of the node of Rubier.
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So Henry Rubier was anatomic
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anatomy professor in France.
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Um, he actually wrote a very extensive
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book on the human lymphatic system and
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all the lymphatic levels that we utilize
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today actually arise from this work.
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And it is due to him that we give it this name.
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So the node of Rubier is located in the lateral,
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um, retropharyngeal space, and it is located
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anterior to the longus colli muscle.
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They extend from the C1, C2 level
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to the level of the hyoid bone.
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As you can see, um, usually the size is very,
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very small, 3 to 5, um, millimeters, and I
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don't know if you caught that we measured
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that, um, node of Rubier, and it was
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2.7 centimeters, so clearly very, very abnormal.
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The reason this is so important to keep in mind
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when you are evaluating head and neck tumors
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in the suprahyoid neck is that these nodes
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are absolutely not detectable, not palpable
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on clinical evaluation, even when they are
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large as the patient that I just showed you.
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And, um, if the clinician doesn't
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know about it, they cannot treat it.
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And it can be a source, um, of course
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of residual tumor, uh, resulting in
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a much worse prognosis for the patient.
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Um, uh, which actually has
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been proven in the literature.
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So if we don't tell the clinicians that this
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node is there, they're not going to treat it.
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And the patient outcome is
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going to be much poorer.
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So, please make sure that you look
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at these nodes in your evaluation.
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So just a brief, um, anatomy review.
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So, um, MRI neck axial T2 weighted sequence.
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We can see that the retropharyngeal space
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is located posterior to the, um, pharynx and
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is here located in this, uh, blue line with our
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longus colli muscles, um, which are located
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posterior to the retropharyngeal space.
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And then we have this fat line here anterior to
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the vertebral body, which is the um, prevertebral
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space and then lateral to the longus colli muscle.
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It's where we have the lateral retropharyngeal
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space where the nodes of Rubier live.
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So I want you to see that if you have
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a big mass here, right, located in the
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lateral pharyngeal space, that's going to
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move the longus colli muscles posteriorly.
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And that's an indication that you know,
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also you have a lesion in this space.
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Now, um, this has nothing to do with the nodes
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of Rubier, but the longus colli muscles are
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very important in this region of the neck.
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If they're, uh, uh, you know, displaced
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posteriorly, then you must have a mass
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anteriorly in the retropharyngeal space.
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If the muscles are moved anteriorly, then you
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must have a lesion in the prevertebral space.
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Um, so the longus colli muscles are a great
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anatomical marker for location of lesions
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within, uh, the neck, uh, deep spaces.
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So the retropharyngeal space, um, as I
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mentioned already, you must evaluate the
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longus colli muscles to know, uh, where
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the, um, lesions are located.
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Uh, know that the retropharyngeal
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space spans from the base of the
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skull base to the mediastinum.
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Um.
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As we have mentioned already, it is
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anterior to the prevertebral muscles and
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posterior to the pharynx and esophagus.
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And this is also important to understand
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that it's not a single space; it's actually
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a double space with two components.
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The true retropharyngeal
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space and the danger space.
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And so this is what we're talking about, okay?
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So you have the anterior retropharyngeal
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space, which terminates at C7.
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Uh, this space will not extend
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into the mediastinum and will
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not result in um, mediastinitis.
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Whereas the danger space is posterior
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to the, uh, retropharyngeal space altogether.
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It extends past the C7 vertebral body into
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the mediastinum and can cause, uh, severe
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mediastinitis and other, uh, problems.
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So this is also a, um, source of
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spread of, um, metastatic disease.
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So notice the Rubier nodes.
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What happens with the longus colli muscles?
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Okay, good.
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So most of you got the, uh, correct answer,
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which is that they're displaced posteriorly.
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