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Patient with Dysphagia and Lesion in the Retropharyngeal Space

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0:00

So, we're just going to get right to it.

0:03

Um, so a little bit about the format, we're going

0:05

to show you an indicative image, then we're

0:09

going to preview the audience question, show you

0:13

the case, go through a little bit of didactics.

0:16

And then go to an audience poll for the question.

0:19

So, the first case we're going to review is

0:21

retropharyngeal lymph node of Rubier.

0:24

Um, so this is the indicative lesion, um, and, um,

0:30

think about it and we'll discuss it here shortly.

0:32

And this is the audience question that I want you

0:35

all to think about, um, as we do the presentation.

0:38

So, nodes of Rubier displace

0:40

the longest colic muscle how?

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A, there's no displacement, B, anteriorly,

0:44

C, posteriorly, or D, I don't know.

0:49

So, um, let me show you the image.

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So this is a patient that came to us, um,

0:55

with, uh, difficulty swallowing and some, um,

0:58

dysphagia, and you can see that there is this,

1:01

uh, rim-enhancing lesion, centrally necrotic.

1:05

Located at the lateral retropharyngeal space

1:08

and extending into the peripharyngeal space.

1:11

You can see the normal peripharyngeal

1:12

space on the contralateral side here, and

1:15

you can see how small it is on the other side.

1:18

There is mass effect on the mucosal space and the

1:22

oropharynx here, and this is the torus tubarius.

1:26

This is the fossula supramandibularis.

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You can see how there's mass

1:29

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?

1:43

Um, so the reason I wanted to

1:46

discuss this area of the, um,

1:51

of the, um, suprahyoid neck, um,

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is that it is an area that is very

1:56

difficult for clinicians to see.

1:58

So just a little bit of history

2:00

on the name of the node of Rubier.

2:01

So Henry Rubier was anatomic

2:04

anatomy professor in France.

2:06

Um, he actually wrote a very extensive

2:08

book on the human lymphatic system and

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all the lymphatic levels that we utilize

2:12

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

2:40

that, um, node of Rubier, and it was

2:42

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

3:19

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

3:30

at these nodes in your evaluation.

3:34

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.

3:57

And then we have this fat line here anterior to

4:00

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?

5:38

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,

6:19

which is that they're displaced posteriorly.

Report

Faculty

Gloria J. Guzmán Pérez-Carrillo, MD, MPH, MSc

Associate Professor of Radiology, Neuroradiology Section Co-Director, Advanced Neuroimaging Clinical Service

Mallinckrodt Institute of Radiology, Washington University School of Medicine

Rami Eldaya, MD, MBA

Assistant Professor

M.D. Anderson Cancer Center

Tags

Oral Cavity/Oropharynx

Neuroradiology

Neoplastic

Head and Neck

CT

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